Pain Management

Question 1

What are the different levels of pain

Answer 1

Mild pain:
Non-opiates: paracetamol, nsaids, aspirin

Mild-moderate
Weak opiates: codeine, dihydrocodeine, co-drydromol
Moderate: tramadol (lowers the seizure threshold, serotonin syndrome, increased risk of bleed, psychiatric disorders

Moderate-severe
Strong opiates: morphine, oxycodone, methadone, buprenorphine and fentanyl

Question 2

What are the counselling points of codeine

Answer 2

Use in patients over the age of 12
Do not use in children under 18 who have had tonsils removed due to sleep apnoea
Avoid in patients who are ultra-rapid metabolisers (Afro-Caribbean) due to toxicity
Avoid in breast feeding patients
Can’t give codeine linctus to those under the age of 18

Question 3

What are opiates side effects

Answer 3

Act on the my pathway
Dry mouth
Constipation
CNS depression
Nausea and vomiting
Hypotension
Miosis (pupil constriction)

Question 4

What are the side effects of strong opiates

Answer 4

Prolonged use: hypogonadism, adrenal insufficiency, hyperalgesia

Question 5

How do you reverse an opiate overdose

Answer 5

Naloxone

Question 6

When do you avoid strong opiates

Answer 6

Avoid in paralytic ilieus will give intestinal block, respiratory disease and head injury CNS depression

Question 7

What is breakthrough pain

Answer 7

Max is 1/6
Min 1/10 of the daily dose
Every 2-4 hours

Question 8

How much do you increase/decrease doses of opiates by

Answer 8

Increase doses of opiates by 1/2 to 1/3 each day

Reduce dose by1/2 to 1/3 when switching between opiates to prevent overdose

Question 9

When would oxycodone be appropriate rather than morphine

Answer 9

Oxycodone is more potent than morphine- more appropriate in patients who can’t consume large quantities due to nausea

Question 10

For opiate patches what are the counselling points

Answer 10

Avoid exposure to heat, apply to dry hairless area, rotate site

Question 11

What do you do to fentanyl patch if there is signs of toxicity

Answer 11

Remove patch immediately

Question 12

What drugs would you use in Neuropathic pain

Answer 12

TCAS: Amitriptyline or nortrptyline

Anti epileptics: gabapentin, pregabalin don’t withdrawal immediately one week withdrawal regimen

Opiates: tramadol, morphine or oxycodone

Topical localised: lidocaine or capsaicin