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CNS > Pain management > Flashcards

Pain management Flashcards

1
Q

What are the different definitions of pain?

A

Chronic pain: more than 12 weeks (3 months)

Chronic primary pain: no clear underlying condition

Chronic secondary pain: Has underlying condition like arthritis.

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2
Q

What is normally connected to chronic pain?

A

Depression

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3
Q

Which drugs are usually used for mild pain?

A

Non-opioids:
- Paracetamol
- NSAID
- Aspirin

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4
Q

Which drugs are usually used for mild-to-moderate pain?

A

Weak Opioids:
- Codeine
- Tramadol
- Low-dose morphine

Can be used in adjuvant to non-opioid

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5
Q

Which drugs are usually used for moderate-to-severe pain?

A

Strong opioids:
- Morphine
- Fentanyl
- Oxycodone
- Buprenorphine

Can be used in adjuvant to non-opioid

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6
Q

What are NSAIDs, Aspirin & Paracetamol normally used for?

A

Musculoskeletal pain

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7
Q

What are Opioids normally used for?

A

Visceral pain - the pain we feel when our internal organs are inflamed, diseased, damaged or injured.

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8
Q

What is used for Sickle cell disease?

A

Paracetamol & NSAIDs, codeine and dihydrocodeine

Severe crisis - morphine or diamorphine may be needed

Avoid pethidine - can cause seizures

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9
Q

What are the paracetamol doses for children?

A

1-2 months:
- 30-60mg every 8 hours as required. Max daily dose given in divided doses. Max 60mg/kg per day

3-5 months:
- 60mg every 4-6 hours; max 4 doses per day

6-23 months:
- 120mg every 4-6 hours; max 4 doses per day

2-3 years:
- 180mg every 4-6 hours; max 4 doses per day

4-5 years:
- 240mg every 4-6 hours; max 4 doses per day

6-7 years:
- 240-250mg every 4-6 hours; max 4 doses per day

8-9 years:
- 360-375mg every 4-6 hours; max 4 doses per day

10-11 years:
- 480-500mg every 4-6 hours; max 4 doses per day

12-15 years:
- 480-750mg every 4-6 hours; max 4 doses per day

16-17 years:
- 0.5-1g every 4-6 hours; max 4 doses per day

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10
Q

What are the Ibuprofen doses for children?

A

3-5 months:
- 50mg 3 times a day

6-11 months:
- 50mg 3-4 times a day

1-3 years:
- 100mg 3 times a day

4-6 years:
- 150mg 3 times a day

7-9 years:
- 200mg 3 times a day

10-11 years:
- 300mg 3 times a day

All max daily doses given in 3-4 divided doses; max 30mg/kg per day

7-11 years - max 2.4g per day

12-17 years:
- Initially 300-400mg 3-4 times a day, increased if necessary up to 600mg 4 times a day; maintenance 200-400mg 3 times a day, may be adequate.

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11
Q

What are the Ibuprofen doses, in bottles, for children?

A

Strength: 100ml/5mg
Dose every 6-8hrs, 3 doses in 24hrs.

3-6months:
- 2.5ml then 2.5ml after 6hrs if required

3-6months:
- 2.5ml

6-11 months:
- 2.5ml

1-3 years:
- 5ml

4-6 years:
- 7.5ml

7-9 years:
- 10ml

10-12 years:
- 15ml

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12
Q

What can be given for Dental & Orofacial pain?

A
  • NSAIDs (Ibuprofen, Aspirin, Diclofenac), Paracetamol used temporarily
  • Benzydamine mouthwash/spray can be used
  • Paracetamol, Ibuprofen & aspirin are adequate for dental pain.
  • Diazepam - Has muscle relaxant and anxiolytic properties (only prescribe short term)
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13
Q

What drugs can be used to treat Dysmenorrhoea?

A
  • Antiemetic can be used to prevent vomiting.
  • Paracetamol or NSAID used for pain relief
  • Oral contraceptives used to prevent pain associated with ovulatory cycles
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14
Q

What is Aspirin indicated for and what are some problems associated with it?

A

Indicated for headache, musculoskeletal pain, dysmenorrhoea & pyrexia.

Can cause G.I problems but can be minimised by taking dose after food.

Enteric coated preps have a slow onset of action & therefore unsuitable.

It interacts with other drugs esp warfarin which is a high hazard.

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15
Q

Is Aspirin or Paracetamol preferred?

A

Paracetamol because it is safer, esp in elderly.

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16
Q

What can overdosage of paracetamol cause?

A

Hepatic damage.

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17
Q

When can Nefopam be used?

A

Used for pain not responding to non-opioid analgesics.

But has more side effects.

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18
Q

What can NSAIDs be used for?

A
  • Chronic disease accompanied by pain & inflammation
  • Can be used as short term treatment of mild-to-moderate musculoskeletal pain
  • Suitable for dysmenorrhoea
  • Can treat pain caused by secondary bone tumours
  • Used for post-operative analgesia
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19
Q

What painkiller should patients with high risk of G.I side effects be given?

A

Selective inhibitors of cyclo-oxygenase-2

Preferred over NSAIDs for these patients.

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20
Q

Is compound analgesics or single ingredient analgesics preferred?

A

Single ingredient analgesics is preferred due to having to titrate each drug.

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21
Q

What is caffeine used for in analgesics?

A

It is a weak stimulant and enhances analgesics effects

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22
Q

What caution is given with Opioid analgesics?

A
  • Repeated use can cause dependence and tolerance.
  • Caution in impaired respiratory function (avoid COPD), asthma, hypotension, MG, shock and convulsive disorders
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23
Q

What are the side effects of Opioids?

A
  • Respiratory depression: Treated by artificial ventilation or reversed by naloxone
  • Dependence & withdrawal: Tolerance can develop during long term use
  • Overdose: Cause coma, respiratory depression & pinpoint pupils
  • N&V
  • Constipation
  • Dry mouth
  • Drowsiness
  • Biliary spasm

Larger doses can cause muscle rigidity, hypotension, respiratory depression

Long terms use can cause hypogonadism & adrenal insufficiency

24
Q

What can happen when Opioids are used in Pregnancy?

A

Respiratory depression & withdrawal symptoms have been reported.

Gastric stasis & inhalation pneumonia (infection in lungs)

25
Q

What can happen when Opioids are used in Hepatic impairment?

A

May precipitate coma

26
Q

What are the rules with stopping Opioids?

A

Do not stop abruptly after long term treatment

27
Q

What are the patient & carer advice for Opioids?

A

Can cause drowsiness, so may affect driving or skilled tasks

28
Q

What is the caution with Morphine?

A

Can cause exhilaration and a detached state.

29
Q

What is the dose interval for Morphine?

A

Given every 4 hours (every 12 or 24 hours as modified-release preps)

30
Q

What must be known with Buprenorphine?

A
  • Has both opioid agonist & antagonist properties
  • Can cause withdrawal symptoms
  • Can be abused & can cause dependence
  • Longer duration of action than morphine
  • Effective sublingually for 6-8 hours
31
Q

What drug can help to partially reverse Buprenorphine?

A

Naloxone.

Only partially reverse.

32
Q

What is the patient & carer advice on the use of Buprenorphine patches?

A

How to apply patches:
- Apply patch to dry, non-irritated, non-hairy skin on upper torso or outer arm

  • Heat or fever can increase absorption, so avoid heat and sauna
  • Remove after (72hrs/96hrs/7hrs)
  • Avoid same area for at least 3 weeks, 6 days for transtec, (or 7 ays prenotrix, hapoctasin, bupeaze, buplast & relevtec)
33
Q

In what cases should Buprenorphine patches be quickly removed?

A
  • Breathing difficulties
  • Drowsiness
  • Confusion
  • Dizziness
34
Q

What is the conversion rules for opioids?

A

From Buprenorphine to fentanyl
- convert first to morphine, then to fentanyl

35
Q

Learn and practice breakthrough pain calculations

A
36
Q

How often are the different Buprenorphine patches used?

A

Every 7 days:
- Butec, Butrans, Bupramyl, Sevodyne, Reletrans, Panitaz

Every 4 days (96hrs):
- Transtec, Relevtec, Buplast, Bupeaze

Every 3 days (72hrs):
- Hapoctasin, Prenotrix

37
Q

What is a good tip for how often patches are put on for?

A

5mcg patches are usually 7 days

35mcg patches are usually 4 days

38
Q

What must be done for Methadone?

A
  • It should not administered more than twice a day due to risk of accumulation and opioid overdosage
  • Patients who miss 3 or more days are at risk of overdose due to tolerance. So their dose must be reviewed.
  • Less sedating than morphine
39
Q

What patient n carer advice must be given for Methadone?

A
  • Driving counselling
40
Q

What must be known for Opioids?

A

Oxycodone:
- Main use is pain control in palliative care

Pethidine:
- Prompt but short lasting analgesia
- Less constipating than morphine

Tramadol:
- Analgesia by opioid effect and enhancement of seratogenic n adrenergic pathways

41
Q

What causes Neuropathic pain?

A

Damage to neural tissue (phantom limb pain, trauma, central pain)

42
Q

What can be used to treat Neuropathic pain?

A
  • Amitriptyline, Nortriptyline
  • Pregabaline
  • Gabapentin
  • Tramadol
  • Lidocaine plasters
  • Capsaicin cream - burning sensation can occur during initial treatment and limit use
43
Q

What is used for the treatment of acute migraine?

A
  • Aspirin, paracetamol (soluble) are usually effective
  • Offer 5HT1 receptor agonist (triptan) if above meds inadequate
  • Tofenamic acid is licensed specially for migraine attacks
  • Other NSAIDs (diclofenac potassium, flurbiprofen & ibuprofen) also licensed for it.
  • Antiemetic may be needed
44
Q

What can excessive use of Migraine medications cause?

A

Overuse headaches

45
Q

Give examples of 5HT receptor agonists?

A
  • Almotriptan
  • Eletriptan
  • Frovatriptan
  • Naratriptan
  • Rizatriptan
  • Sumatriptan
  • Zolmitriptan

If one is ineffective, try another one

46
Q

When is 5HT receptor agonists used?

A

When conventional analgesics is not effective.

47
Q

Which 5HT receptor agonists can be used to treat cluster headaches?

A

Sumatriptan or Zolmitriptan

48
Q

Which migraines can 5HT receptor agonists not be used for?

A
  • Hemiplegic
  • Basilar
  • Ophthalmoplegic migraine
49
Q

What is an example of Ergot Alkaloids?

A

Ergotamine tartate

50
Q

Why is the use of Ergotamine tartate minimal?

A
  • Difficulties in absorption
  • Has side effects of N&V, Abdo pain and muscular cramps
  • Cannot repeat treatment at intervals of less than 4 days.
  • Cannot use more than twice a month (prevents habituation)
51
Q

What can be used as Nausea & Vomiting for Migraine?

A

Antiemetics such as metoclopramide, domperidone, phenothiazine or antihistamines emetics

Give emetics I.M or rectally, if vomiting is a problem

52
Q

Which patients can be give preventative treatment for Migraines?

A
  • Suffer two or more attacks a month
  • Suffer increasing frequency of headaches
  • Suffer significant disability despite suitable treatment for migraine attacks
  • Cannot take suitable treatment for migraine attacks
53
Q

Which medications are used in migraine prevention?

A
  • Beta blockers (propranolol, atenolol, metoprolol, nadolol, timolol.
  • TCAs
  • Gabapentin
  • Topiramate
  • Sodium valproate
  • Pizotifen (can cause weight gain)
  • Botulinum toxin type A (only for chronic migraines in adults)
54
Q

What can be used to treat Cluster headaches & Trigeminal autonomic cephalagais?

A
  • Sumatriptan by SC injection (this is the drug of choice in treatment of cluster headaches)
  • Sumatriptan nasal spray or Zolmitriptan can be used, if injection is not suitable - unlicensed
  • 100% oxygen at a rate of 10-15L/min for 10-20mins is useful in aborting an attack
55
Q

When is the prevention of Cluster headache considered?

A
  • Attacks are more frequent
  • Last for more than 3 weeks
  • Cannot be treated effectively
56
Q

What medications are used for the prevention of Cluster headaches?

A
  • Verapamil or lithium (unlicensed)
  • Prednisolone (short term)
  • Ergotamine tartate (short term)

CNS (14 decks)

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