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Therapeutics > Pain Management > Flashcards

Pain Management Flashcards

1
Q

What are the types of pain?

A

Acute

Chronic- nociceptive, neuropathic (central/peripheral), visceral and mixed

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2
Q

What are some examples of nociceptive and neuropathic pain?

A

Nociceptive- osteoarthritis, rheumatoid arthritis
Neuropathic central- post stroke, MS, spinal cord injury, migraine, HIV related
Neuropathic peripheral- post hepatic neuralgia, diabetic neuropathy

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3
Q

What are some examples of mixed pain?

A

Lower back
Cancer
Fibromyalgia

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4
Q

What are some examples of visceral pain?

A

Internal organ
Pancreatitis
IBS

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5
Q

What are the goals for treating post-surgical pain?

A

Patient comfort and satisfaction
Easier mobilisation
Reduce hospital stay and costs

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6
Q

What are the goals of treating pain generally?

A

Minimise stress response/neuroendocrine effects

Minimise adverse effects on respiratory, cardiovascular, GI, urinary and musculoskeletal systems

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7
Q

What is the WHO pain ladder?

A

Step 1- simple analgesics e.g aspirin, paracetemol
Step 2- opioids suitable for mild to moderate pain and simple analgesics
Step 3- opioids suitable for use in severe pain and simple analgesics

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8
Q

How much paracetamol has to be taken for liver damage?

A

14 tablets

Treatment with acetylcysteine

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9
Q

How do NSAIDs work?

A

Inhibit COX responsible for arachidonate metabolism of cyclic endoperoxides, preventing formation of prostaglandins and thromboxanes
Analgesic, antipyretic, anti-inflammatory

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10
Q

What are the adverse effects of NSAIDs?

A

GI tract- GIT erosion and ulceration
Renal- reduced blood flow, acute failure, sodium, potassium and water retention
Respiratory- bronchospasm
Haematological- reduce platelet aggregation (aspirin irreversible, NSAIDs reversible)

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11
Q

What should you take precaution with when prescribing NSAIDs?

A

Used at lowest effective dose, shortest period of time, regular review
Co-prescription of PPI
No support to use coxs alone before NSAIDs and PPI

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12
Q

What are examples of weak opioids?

A

Codeine
Dihydrocodeine
Dextropropoxyphene
Tramadol

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13
Q

What are examples of strong opioids?

A 
Morphine
Diamorphine
Oxycodone
Buprenorphine 
Fentanyl
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14
Q

When are weak opioids most effective?

A

When used in combination with paracetamol

Available as combination products

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15
Q

How is codeine metabolised to morphine?

A

Cap P450 2D6
10% caucasian population unable to convert
90% Chinese population unable to convert

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16
Q

What are the adverse effects of opioids?

A 
Nausea and vomiting 
Constipation 
Sedation 
Respiratory depression 
Hypotension 
Urinary retention
17
Q

What needs to be considered when initiating morphine?

A

Pain assessment, current analgesia
Determine opioid requirement (short acting preparation regularly plus PRN)
Convert total daily dose to MR formulation (i.e taken every 12 hrs)

18
Q

What is breakthrough pain?

A

Transient exacerbation or recurrence of pain in patient who has mainly stable or adequately relieved background pain
End of dose failure
Incident pain
Spontaneous, unpredictable pain
10% total daily regular dose prescribed PRN

19
Q

What needs to be considered when converting to an alternative opioid?

A

Determine 24 hr requirement
Use conversion factor for alternative opiate to determine new 24 hr requirement
Convert to appropriate dosage regimen

20
Q

What are opioid equivalencies?

A

Morphine (po) 60mg
Hydromorphone (po) 9.8mg
Oxycodone (po) 30mg
Fentanyl (transdermal) 25 Microg/hr

21
Q

What are IM opioids?

A

Prescribed 4 hourly
Takes several doses to achieve adequate levels
Variable absorption
Painful- SC route preferred

22
Q

What drugs are used for patient controlled analgesia?

A

Morphine IV is the drug of choice (1mg bolus, 5 minute lock-out typical settings)
Tramadol, oxycodone or fentanyl if morphine allergy

23
Q

What are the advantages of patient controlled analgesia?

A 
Rapid analgesia once pain at steady state 
Ready prepared
Patient satisfaction 
No dose delay
Patient acceptability 
No peaks or troughs
24
Q

What are the disadvantages of patient controlled analgesia?

A

Expensive
Requires IV access
Training
Monitoring

25
Q

What are epidural opioids?

A

Alternative to PCA esp in maternity, lower limb, spine or abdominal surgery
Mixture of local anaesthetic and opioid usually
Act synergistically
Commonly fentanyl with (levy)bupivicaine
Respiratory depression less likely due to lipophilicity of fentanyl
Adverse effects- hypotension, wrong route infection

26
Q

What are the indications for syringe drivers?

A

Unable to take medicines by mouth (N&V, dysphagia)
Bowel obstruction
Patient does not wish to take regular medication by mouth

27
Q

what is the optimal choice for syringe drivers?

A

Diamorphine due to excellent aqueous solubility

28
Q

What other drugs can you mix in syringe drivers?

A

Haloperidol, cyclizine (N&V)
Levomepromazine, midazolam (restlessness and confusion)
Midazolam (seizures)
Hyoscine N-butylbromide (excessive respiratory secretions)

29
Q

What needs to be monitored during opioid therapy?

A 
Pulse 
BP
Respiration rate
Oxygen saturation 
Pain intensity
Sedation score
Opioid usage
Opioid side effects
30
Q

What is tramadol?

A

u agonist (30% of analgesic effect)
Inhibits noradrenaline uptake and 5-HT release
70% absorbed po (peak = 2 hours)
Less pronounced opioid side effects (constipation)
More pronounced side effects (nausea and hallucinations), although evidence not convincing

31
Q

What is naloxone?

A

Opioid antagonist
Higher affinity for opioid receptor than agonist
Short half life when given IV (therefore may need repeat doses)
May induce pain
Titrate gradually until effect is achieved

32
Q

What are the symptoms of neuropathic pain?

A 
Burning 
Electric shock
Pins and needles
Scalding 
Shooting 
Srabbing
33
Q

What are the signs of neuropathic pain?

A

Continuous v evoked
Hyperalgesia (brush evoked, pressure evoked, punctate)
Allodynia

34
Q

What are the pharmacological treatments for neuropathic pain?

A 
Tricyclic antidepressants 
Anticonvulsants (carbamazepine, gabapentin, pregabalin)
Opioids
Local anaesthetics
Capsaicin
35
Q

Why are tricyclic antidepressants limited in neuropathic pain?

A

Side effects within hours but analgesic effect may not be seen for several weeks
Adverse effects minimised by starting with low dose and small incremental changes

36
Q

Which anticonvulsants are used for neuropathic pain?

A

Gabapentin and pregabalin
Prevent voltage dependent Ca2+ channel activation in dorsal horn neurones
Do not affect voltage gated Na+ channels
Fewer adverse effects than anticonvulsants

Therapeutics (17 decks)

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