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Clinical pharmacology and therapeutics > Pain management > Flashcards

Pain management Flashcards

1
Q

Why should you not mix types of opioids?

A

Difficult to assess which is causing the side effects, titrate the dose and difficult to determine which is effective

Increases side effects due to different side effect profiles

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2
Q

List some examples of NSAIDs

A

Naproxen

Ibruprofen

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3
Q

List some examples of opioids

A

Tramadol
Codeine in co-codamol
Fentanyl

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4
Q

List some ant epileptic neuropathic pain agents

A

Pregabalin

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5
Q

List some antidepressent neuropathic pain agents

A

Amitriptyline

Duloxetine

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6
Q

Name a benzodiazepine

A

Diazepam

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7
Q

What must you do if a drug is ineffective?

A

Stop the drug

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8
Q

Which acryonm is use in essential pain management?

A

Recognize
Assess
Treat

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9
Q

What challenges may you face in recognizing a person has pain?

A

Does this person have pain?
May have learning difficulties or dementia or may not be able to communicate effectively
Look for subtle signs

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10
Q

What can change how we perceive pain?

A 
Culture 
Beliefs
Psychological factors 
Other illness 
Personality 
Social factors
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11
Q

How do you assess pain?

A

SOCRATES

Verbal or visual rating scale

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12
Q

Why is it important to assess pain?

A

Affects treatment

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13
Q

What is visceral pain?

A

Pain felt in organs that are sensitive to stretch, ischaemia and inflammation

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14
Q

Give some examples of somatic pain

A

Broken bones

Muscle sprains

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15
Q

What pain do peripheral nerve blocks help with?

A

Somatic pain

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16
Q

What pain do central nerve blocks help with?

A

Visceral pain

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17
Q

How does inflammatory pain present?

A

Throbbing, aching, localised to the affected area

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18
Q

Which drugs work best on inflammatory pain?

A

NSAIDs

Paracetamol

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19
Q

How does nociceptive somatic pain present?

A

Sharp pain and localised to the area

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20
Q

Which drugs work best on nociceptive somatic pain

A

NSAIDs
Opioids
Paracetamol

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21
Q

How does nociceptive visceral pain present?

A

Deep, aching, poorly localised and cramping pain

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22
Q

Which drugs work best on nociceptive visceral pain?

A

NSAIDs
Paracetamol
Opioids
Neuropathic agents

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23
Q

How does neuropathic pain present?

A

Shooting, burning, hypersensitive, tingling, numbing pain

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24
Q

Name some treatments for migraines

A

Triptans
Propranolol
Pizotifen

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25
Q

Name some treatments for trieminal neuralgia

A

Carbamazepine

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26
Q

What class of drug is triptan?

A

5HT1 receptor agonist

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27
Q

What class of drug is pizotifen?

A

antihistamine

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28
Q

What drugs are used to treat mixed neuropathic and nociceptive pain?

A

Multimodal approach

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29
Q

Describe acute pain

A

Warning sign or injury
Well defined onset <6 months
Responds well to treatment - should be treated promptly and stepped up readily
Generally produces anxiety
Often associated with physical sins - tachycardia, tachyponea and decreased immunity and well being

30
Q

Describe chronic pain

A

Persists beyond expected healing time
May or may not have defined onset
Often difficult to treat - better to prevent
Can have psychological element
Pain signals remain active in nervous system for weeks or months or years
Progressive physical deterioration
Impacts on quality of life

31
Q

What pain management does acute pain respond well to?

A

Conventional analgesics - Paracetamol, NSAIDs, opiods

32
Q

What pain management does chronic pain respond well to?

A

Neuropathic agents
Psychological therapies
Pain education
Non pharmacological treatments

33
Q

Describe how acute on chronic pain should be treated

A

Short term treatment with conventional analgesics plus their regular analgesics
Can be complicated by increased tolerance and hypersensitivity to pain

34
Q

What are the simple analgesics?

A

NSAIDs

Paracetamol

35
Q

What are the opiods?

A

Weak or strong

36
Q

What are the neuropathic agents?

A

Anticonvulsants - gabapentin, pregabalin, carbamazepine

Antidepressants - amitriptyline, duloxetine

37
Q

Describe the WHO pain ladder for acute pain

A

Step 1 - non opioids
Step 2 - Mild opioids
Step 3 - Strong opioid
Step 4 - Nerve blocks, Patient controlled analgesia pumps

38
Q

Where do you start on the WHO pain ladder in surgical pain?

A

Start relative to pain severity and move down the ladder

39
Q

What is the usual dose of paracetamol

A

1g QDS PO/IV
If pt is <50Kg, 500mg QDS PO/IV
Max 15mg/KG IV

40
Q

What is the usual dose of ibruprofen?

A

400mg TDS PO

41
Q

What is the usual dose of naproxen?

A

250-500mg BD PO

42
Q

What is the risk of prescribing NSAIDs?

A

GI bleeds

Cardiovascular side effects

43
Q

Which is stronger: Naproxen or ibruprofen?

A

Naproxen

44
Q

What is the potency of NSAIDs linked to?

A

Increase in adverse effects

45
Q

What are the adverse effects of NSAIDs?

A

Renal - Prostanoid inhibitor - decreased renal blood flow, imbalance in vasodilation mechanism, ischemia and water/sodium retention

Reduced platelet aggregation - aspirin is an antiplatelet. - inhibitoin of COX2

Reyes syndrome in children (aspirin) - encephalopathy

Hypersensitivity and cross reactions

GI side effects - inhibition of COX 1 - Gastric ulcers

46
Q

Who should you take caution with prescribing NSAIDs in?

A

Asthmatics
Heart failure
Ascites

47
Q

What drugs do NSAIDs interact with ?

A

Warfarin
Methotrexate
Lithium

48
Q

What are the risk factors for GI side effects in NSAIDS

A 
Age >65 
Previous history of peptic ulcer 
Previous upper GI bleeding 
Dyspepsia 
Oral anticoagulant therapy 
Long term NSAIDs use for RA and OA
Excessive alcohol consumption 
Corticosteroid treatment 
Treatment dose heparin and LMWH
49
Q

If a patient has one or more risk factors for GI side effects while on NSAIDs what must you prescribe alongside the NSAID?

A

PPI

50
Q

Give an example of a PPI and dose

A

Lansoprazole 15mg OD

51
Q

What are weak opioids used for?

A

Moderate pain and anti - diarrhoal properties

52
Q

What is the first line weak opioid?

A

Dihydrocodeine 30mg every 4-6hrs

53
Q

What is codeine?

A

Pro-drug converted to morphine (CYP450-CYP2D6)

54
Q

What is the problem with codeine in comparison to dihydrocodeine

A

Codeine metabolites are more likely to accumulate

55
Q

Who must not be prescribe the full dose of codeine to?

A

Renal failure

Liver failure

56
Q

What are strong opioids used for?

A

Severe or moderate acute pain

57
Q

Name some strong opioids

A

Fentanyl
Morphine
Oxycodone

58
Q

Which patients require lower doses of strong opioids?

A

Renal impairment
Liver impairment
Elderly

59
Q

What is the strong opioid breakthrough dose?

A

1/6th - 1/10th the 24hr dose

60
Q

How does potency vary amongst opioids

A

Differs on the type of opioid and route

61
Q

If a strong opioid dose is ineffective how would you go about increasing the dose?

A

Increase by 30-50%

62
Q

What IV morphine does oral morphine equal

A

Oral morphine = IV morphine x 2

63
Q

What diamorphine sc does Oral morphine equal?

A

Oral morphine = SC diamorphine x 3

64
Q

What oral oxycodone does oral morphine equal

A

Oral morphine = oral oxycodone x 2

65
Q

What are the adverse effects of opioids?

A

Respiratory depression

Constipation

Nausea and vomiting

Sedation

Pruitius

Tolerance

66
Q

What must be prescribed alongside opioids

A

PRN Naloxone 100mcg IV/IM
Stimulant laxative such as senna
PRN antiemetics

67
Q

What is nefopam?

A 
Non opioid and non NSAID
Affects serotonin, dopamine and noradranaline uptake and glutamate release 
60mg TDS (30mg in elderly), titrated up to 90mg TDS as needed
68
Q

What are the side effects of nefopam?

A 
Nausea
Dizziness
Urinary retention 
Dry mouth 
Can turn urine pink
69
Q

What is nefopam contraindicated in?

A

Convulsive disorders

70
Q

Describe gabapentin

A

Neuropathic pain agent
Acts on voltage gated calcium channels, blocking neuronal influx of calcium and decreasing glutamate release
Opioid sparing so reduces side effects such as nausea and constipation

71
Q

What trial of gabapentin is usually given?

A

300m STAT - effects seen within 30 mins if effective

72
Q

Who requires a lower dose of gabapentin?

A

Renal impairment

Elderly

Clinical pharmacology and therapeutics (27 decks)

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