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Prescribing PSA / Management > Pain management > Flashcards

Pain management Flashcards

1
Q

What risk is associated with concomitant oxycodone and amitriptyline use? What are the signs of this risk?

A

Increases the risk of serotonin syndrome
o Confusion, hallucinations, extreme changes in bp, tachycardia, shivering, heavy sweating, nausea, diarrhoea, coma, death

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2
Q

Prescribe the safest analgesia in pts w/ chronic liver disease. Why are other analgesics not safe?

A

Paracetamol 500mg PO qds

  • NSAIDs may further increase bleeding risk on top of already having clotting abnormalities from the liver disease
  • Opioids may precipitate hepatic encephalopathy
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3
Q

Which NSAIDs have increased/lower risk of GI toxicity?

A
  • COX-1 inhibitors > COX-2 inhibitors (celocoxib, etoricoxib)
  • In terms of COX1/2 inhibitors: Aspirin/ketorolac > ibuprofen
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4
Q

When is ibuprofen not recommended?

A

High dose ibuprofen (≥2400 mg/day) should be avoided in ischaemic heart disease, peripheral arterial disease, cerebrovascular disease, congestive heart failure (NYHA II-III) and uncontrolled hypertension.

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5
Q

What’s the equivalent dose of 50mg of dihydrocodeine as codeine?

A

50mg if the dihydrocodeine was po, or 100mg if it was injected

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6
Q

What are the Sx of local anaesthetic toxicity?

A

o Mild -> tingling around mouth/extremities, metal taste, visual disturbance
o Moderate -> altered consciousness, convulsions
o Potentially fatal -> dysrhythmias, cardiovascular collapse, respiratory distress

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7
Q

What are the common co-codamol doses and what’s the max dose per day?

A

Codeine(mg)/paracetamol: 8/500, 15/500 or 30/500 po

Max dose dictated by paracetamol = 2 tabs QDS (4g/day)

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8
Q

What route is buprenorphine given?

A

Transdermal patches

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9
Q

How do you convert from codeine/tramadol to morphine?

A

Add up total in day and divide by 10 (as it’s 10 times weaker than morphine)

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10
Q

Give 4 examples of weak opiates

A

Codeine
Dihydrocodeine
Tramadol
Low dose buprenorphine

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11
Q

What’s the dose of po AND iv paracetamol for adults <50kg?

A

PO: Max 2 g in 24 hours (i.e. 500 mg every 4-6 hours)

IV: 15mg/kg over 15 mins every 4-6hrs, max 60mg/kg in 24 hours (i.e. up to 4 doses)

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12
Q

Give 3 examples of co-analgesics (i.e. paracetamol with something). What’s one thing you need to be wary of when giving these specifically (compared to other analgesics)?

A

o Co-dydramol: 10/20/30mg dihydrocodeine with 500mg paracetamol
o Co-codamoml: 8/15/30mg codeine with 500mg paracetamol
o Tramacet: 37.5mg tramadol with 325mg paracetamol

o BEWARE of increasing sodium

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13
Q

How much codeine can be given a day? What’s the equivalent in morphine?

A

120mg/day po == 12mg morhpine

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14
Q

In general, how do you convert dosages between opiate pain reliefs?

A
  • Convert to equivalent daily oral morphine (oramorph)

- 2 ppl (or person + conversion chart) to calculate converted dose

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15
Q

When is oxycodone useful to use? And when not?

A

eGFR 30-60

But avoid in severe renal impairment!

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16
Q

What are the 2 preparations of morphine? Give 2 examples of each

A

Immediate release

  • Oramorph liquid
  • Sevredol tablets

Sustained release (tablets/capsules)

  • Zomorph / MSL
  • MXL
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17
Q

What pain relief class for muscle pain/spasm? Give an example

A

Relaxant e.g. diazepam

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18
Q

How do you start someone on morphine?

A
  • ~ start on immediate release oral morphine sulphate
  • Start at 2.5-5mg po 4 hourly prn
  • If been on max codeine, can start on 10mg po 4 hourly prn instead
  • Then convert to modified release twice/day

NB when starting a PCA in an opioid naïve pt, also prescribe naloxone as required in case of respiratory depression

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19
Q

What’s the equivalent dose of 50mg of codeine as dihydrocodeine?

A

50mg po

or 25mg injected

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20
Q

Describe the steps of the WHO pain ladder

A

1: non-opioid e.g. paracetamol
2. weak opioid e.g. codeine + non-opioid
3. strong opioid e.g. morphine + non-opioid

+ at any stage: adjuvant analgesia if required e.g. anticonvulsant / antidepressant

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21
Q

What’s 12mg/day morphine converted to oxycodone po? and sc?

A

12mg oramorph ->
6mg oxycodone po ->
3mg oxycodone sc

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22
Q

What must you advise pts taking opioids (i.e. regards side effects)? How can you combat side effects?

A
  • Constipation -> laxatives
  • Drowsiness -> ~ resolves w/in 24-48hrs / lower dose (ILLEGAL TO DRIVE 24hrs after taking / 48hrs after dose change)
  • Nausea -> ~ resolves / anti-emetic (cyclizine / metoclopramide)
  • Inform of signs of toxicity (confusion, hallucinations)
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23
Q

What are the constituents of epinephrine? How do the constituents alter the effect?

A

Lidocaine and adrenaline

Adrenaline diminishes local blood flow -> slows rate of absorption -> prolongs anaesthetic effect

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24
Q

What pain relief for diabetic neuropathy?

A

SNRI e.g. duloxetine

  • Carbamazepine off-label
  • Possibly capsaicin cream
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25
Q

What pain relief classes for neuropathic pain? Give 2 examples of drugs

A

TCA e.g. amitripytyline

Anticonvulsant e.g. pregabalin / gabapentin

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26
Q

How do NSAIDs like aspirin increase bleeding risk?

A
  • COX-1 inhibition -> prevents platelet aggregation for ~ 7d (platelet lifespan) -> reduced clotting
  • Suppress prostaglandins, which ~ protect GI mucosa -> GI ulceration
  • Also damage mucosa in other ways (irritant, impaired barrier function, reduced blood flow, interfere w/ repair)
  • Can make pre-existing GI ulcers bleed
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27
Q

When do you consider switching opiate? What measures can you try to avoid switching?

A

Try antiemetics, laxatives, reducing dose, adding in adjuvants like pregabalin

Switch if persistent confusion, drowsiness, nausea, nightmares, itch, toxicity due to renal impairment (if not fluid responsive), still in pain

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28
Q

1st line drug for trigeminal neuralgia

A

Carbamazepine

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29
Q

How do you convert morphine to oxycodone?

A

Oxycodone is stronger than morphine

PO Oramorph -> /2 -> PO Oxycodone -> /2 -> SC Oxycodone

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30
Q

How long can fentanyl patches be left on?

A

Usually 72 hours

Occasionally 48 hours

31
Q

When is diclofenac contraindicated?

A

ischaemic heart disease, peripheral arterial disease, cerebrovascular disease and congestive heart failure (NYHA II-IV)

32
Q

2 examples of COX-1 inhibitors and 4 examples of non-selective NSAIDs

A

COX2: celecoxib and etoricoxib

Non-selective (i.e. both COX1 and COX2): diclofenac, ibuprofen, aspirin, naproxen

33
Q

What’s 80mg/day codeine converted to morphine?

A

10x weaker

so 8mg morphine

34
Q

Give 2 examples of local anaesthetics

A

Lidocaine

Bupivacaine

35
Q

How much weaker are codeine and tramadol than morphine?

A

10x weaker

i.e. 100mg tramadol = 10mg morphine

36
Q

Give 3 examples of non-pharmacological methods of treating pain

A

Acupuncture, physio, psychological therapy, pain management programmes, self-management tools, transcutaneous electrical nerve stimulation (TENS)

37
Q

When is buccal/sublingual fentanyl useful? How long does it take to have effect?

A
  • Incident pain i.e. predictable pain (e.g. painful ulcer going to be dressed / bony mets give you pain on walking)
  • You can give it 20mins before e.g. the ulcer is dressed
38
Q

How is local anaesthetic toxicity managed?

A

 Stop ongoing LA infusions
 Resuscitate through ABCDE (Maintain oxygenation, stop convulsions, support circulation)
 Cardiopulmonary resuscitation if cardiovascular collapse
 Intralipid infusion used sometimes by anaesthetists

39
Q

How does clopidogrel increase bleeding risk?

A
  • Irreversibly inhibit platelet aggregation -> reduced clotting
40
Q

How long does it take for paracetamol to reach peak concentration?

A

30-60 mins

41
Q

How long do fentanyl patches take to have effect? What do you need to do in the meantime?

A
  • About 24hrs

- Continue other opioids 8-12hrs after starting patch, until patch starts working

42
Q

What are the 3 main classes of adjuvants for pain relief? Give 2 examples of each

A

Antidepressants

  • TCAs like amitriptyline
  • SNRIs like duloxetine

Anticonvulsants
- Carbamazepine, gabapentin, pregabalin, lamotrigine

NMDA-receptor anatagonists
- Amantadine, ketamine, magnesium, methadone

43
Q

What are the doses that oramorph comes in?

A

Available as:

  • 10mg/5mls
  • concentrated: 20mg/1ml
44
Q

How can morphine be given if unable to swallow? How do you convert the dose from oral morphine?

A

Parenteral morphine

  • SC morphine sulphate injection (NB IM is painful)
  • Can set this up as an infusion (CSCI (continuous SC infusion))
  • Half the daily dose given over 24 hrs

Also:

  • fentanyl patches
  • buccal/sublingual fentanyl
  • parenteral sc diamorphine (divide morphine dose by 3)
  • parenteral sc alfentanil (BEWARE 30x stronger than morphine)
45
Q

Which pain meds should be avoided in severe renal impairment and why? Which are ok to use?

A

Avoid:

  • Build up of toxic metabolites
  • Codeine and Oxycodone
  • Modified release preparations bc will have much longer T1/2 bc of renal impairment so increased risk of overdose

Ok to use:

  • Oxycodone if eGFR 30-60
  • Fentanyl / butrans patch
  • Parenteral alfentanil
46
Q

Who needs a different to “normal” dose of paracetamol? What measures can be used to try avoid errors?

A
  • Neonates and children; prescribe in mg not ml in hospital, be exact about dose and volume to parents, use dosing table for IV administration and only use the 50ml vials
  • <50kg
  • Active liver disease / heavy alcohol intake
  • IV administration
47
Q

List 4 advantages of tramadol

A

 When NSAIDs contraindicated
 Chronic / neuropathic pain
 Causes less respiratory depression
 Less constipating

48
Q

Signs of opioid toxicity

A 
Sedation
Confusion
Hallucinations
Myoclonic jerks
Pinpoint pupils
Coma

Respiratory depression if taken an overdose

49
Q

Give 3 risk factors which need to be considered when giving epidural analgesia

A

impaired coagulation, infection, compromised immunity, cardiovascular instability

50
Q

Main differences of risks between COX-1 and COX-2 inhibitors?

A
  • COX-1: More GI toxicity
  • COX-2: Lower risk of GI toxicity with short-term use (although not absolutely no risk)
  • COX-2i and “traditional” NSAIDs (like aspirin/ibuprofen) have increased risk of cardiovascular events
51
Q

When would you consider giving a PPI in addition to an NSAID?

A

o Older adults, previous peptic ulcer disease/GI complaints
o Concomitant SSRIs, steroids
o Long term NSAIDs

52
Q

What route can codeine be given? What route should it not be given and why?

A

PO or IM

NOT IV bc of anaphylaxis risk

53
Q

Give 3 uses for acupuncture recommended by NICE

A

o Frozen shoulder, lower back pain, tennis elbow, osteoarthritis
o Headache, migraine
o Peripheral neuropathies, sciatica, trigeminal neuralgia
o Peripheral vascular disease

54
Q

How do you convert from codeine to dihydrocodeine?

A

Same strength po

Injected dihydrocodeine is twice as strong, so divide codeine dose by 2

55
Q

When are fentanyl patches useful?

A
  • Stable pain ONLY
  • Poor oral absorption e.g. bowel obstruction (metastatic ovarian Ca), head/neck Ca
  • If difficulty with constipation on morphine
56
Q

What programme is used in treating pain? Very, very briefly describe it

A

Pain management programmes (PMP)

group-based rehabilitation to patients with chronic pain, ~ cbt

57
Q

What pain relief class for bone pain?

A

NSAID +/ opiate +/ bisphosphonate +/ calcitonin

58
Q

What’s the common dose of tramadol? How much morphine is this? How much can be given/day?

A

50-100mg QDS po
i.e. 5-10mg morphine

Max 400mg/24hrs i.e. 100mg QDS i.e. 40mg morphine/day

59
Q

Give 5 methods to help decrease risk of dependence and addiction to opioids

A

o Discuss risks of prolonged use with pt (dependence, addiction, tolerance, fatal overdose)
o Develop tx plan, including when tx will end, before starting
o Provide regular monitoring
o Taper dosage slowly when stopping to reduce risk of withdrawal
o Sign-post pts to resources like Patient Information Leaflet

60
Q

When do you uptitrate morphine and by how much?

A
  • After 24hrs can consider increasing by 1/3-1/2 if pain not 90% relieved
  • Can add breakthrough doses to total/day if >2 breakthrough doses/day
61
Q

Give 4 examples of strong opiates

A 
Morphine
Diamorphine
Hydromorphone
Fentanyl
Oxycodone
Alfentanil
High dose buprenorphine
Methadone
62
Q

What are some relative / absolute contraindications to NSAIDs in general? Briefly explain why

A

o AVOID if on warfarin or other anticoagulants (bleeding risk)
o May worsen asthma
o AVOID in severe liver disease (bleeding risk, fluid retention, renal blood flow reliant on prostacyclins (which are reduced by NSAIDs)
o Avoid or use with caution in compromised renal function

63
Q

3 contraindications to codeine

A

o Severe renal impairment bc of risk of build up of toxic metabolites
o NOT recommended <12yo bc of overdose risk in fast metabolisers (CYP450 -> different analgesic response depending on fast or slow metabolisers)
o NOT for <18yo for tonsillectomy, adenoidectomy or sleep apnoea

64
Q

Normal dose of aspirin for pain relief?

A

PO: 300-900mg every 4-6 hours, max 4g/24hrs

65
Q

What pain relief class for nerve compression and increased oedema/ICP?

A

Steroid

66
Q

Give 3 contraindications to using TENS

A

 Over pregnant uterus
 At anterior aspect of neck (carotid sinus)
 Over allodynic, insensate or broken skin
 Older demand pacemaker
 Epilepsy or heart rhythm disorder (speak to doctor first)

67
Q

What’s the normal dose and max dose of oral and IV paracetamol if >50kg?

A 
4 g (or 8 X 500 mg tablets) in a 24 hour period
Dosing should not exceed four times a day (4g), leaving at least 4‒6 hours between each dose

Same IV, give over 15mins

68
Q

Risk specific to aspirin?

A

AVOID aspirin if <16yo (Reye’s syndrome)

69
Q

How do you calculate breakthrough dose for morphine? How often can you give this? What’s the best preparation?

A
  • Add up total in 24hrs and divide by 6
  • Can be given up to every 4 hours prn for breakthrough pain
  • Ideally a fast acting preparation like immediate release morphine sulphate tablets
70
Q

Give 3 routes local anaesthetic can be given

A

Epidural block
Peripheral nerve block
Surface anaesthesia (topical)

71
Q

Give 3 common complications of epidural analgesia

A

hypotension, respiratory depression, motor block, urinary retention, inadequate analgesia, pruritis

72
Q

What’s 75mg/day tramadol converted to morphine?

A

10x weaker

so 7.5mg morphine

73
Q

List 4 disadvantages of tramadol

A

 Severe n&v
 No analgesic effect in some pts
 Caution in epilepsy
 Non-formulary in some NHS trusts

Prescribing PSA / Management (8 decks)

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