Pain relief

Question 1

if no pain?

Answer 1

PRN paracetamol 1g

<6 hourly

Question 2

mild pain?

Answer 2

regular paracetamol 1g 6 hourly
\+
PRN codeine 30mg
<6 hourly
(or tramadol)

Question 3

severe pain?

Answer 3

regular co-codamol 30/500
2 tablets 6 hourly
\+
PRN morphine sulphate titrate <10mg*
<6 hourly PO
(as Oromorph, S/C, or IV)

*start 2.5-5mg depending over patient

Question 4

what is the strength of Oromorph mostly used?

Answer 4

it comes in two strengths (the more concentrated is rarely used)

usually 10mg/5ml

Question 5

when to introduce an NSAID into the pain management ladder?

Answer 5

eg Ibuprofen 400mg 8 hourly

at any stage regularly or PRN if not CI

Question 6

Tx of neuropathic pain?

Answer 6

(ladder, check treatment summary)

1st line paracetamol

2nd offer a choice of

• amitriptyline 10mg nightly (but - anticholinergic S/E)
• pregabalin 75mg 12 hourly
• gabapentin 300 mg <3 times daily
• duloxetine

Question 7

Tx of painful DM neuropathy?

Answer 7

duloxetine

60mg PO daily

Question 8

common trap in paracetamol prescribing?

Answer 8

beware paracetamol and co-codamol given together (the level of pain dictates which to stop)

ensure no more than 4g a day given

Question 9

NSAIDs contraindications?

“NSAID” mnemonic

Answer 9

No urine (AKI)
Systolic dysfunction (HF!)
Asthma
Indigestion
Dyscrasia (abnormal platelets)

Question 10

if someone is flushed, N, V, GI problems and is taking tramadol?

Answer 10

SSRIs

taking both can lead to serotonin syndrome

Question 11

how to write up a prescription of modified release morphine sulphate?

Answer 11

morphine sulphate M/R (and brand name)

Question 12

max percentage increase of baseline morphine per day?

Answer 12

30-50 percent

Question 13

neuropathic pain in postherpetic neuralgia?

Answer 13

first-choice - paracetamol
then - amitriptyline if doesn’t work (various anticholinergic adverse effects (e.g. dry mouth, blurred vision, tachycardia, urinary retention)

Question 14

Sx opiate toxicity?

Answer 14

↓RR, ↓HR, ↓O2 sats, drowsy

Question 15

morphine in AKI?

what to give instead?

Answer 15

stop! accumulate

replace morphine with oxycodone (metabolised by the liver to inactive metabolites, good for strong analgesia in renal impairment)

morphine also hepatically metabolised, but metabolite (morphine 6-glucuronide - active and more potent than morphine) is renally excreted and accumulates

Question 16

paracetamol dose if <50kg?

Answer 16

500mg 6 hrly (rather than 1g)

Question 17

codeine in pregnancy?

Answer 17

no!