Palliative Care Flashcards
What is pain?
An unpleasant sensory & emotional experience associated with actual or potential tissue damage or described in terms of such damage.
Subjective phenomena with physiological, social and spiritual dimensions
Nociceptive somatic pain is the stimulation of:
Treatment?
peripheral receptors in skin bone joints and muscle.
It is a LOCALISED ache, throbbing, gnawing.
Good response from non-opioids and opioids
Nociceptive visceral pain is the stimulation of:
Treatment?
receptors in internal organs.
It is a poorly localised, deep ache
Good response from non-opioids and opioids
What is neuropathic pain?
What are the features/ types? e.g. shooting pain, etc?
What is the treatment?
Usually pain that arises from damage to peripheral nervous system.
Features: burning, sharp, itching, stabbing, shooting
More complex pain to treat. May need specialist advice. Adjuvant drugs are usually needed.
What is in Step 1 of the WHO ladder?
Non opioids
What is in Step 2 of the WHO ladder?
Weak opioids
What is in Step 3 of the WHO ladder?
Strong opioids
Give examples of non opioids
paracetamol
NSAIDS
Give examples of WEAK opioids
Codiene DHC Tramadol Buprenorphine \+ paracetamol
Give examples of STRONG opioids
Morphine Oxycodone Fentanyl Methadone Alfetanil \+Paracetamol
What can you give with weak/strong opioids?
+/- adjuvants, laxatives and anti-emetics (prevent vomiting)
What COX does Paracetamol inhibit in the CNS?
3
What is the safest NSAID?
Naproxen
How do NSAIDs work?
Inhibit prostaglandin synthesis. Inhibits the pain & inflammatory response
Mild to moderate pain treated with?
Give examples
Step 2 - Weak opioid + non opioid
e. g.
- Tramadol (combines weak opioid with SSRI effect)
- Paracetamol 500mg + Codeine 30mg combination
- Buprenorphine (usually transdermal)
Mild pain treated with?
Step 1 - Non opioid
e.g. NSAIDS.
naproxen is the safest - evidence based
Moderate to severe pain treated with?
1st line
2nd line
3rd line
Strong opioids
Morphine
Oxycodone, Fentanyl transdermal, Alfentanil. Diamorphine used occassionaly when need large dose of analgesia in small volume.
Methadone
If morphine is contraindicated e.g. due to intolerance, what do you give?
Switch to Oxycodone
What is breakthrough pain?
Sudden sharp / severe pain despite adequate background
analgesia. Can be due to incident e.g. movement, or spontaneous.
What is the onset of breakthrough pain?
What is the duration of breakthrough pain?
3 minutes
30 minutes
How do you treat breakthrough pain?
IR opioids e.g. oral morphine/ oxycodone liquid
Faster acting Fentanyls (FAFs) now available.
What is the dose for breakthrough pain?
1/6 total daily dose, given initial.
What is an alternative opioid analgesic for moderate-severe pain?
Benefits of Fentanyl Transdermal Patch over Morphine/ Oxycodone
Fentanyl transdermal patch
Less constipating
Reduces pill count, so increase compliance
Useful for patients with renal impairment.
Methadone is a 3rd/4th line opioid analgesic, useful for patients with:
- neuropathic pain
- renal impairment
- poor responders/ side effects to other opioids
Alfentanil is a 2nd line opioid sc injection, useful for patients with:
- renal impairment
- morphine/oxycodone intolerance
What is neuropathic pain caused by?
Damage caused by: - compression - chronic local inflammation - invasion by tumours. USUALLY REQUIRES ADJUVANT ANALGESIA.
NERVE BLOCKS MAY BE NECESSARY
When are TCAs such as amitriptyline used?
Useful if depression or insomnia is associated with pain
TCA’s are contradicted in patients with?
- Cardiac problems
- Prostate problems (OK if catheterised)
- Glaucoma
- Confusion/ fits
Which anticonvulsant interacts with oxycodone to cause increased drowsiness?
Pregabalin
Name two anticonvulsants used for neuropathic pain:
Gabapentin
Pregabalin
Which anticonvulsant should you avoid due to interaction profile with other drugs?
Carbamazepine
What is an alternative anti convulsant if 1st/ 2nd line choices are not effective?
Sodium valporate
Which anticonvulsant is useful if patient has: anxiety, muscle spasm, and sleep problems that coexist with the neuropathic pain?
Clonazepam
Name a corticosteroid used for pain?
Dexamethasone
How does Dexamethasone help in pain?
Reduces tumour mass/ pain due to compression
Reduce headache due to cerebral oedema
What drug helps reduce the rate of bone turnover and reduce cancer-related bone pain?
Biphosphonates
