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WEEK 3 - PAIN

PAIN AND ANALGESICS LADDER

ANALGESICS
Opioid / Narcotic / Morphine Non opioid / Non-narcotic /
like analgesics
Aspirin like analgesics

WEEK 3 - PAIN
PAIN

MOA

Salicylate
ASPIRIN

NSAIDS

Propionic acid
IBUPROFEN
NAPROXEN
Heteroaryl
acetic acid
Diclofenac

blocks prostaglandin
synthesis at the
thermoregulatory
centres in the
hypothalamus and at
peripheral target sites
Aspirin may also supress
pain stimuli at subcortical sites (thalamus
and hypothalamus).

blocking cyclooxygenase (COX) and


hence prostaglandin
synthesis

INDICATIONS
anti-inflammatory, anti-pyretic
and analgesics effects
Chronic Inflammation
RA
Severe OA
Chronic back pain
Acute injury with Inflammation
Dysmenorrhoea
Pain from lytic bone
metastases

OPIODS

MORPHINE

exert their effects by binding


to and activating the DIAMORPHINE/ opioid receptor
HEROIN

GI symptoms /
peptic ulcer disease
Liver or renal
impairment
Asthmatic with
aspirin sensitivity
Coagulation
disorders /
treatment

Aspirin should be
avoided in pregnancy
and during lactation

GI disturbances
Skin reactions
Fluid retention
worsening of CF
Renal effects

Less intense than


aspirin in term of GI
effects propionic acid

INTERACTIONS

RA, OA and Ankylosing


Spondylitis
Ophthalmic preparation

CODEINE

ADVERSE EFFECTS

Acts at receptors which


cause spinal analgesia,
psychotomimetic effects,
slow GI transit

CONTRAINDICATIONS

Relef of Pain Ischaemic


pain, visceral pain, palliative
pain
Pre-anaesthetic medication
Symptomatic treatment of
Diarrhoea
Acute Left ventricular
failure

Cough
Severe pain of cancer

5H

Hypotension
Hepatic disease
BPH
Head injury

3B
Bronchial asthma
Biliary colic
Babies & elderly

Respiratory
depression
Sedation
Euphoria
Pupil constriction
Nausea & vomiting
Reduced gut
motility
Constipation
Pruritis
Hypotension
Bronchospasm
Urinary retention

Oral anticoagulants
Lithium
antiHPT
digoxin
phenytoin with
ibuprofen
MTA
Insulin with
salicylates
Antacids with
naproxen sodium or
salicylates
Probenecid with
naproxen

TCA,
Phenothiazines,
MAO Inhibitors
potentiate
morphine
Morphine retards
absorption of many
orally administered
drugs by delaying
gastric emptying

N-OPIATE
OPIOID

WEEK 3 - PAIN

Tramadol

PARACETAMOL

GABAPENTIN

exert their effects by binding


to and activating the opioid receptor

Moderate to moderately
severe pain

Analgesic / Antipyretic
Substitute aspirin for those
with gastric complaints
Children w/ viral infection
or chickenpox

Inhibits prostaglandin
synthesis in the CNS
Metabolized by Liver
can cause hepatic
toxicity

Acts on Ca channels

STEP 1
PRN/Regular paracetamol and
PRN/regular NSAID (if safe)

Patients on MAOi

Hepatic disease,
viral hepatitis
Alcoholism

Neuropathic pain

STEP 2
Regular paracetamol and
regular NSAID (if safe)
PRN weak opiate i.e. Codeine

STEP 3
Regular paracetamol and regular
NSAID (if safe)
Regular weak opiate i.e. Codeine
PRN opiate for breakthrough pain
i.e. Oramorph

SSRI
TCA
Renal tubular necrosis
Virtually free of any
significant adverse
effects

Alcohol

Benign side effect


profile

STEP 4
Regular paracetamol and
regular NSAID (if safe)
Regular opiate i.e. Oramorph
PRN opiate for breakthrough
pain i.e. Oramorph

STEP 5
REFER TO ACUTE PAIN SERVICE