1. Analgesia Quiz
By Clare Di Bona

2. Paracetamol dose should be reduced in which circumstances1. 2. 3.

3. Paracetamol dose is usually 1g 6hrly oral or IV
It should be reduced to 500mg 4hrly in:
Elderly
Significant liver dysfunction
Cachexia/low body weight (<45kg)
Severe alcoholism

4. High doses of paracetamol can increase the INR of patients on warfarin
TRUE or FALSE?

5. TRUE
Monitor INR closely when using regular Warfarin and high doses of paracetamol (>9.1g/week) as INR can increase

6. NSAIDs should always be prescribed routinely for simple analgesic requirements
TRUE or FALSE

7. FALSE
Not to be used as routine background analgesics
Use only in selected patients with good indications (bone pain, inflammation, somatic pain with poor response to other analgesics).
Should be prescribed with a time limit

8. List four categories of NSAID side effects and the nature of the side effects.1. 2. 3. 4.

9. Non-selective NSAIDs inhibit cox-1 and cox-2
GIT: by inhibiting cox-1 (non-selective) the prostaglandins responsible for gastric mucosal protection are also inhibited. This puts patients at risk of gastric ulcers and/or bleeding
Platelet: by inhibiting cox-1 (non-selective) this interferes with platelet function by inhibiting platelet aggregation
Cardiovascular: increased risk of cardiovascular events ie MI and stroke for both selective and non-selective. In post-MI patients, NSAIDs increase the risk of death and recurrent MI for at least 5 yrs after MI
Renal: Pre-existing renal impairement increases the risk of NSAID-induced impairement for both non-selective and selective NSAIDs.

10. It is reasonable in severe pain to use an opioid as a first line analgesic
TRUE or FALSE

11. TRUE
Certain conditions are known to be very painful ie renal colic and it may be reasonable to use opioid as a first line choice
Simple drugs such as paracetamol should be promptly added as these drugs have been shown to be opioid sparing and may improve the effectiveness of the opioid

12. It is reasonable to write two PRN options for oral opioid on the back of the medication chart
TRUE or FALSE

13. FALSE
You can only ever prescribe one opioid by one route as a PRN option
Combining opioids leads to additive side effects such as respiratory depression and sedation which can be fatal for some patients
It is reasonable to have tramadol plus an opioid as PRN

14. Name 5 opioid side effects1. 2. 3. 4. 5.

15. Opioid Side Effects

16. Which is a better determinant of opioid dose age or weight?

17. The best predictor of dosage is pain severity and age
The preferred PRN opioid for severe pain is oxycodone IR
<40yrs
Oxycodone IR 10-20mg 2hrly oral PRN
40-70yrs
Oxycodone IR 5-10mg 2hrly oral PRN
>70yrs
Oxycodone 2.5-5mg 2hrly oral PRN
IV opioids should only be used with EXTREME caution in the elderly

18. Give four opioid safety tips1. 2. 3. 4.

19. Opioid Safety Tips
If you are unsure about a drug dose/route/frequency please ask first!
Sedation is the first marker of opioid over use (sedation score goes down before respiratory rate)
Be especially careful in elderly, children, obese, those with respiratory disease (OSA, COPD) and renal impairement
Be aware of mixing sedatives especially benzodiazepines with opioids or mixing different types of opioids
Tramadol, tapentadol and gabapentin can accumulate in renal impairement
JHC policy that all people receiving up to 2hrly PRN opioids are reviewed routinely by nurses 1hr following the dose

20. At JHC the most common prescribing error is…
A) Giving the drug to the wrong patient
B) Giving the wrong drug
C) Prescribing a drug the patient is allergic to
D) Writing the wrong frequency for a drug

21. The most common medication error is prescribing a drug the patient is allergic to.

22. In regards to Migraine, give three non-pharmacological options for treatment1) 2) 3)

23. 1) avoidance of triggers: sleep deprivation, stress, bright lights, exercise, alcohol
2) environmental modification: sleep in a quiet dark room
3) well hydrated

24. In regards to pharmacological management of migraine give four categories/groups of drugs with an example for each 1. 2. 3. 4.

25. Migraine pharmacological treatment
1. Simple analgesia
Aspirin soluble mg repeat in 4hrs if required OR
Diclofenac mg repeat in 6hrs if required OR
Ibuprofen 400mg repeat in 6hrs if required OR
Naproxen 550mg repeat in 6hrs if required OR
Paracetamol soluble 1g 4hrly max dose 4g daily
2. Anti-emetic combined with IVH
Stemetil mg in 1L over 1hr or
Largactil 25mg In 1L over 1hr
3. Oral opioid+/- tramadol
Oxynorm 5mg 4hrly oral PRN +/- Tramadol mg 6hrly oral/IV PRN
4. Triptan are not recommended in hospital due to high recurrence of rebound headache
Sumatriptan mg ORAL (300max 24hrs) or intranasal 10-20mg (max 40mg in 24hrs)

26. Bob is 60yrs old he has severe loin pain
Bob is 60yrs old he has severe loin pain. He tells you its probable his kidney stones. Give four DDX 1) 2) 3) 4)

27. DDx for Renal Colic

28. The nurse passes you the medication chart asking for an intravenous opioid what will you write up?

29. Titrating IV opioids
Morphine 5-20mg titrated using 1mg bolus every 5 minutes OR
Fentanyl mcg titrated using 20mcg bolus every 5 minutes
Titrated to effect
Stopped if sedation or respiratory depression occur
IV route to be used with extreme caution in elderly as side effects less well tolerated

30. Doctor, please explain to me why some doctors use fentanyl and why others use morphine
Name 1 difference
Name 1 similarity

31. Fentanyl IV versus Morphine IV
Fentanyl is metabolised in the liver and suitable for patients with renal failure. Morphine is excreted renally and can accumulate in renal impairement
Fentanyl is shorter acting duration of action 0.5-2hrs versus morphine 4-6hrs
The adverse effects are similar to morphine but a slightly lower incidence of confusion and constipation

32. You have recommended Tamsulosin 400mcg daily for 2 weeks on discharge
You have recommended Tamsulosin 400mcg daily for 2 weeks on discharge. Bob asks you how does this medication work?

33. How does Tamsulosin work?
Blocks a1 receptors relaxing smooth muscle in the bladder neck and prostate, decreasing resistance to urinary flow.
Evidence that tamsulosin is superior in comparative to other smooth muscle relaxants in terms of increased stone expulsion and a reduction in analgesia requirements, surgical interventions, duration of hospital stay and days off work

34. List four non-pharmacological treatment options for musculoskeletal back pain1. 2. 3. 4.

35. Non-pharmacological options for back pain
Stay active: resting in bed will increase muscle stiffness. Staying active has been shown to increase the rate of recovery and decrease the time spent off work
Explanation and reassurance: Dispell myth that moving around when there is pain is dangerous. Dispell myth that analgesia will get rid of all the pain. Explain that most cases of back pain will resolve in 4-6 weeks. Focus on positive attitude
Work participation: early re-integration into the workplace plays an important role in recovery
Gentle exercises to strengthen spinal stabilising muscle is important. An outpatient physio follow-up should be arranged by the patient
Thermal therapies such as heat or cold may be transiently useful
Acupuncture may provide a small benefit in pain management

36. In regards to musculoskeletal back pain; true or false?
Patients should expect to have no pain in hospital after appropriate analgesia Patients should expect to have some kind of routine imaging of their back pain in hospital Red flags such as fever, loss of weight, trauma indicate possible serious cause of back pain other than musculoskeletal pain Oxynorm and diazepam are ideal medications for discharge Early re-integration into the workplace is important for recovery

37. In regards to musculoskeletal back pain; true or false?
Patients should expect to have some kind of routine imaging of their back pain in hospital FALSE Red flags such as fever, loss of weight, trauma indicate possible serious cause of back pain other than musculoskeletal pain TRUE Oxynorm and diazepam are ideal medications for discharge FALSE Early re-integration into the workplace is important for recovery TRUE

38. Doctor I need an MRI for my back pain. How will you respond to this?

39. Responding to requests for imaging in back pain
X-rays are rarely useful when there has been no history of significant trauma however they are a simple test that is often considered
CT scans are not routinely recommended as there is a high prevalence of disc abnormalities on CT in patients without back pain.
MRI is urgently needed only when there is symptoms/signs for spinal canal compression; saddle anaesthesia, poor anal tone, bladder incontinence/retention
CT can be considered in the context of neurological symptoms; unilateral numbness or weakness and discuss with senior regarding inpatient or outpatient

40. In regards to suspected acute coronary syndrome; true or false?
Prompt control of chest pain to minimal pain is an important treatment goal in non-ST elevation acute coronary syndrome is no longer routinely used for chest pain unless the 02 sats are <94% GTN should always be given for patients with chest pain If pain does not quickly respond to aspirin or GTN then IV morphine should

41. In regards to suspected acute coronary syndrome; true or false?
Prompt control of chest pain to minimal pain is an important treatment goal in non-ST elevation acute coronary syndrome FALSE the target is 0/ is no longer routinely used for chest pain unless the 02 sats are <94% TRUE GTN should always be given for patients with chest pain FALSE (contraindicated if had Viagra last 24hrs or hypotensive) If pain does not quickly respond to aspirin or GTN then IV morphine should TRUE