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What Analgesics?. Paracetamol – Aspirin Nefopam NSAIDS Opioids Topical – capsaicin, rubifacients , nsaids , Local anaesthetics. Add on’s. Diazepam, methocarbamol. Amitriptylline TENS machine Stretching, massage, physio Osteopathy, Acupuncture Antidepressants. 3.

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what analgesics
What Analgesics?
  • Paracetamol –
  • Aspirin
  • Nefopam
  • NSAIDS
  • Opioids
  • Topical – capsaicin, rubifacients, nsaids, Local anaesthetics
add on s
Add on’s
  • Diazepam, methocarbamol.
  • Amitriptylline
  • TENS machine
  • Stretching, massage, physio Osteopathy, Acupuncture
  • Antidepressants
slide3

3

WHO\'s three step ladder to use of analgesic drugs

www.who.int/cancer/palliative/painladder

2

1

s e of opiates
S/e of opiates
  • constipation, nausea, somnolence, itching, dizziness, vomiting
  • Tolerance to SE usually occurs within few days,
  • Constipation & itching tend to persist
  • Manage with antiemetics (cyclizine), aperients (movicol), antihistamines
  • Respiratory depression only likely with major changes in dose, formulation or route.
  • Accidental overdose is most likely cause
  • Caution if >1 sedative drug or other disorders of respiratory control ( eg OSA)
long term adverse effects
Long-term adverse effects
  • Endocrine impairment in both men and women
  • Hypothalamic-pituitary pituitary-adrenal/ gonadal axis suppression leading to amenorrhoea, infertility, reduced libido, infertility, depression, erectile dysfunction.
  • Immunological effects- in animals, effects on antimicrobialresponse and tumour surveillance.
  • Opioid induced hyperalgesia - reduce dose, change preparation
  • Pregnancy & neonatal effects
stopping strong opioid medication
Stopping strong opioid medication
  • Large differences between individuals in susceptibility to, and severity of, withdrawal syndrome
  • Symptoms last up to 72hrs following reduction/withdrawal.
  • Incremental dose reductions 10% -25% depending on patient response and bear in mind half life of preparation
recommendations 1
Recommendations 1:
  • Useful analgesia in the short and medium term. No data to support longer term use.
  • Useful in neuropathic pain too.
  • Complete relief of pain is rarely achieved. The goal should be to reduce pain sufficiently to facilitate engagement with rehabilitation and the restoration of useful function. Use as part of a wider management plan to reduce disability and improve QOL.
recommendations 2
Recommendations 2
  • 80% of patients taking opioids experience at least one adverse effect. Discuss before treatment! DO NOT USE in pregnancy / children and use with caution in Elderly.
  • Resp. depression commoner if elderly/coprescription / comorbidity e.g. OSA.
  • Withdrawl symptoms – yawning, sweating abdo cramps common with abrupt withdrawl even short courses of tramadol.
recommendations 3
Recommendations 3
  • Educate re long term effects of opioids, particularly in relation to endocrine and immune function. Warn re Steroid induced Hyperalgesia.
  • Do not use as first line
  • Consider carefully the decision to start long term therapy and make arrangements for long-term monitoring and follow-up.
  • Use modified release opioids for long term use
recommendations 4
Recommendations 4
  • Avoid driving at the start of opioid therapy and following major dose changes. Patients responsibility to advise the DVLA that they are taking opioid medication.
  • Addiction is characterised by impaired control over use, craving and continued use despite harm.
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