ANALGESIA PRESCRIBINGYear 4 Prescribing Tutorial 2019 – 2020

Disclaimer: All cases are fictional for teaching purposes

ResourcesGolden rules of prescription writinghttp://intranet.lothian.scot.nhs.uk/NHSLothian/Healthcare/ClinicalGu

idance/Documents/Golden%20rules%20for%20prescribing.pdf

BNF http://www.bnf.org/ Also BNF App

Lothian Joint Formulary Also LJF Apphttp://www.ljf.scot.nhs.uk/Pages/default.aspx

NHS Lothian pain medicine guidancehttp://intranet.lothian.scot.nhs.uk/NHSLothian/Healthcare/A-

Z/PainMedicine/Pain%20management/Pages/default.aspx

http://intranet.lothian.scot.nhs.uk/NHSLothian/Healthcare/ClinicalGuidance/Documents/Golden%20rules%20for%20prescribing.pdfhttp://www.bnf.org/http://www.ljf.scot.nhs.uk/Pages/default.aspxhttp://intranet.lothian.scot.nhs.uk/NHSLothian/Healthcare/A-Z/PainMedicine/Pain%20management/Pages/default.aspx

GOLDEN RULES OF PRESCRIBING (I)

Select correct prescription chart (14 day ± warfarin chart)

Write clearly in block CAPITALS using a black ballpoint pen

Complete all the required patient details on the front

Use generic names for drugs where possible and appropriate

Write drug dose clearly; remember only g, mg and ml are acceptable abbreviations

Select route of administration

GOLDEN RULES OF PRESCRIBING (II)

Enter correct start date (use original start date when rewriting)

Remember the once only section

Sign and print your name

Enter supplementary charts in use

Never alter prescriptions (cancel and rewrite)

Discontinue prescriptions correctly

LEARNING OUTCOMES

Describe the mode of action of common pain medicines.

List the factors to consider when managing pain.

Describe the WHO pain ladder and apply it to clinical scenarios.

List side effects of common pain medications.

WHAT IS PAIN?

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

Pain management is one of the most commonly encountered prescribing scenarios for the junior doctor.

PAIN PATHWAY

Tissue injury

Sensitising prostaglandins

Nocioceptoractivation

Peripheral nerves

WHAT ANALGESICS CAN YOU THINK OF?

Common:ParacetamolIbuprofenCodeineMorphine

Less common, but still used :

Nefopam

Tramadol

Co-dydramol

Buprenorphine

Diamorphine

Dihydrocodeine

Methadone

Fentanyl

Oxycodone

COMMON ANALGESICS

Paracetamol

NSAIDs (e.g. aspirin, ibuprofen)

Morphine (and other opiates)

Local anaesthetic (e.g. lidocaine)

PAIN PATHWAY

Tissue injury

Sensitisingprostaglandins

Nocioceptoractivation

Peripheral nerves

NSAIDsLocal

AnaestheticsOpiates Paracetamol

Opiates

PAIN LADDER

Acute Pain Assessment

Verbal numeric rating scale

0----------------------10

No pain-----worst pain

Verbal descriptor scale

0 =no pain 1=mild pain undistressing 2=moderate pain,

distressing 3= severe pain, very

distressing

Pain Assessment--Treatment

Mild pain0-3

Moderate pain3-6

Severe pain6-10

No interventionParacetamolMild opioid eg codeine

Give rescue analgesiaParacetamol +/-NSAIDStrong opioid regular and as reqd.

Urgent rescue analgesia (iv morphine)

Paracetamol +/-NSAIDStrong opioid regular and as reqd.

CASE 1A 30 year old male comes into A&E and you are the FY doctor who sees him first. He had been playing football, but fell awkwardly and his right ankle is now swollen and painful.

What is your initial management plan?

CASE 1Analgesia

Whilst examination and investigations are important in reaching a diagnosis, the most important issue at the moment is pain relief.

What do you need to know before you prescribe?o Drug Allergieso Has he taken any medication at homeo Past Medical History (esp. asthma, PUD, liver disease,

renal failure) and regular medicationso Any vomiting?

CASE 1

Oral therapy is usually the preferred choice if adequate analgesia can be achieved via this route.

IV access is not risk-free, so risks should be balanced against benefits.

Some analgesics can be given IM – removing the need for a cannula in someone who is not going to be admitted to hospital.

CASE 1The patient has an x-ray which does not demonstrate any fracture, however 6 months later is still suffering from some joint pain around his ankle.

He is still regularly taking paracetamol and ibuprofen, which he is buying over the counter.

He presents to A&E once more, this time with epigastricpain and vomiting.

o What is the most likely diagnosis?

o What could have been prescribed to prevent this happening?

NSAIDSGood for MSK pain as they act in the tissue to limit the production of PGs which sensitise nocioceptors; they also serve as anti-inflammatory agents.

However, side effects include gastritis and peptic ulceration, and therefore it is important to be careful when using them long term.

They should be taken after food to prevent GI upset, and consideration could be given to co-prescription of a gastro-protective drug (e.g. PPI).

A topical NSAID may be an option

CASE 2A 60 year old man on the orthopaedic ward develops abdominal pain. It is shearing in nature and radiates through to his back. It is very severe – pain 9/10.He had a MI 2 years ago.

What do you do?

CASE 2Observations:o Hypotensive 90/60 mmHgo HR 140 bpmo RR 28o O2 sats 95% on air.o Temp 37.5 oC

HS I+II+0, chest clear. Radial pulse thready in character. Peripheral pulses not palpable.

Abdomen is peritonitic.

What would you like to do?

CASE 2GET HELP!

ABCDE

Oxygen

IV access (2 large gauge cannulae)

Urgent bloods, including crossmatch

Analgesia

CASE 2 Pain can be an important indicator that something is

going wrong.

It is especially important to assess the patient who complains of a new type of pain in hospital, rather than blindly prescribing analgesia and waiting until the ward round the next day to discover that they’ve ruptured their aorta...

CASE 3You are the FY1 on HAN and have just been called to see a 60 year old woman was admitted for an elective laparoscopic cholecystectomy. The procedure proceeded without any problems. However, she is now complaining of abdominal pain.

What do you do?

CASE 3She is now 8 hours post-op and has a history of gallstones and cholecystitis.

Her abdomen is soft, and is only tender around the RUQ/epigastrium. Observations are stable, and she does not look acutely unwell.

You look at her Prescription chart and note that she has had 1g of paracetamol and 50mg of tramadol in the last 3 hours.

What do you do?

CASE 3You prescribe IV morphine.

The nursing staff are busy, so you have to give it yourself. Sadly while you are documenting in the prescription chart that you’ve given the drug, the patient starts to feel sick. She then proceeds to vomit, covering both herself and you.

What should you have done?

CASE 3Nausea and vomiting is a major side effect of opiates, and is a particular problem post-operatively.

Always ensure that you prescribe an antiemetic when giving morphine for the first time to a patient.

ANTIEMETICSCyclizine (Antihistamine)o Good in GI obstruction & post-operative nausea and vomitingo Side-effects include tachycardia and constipation

Metoclopramide (Prokinetic, D2 agonist)o Good for GI causes of vomiting, migraine and nausea in

response to drugs (e.g. opiates).o AVOID IN OBSTRUCTION.o MHRA/CHM advice in BNF

Ondansetron (5HT3 antagonist)o Good for severe/resistant nausea post-operatively or related

to chemotherapy.o Particular use in nausea related to chemotherapy

CASE 3 Different patients will have different levels of pain

following the same procedure and therefore will require differing levels of analgesia.

It is important to assess each patient in order to ensure that they are not becoming acutely unwell, and then to ensure that they have adequate analgesia.

CASE 3It is now several hours since you first saw the 60 year old lady, but again the nursing staff call you with a problem. Now she has become unresponsive.

What are you thinking about as you walk to the ward?

CASE 3You find the patient slumped in her bed. She does not respond to pain. Her RR is 5 and her pupils are pinpoint.

You look at her prescription chart and realisethat you accidentally prescribed the IV morphine without a frequency and the patient has been getting IV morphine every hour.

What’s going on?

SIGNS OF OPIATE TOXICITYMild-moderate:o Hypotensiono Bradycardiao Altered consciousness levelo Myoclonus

Severe:o Respiratory depressiono Pupillary constriction “pin-point pupils”o Coma

Treatment?

CASE 3You give naloxone and the patient comes round. You document this in the notes, and stop the regular morphine on the prescription chart.

However, 45 min later, you are called again by nursing staff as the patient has once again become unresponsive...

Why?

CASE 3Naloxone has a shorter half-life than morphine. Therefore, depending on how much morphine the patient has onboard, one dose of naloxone may not be enough.

Treatment of opiate toxicity may require a naloxone infusion.

OTHER SIDE EFFECTS OF OPIATES

Constipation

Dependence

Tolerance

Difficult with micturition/urinary retention

OTHER DOS AND DONTS!DO!Prescribe regular analgesia and break-thoughStart low and titrate upwards, particularly with morphineBe aware that analgesics can precipitate deliriumSeek advice from the Acute/Chronic Pain Teams

DO NOT!Prescribe NSAIDs to anyone on an ACEi/ARB, or AKI/CKDPrescribe metoclopramide for young femalesPrescribe tramadol for patients with dementia Prescribe nefopam to anyone with normal renal function

THE END

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Analgesia PrescribingResourcesGOLDEN RULES OF PRESCRIBING (I)GOLDEN RULES OF PRESCRIBING (II)LEARNING OUTCOMESWhat is Pain?Pain pathwayWhat analgesics can you think of?Common AnalgesicsPain pathwayPain ladderAcute Pain AssessmentPain Assessment--TreatmentCase 1Case 1Case 1Slide Number 17Case 1Slide Number 19NSAIDsCase 2Case 2Case 2Case 2Case 3Case 3Slide Number 27Case 3Slide Number 29Case 3AntiemeticsCase 3Case 3Case 3Signs of opiate toxicityCase 3Case 3Other side effects of opiatesOther Dos and DONTs!The End