1. Analgesics OpioidsNon-opioids Action: Bind to opioid receptors in the CNS, blocking transmission of pain signals Typical side effects - Prevention of clear thought, clouded consciousness, nausea, vomiting, constipation, drowsiness, respiratory depression Overdose - coma, respiratory arrest, death Paracetamol NSAIDS Typical side effects - Minimal but rarely rashes, blood dyscrasias and pancreatitis Overdose - potentially fatal liver/kidney damage Action: Blocks prostaglandin production in the CNS, reducing pain sensation in the brain and reducing fever Action: Blocks cyclo- oxygenase (COX) enzymes following tissue damage, reducing prostaglan din production leading to reduced pain and inflammati on at the site of injury Typical side effects - Irritation of the GIT, ulceration/bleeding of the stomach/duodenum COX-2 inhibitors Typical side effects - Possible heart attacks in those with previous history Action: Blocks only COX-2 (involved in the inflammatory cascade) but not COX-1 (gastroprotective), reducing GIT side- effects ClassNameIndicationAdult doseRouteImplications for us Paracetamol (Panadol, Disprol) Fever, pain, rheumatic pain500mg-1g, Q4-6HPO IV Look out for skin rashes in chronic use Can cause hypotension NSAIDs (non- selective) Aspirin (Anadin, Dispirin, Alka-Seltzer) Mild-moderate pain (headache, toothache, period pain), fever, cold, flu, rheumatic pain Anti-platelet 300-900mg, Q4-6H 75-300mg, QD POScreen for GIT issues if chronic use May rarely cause SOB, wheeze, tinnitus, dizziness (medical emergency) Ibuprofen (Nurofen, Cuprofen) Rheumatic pain, MSk pain, moderate inflammatory pain, post-op pain, mild-moderate pain, fever, cold, flu 600mg-2.4g, up to QID PORare ankle oedema, SOB, wheeze (medical emergency) Diclofenac sodium (Voltarol) Rheumatic pain, inflammation and other MSk disorders 75-150mg, TIDPO, PR, IV, topical SOB, wheeze (medical emergency) COX-2 inhibitors CelecoxibRA, OA200-400mg, QD-BIDPOIncreased risk of CVS events (stroke, MI) OpioidsCodeine phosphateMild-moderate pain Diarrhoea Cough 120-240mg, QD 30-120mg, QD 45-120mg, QD PO or IVConstipation/decreased gut motility Rash (medical emergency) Fentanyl (Durogesic)Moderate-severe pain, perioperative analgesia, enhances general anaesthetic IV, patchesControolled drug list (risk of abuse) Fatal overdose if patches chewed Morphine sulphate (Oramorph, MS Contin) Severe pain, associated stress and anxiety, perioperative analgesia, enhances general anaesthetic, antidiarrhoeal/antimotility 5-25mg+ per dose Q4H (Q12-24H slow- release) PO, PR, IVControolled drug list (risk of abuse), tolerance, dependence Compound analgesics Paracetamol + codeine (Co-codamol) Mild-moderate pain Moderate pain 8/500mg 30/500mg (Px only) POConstipation Paracetamol + dihydrocodeine (Co- dydramol) Mild-moderate pain10/500mgPOConstipation Aspirin + codeine (Co- codaprin) Mild-moderate pain8/400mgPOConstipation PAIN LADDER Scaled approach to pain control (mild --> strong) Paracetamol +/- adjuvant* NSAIDS +/- adjuvant Combination of the above +/- adjuvant Combination with opioids +/- adjuvant Opioids (mild) +/- adjuvant Opioids (strong) (PO --> patch --> pump) +/- *Adjuvant e.g. tricyclic added as needed to  fear + anxiety (  central sensitisation)