What Analgesics?

1. What Analgesics? • Paracetamol – • Aspirin • Nefopam • NSAIDS • Opioids • Topical – capsaicin, rubifacients, nsaids, Local anaesthetics

2. Add on’s • Diazepam, methocarbamol. • Amitriptylline • TENS machine • Stretching, massage, physio Osteopathy, Acupuncture • Antidepressants

3. 3 WHO's three step ladder to use of analgesic drugs www.who.int/cancer/palliative/painladder 2 1

4. Opioids

5. Opioids

6. Equivalent strengths of transdermalopioids(i.e. Don’t mix up your fentanyl with your butrans!)

8. 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)

9. 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

10. 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

11. 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.

12. 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.

13. 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

14. 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.