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Topics in Analgesic version 5
Physiology and pathophysiology of pain
Getting to know your drugs
Routes of analgesic and adjuvant administration
Special problems with opioid use
Pertinent practical points
Acute pain, chronic pain, and the transition from one to the other
Clinical assessment of pain
Nonpharmacological pain management techniques
Interventional techniques for chronic pain
The pain clinic
Perioperative pain
Procedure-related pain
Trauma pain
Burn pain
Obstetric pain
Pain in children
Special considerations for older people
Complex regional pain syndromes
Miscellaneous conditions requiring analgesia
Legal aspects of prescribing opioids
Appendix
Glossary
Physiology and pathophysiology of pain
- Introduction
- Nociceptive pain
- Neuropathic pain
- Detection of pain
- Peripheral
- Pain receptors (nociceptors)
- Inflammation and primary hyperalgesia
- Sensory afferent fibres
- Central nervous system
- Ascending pathways
- Descending pathways
- The spinal cord and the first central synapse
- Central analgesic receptors
- Modulation of pain
- Central sensitisation
- Wide dynamic range neurones
- Pre-emptive analgesia
- Nerve injury or dysfunction and neuropathic pain
- Central responses to nerve injury
- Physiology of the treatment of neuropathic pain
- Development of nociceptive pathways
Getting to know your drugs
- Analgesics
- Paracetamol
- Mechanism of action
- Dose and toxicity
- Formulations
- Nonsteroidal anti-inflammatory drugs
- Mechanism of action
- Pharmacokinetic properties and dosing schedules
- Paediatric use of NSAIDs
- Adverse effects
- Choice of NSAID
- Topical formulations
- Opioids
- Mechanism of action
- Formulations and properties
- Initial use for severe acute pain
- Adverse effects
- Interactions and precautions
- Opioid use in older people
- Morphine
- Oxycodone
- Hydromorphone
- Fentanyl and fentanyl analogues
- Methadone
- Codeine
- Tramadol
- Buprenorphine
- Opioids not generally recommended
- Pethidine
- Dextropropoxyphene
- Opioid antagonists
- Inhalational agents
- Nitrous oxide
- Methoxyflurane
- Local anaesthetics
- Mechanism of action
- Properties
- Precautions
- Adverse effects
- Lignocaine
- Prilocaine
- Bupivacaine
- Levobupivacaine
- Ropivacaine
- Procaine
- Amethocaine
- Cocaine
- Adjuvants
- Antidepressant drugs
- Tricyclic antidepressant drugs
- NMDA-receptor antagonists
- Benzodiazepines
- Diazepam
- Midazolam
- Lorazepam
- Skeletal muscle relaxants
- Diazepam
- Baclofen
- Quinine
- Corticosteroids
- Complementary and alternative medicine
- Off-label or unlicensed use of medicines
- Off-label use of medicines
- Unregistered (unlicensed) medicines and the Special Access Scheme
Routes of analgesic and adjuvant administration
- Oral
- Oral bioavailability
- Modified-release preparations
- Buccal/sublingual
- Intranasal
- Inhalational
- Topical and transdermal
- Creams and lotions
- Transdermal patches
- Rectal
- Subcutaneous
- Intravenous
- Intramuscular
- Epidural
- Intrathecal
- Intracerebroventricular
Special problems with opioid use
- Opioids for chronic pain
- Commencing a trial of opioids
- Patients on opioids long term
- Opioid rotation
- Effects of long-term opioid therapy
- Central nervous system effects
- Immune changes
- Opioid-induced hyperalgesia
- Drug interactions
- Increased or new pain
- Analgesia in opioid-dependent patients
- Principles of management for patients with substance abuse disorders
- Special considerations with particular drugs
- Methadone
- Naltrexone
- Buprenorphine
- Inappropriate opioid use
Pertinent practical points
- Dose modification
- Concurrent conditions that can affect dosing
- Central nervous system
- Respiratory depression
- Sleep apnoea
- Depression
- Anxiety/agitation/distress
- Cardiac disease
- Respiratory disease
- Renal disease
- Liver disease
- Gastrointestinal disease
- Prescribing at the extremes of age
- Drug-to-drug interactions
- PRN versus regular use of analgesics
- Dose titration
- Acute neuropathic pain
- Placebos, placebo effect and placebo response
- Analgesics in the anticoagulated patient
- Nausea and vomiting and opioids
- Concurrent laxatives and opioids
- Competitive sport
- Fitness to drive
- Complementary and alternative medicine
Acute pain, chronic pain, and the transition from one to the other
- Introduction and definitions
- Acute pain
- Changes with continued pain
- Neurological changes
- Physical changes
- Psychological changes
- Social changes
- Chronic pain
- General management issues
- Acute pain
- Transition between acute pain and chronic pain
- Chronic pain
- Pharmacological therapy
- Procedural interventions
- Other management issues
- Single modality versus multimodal approaches
- Multidimensional approach
- Medicolegal issues
- The treating practitioner
- Medically unexplained syndromes
- Contribution to pain from psychological disorders
Clinical assessment of pain
- Defining pain
- Types of pain
- Nociceptive pain
- Neuropathic pain
- Breakthrough and incident pain
- Breakthrough pain
- Incident pain
- Pain assessment
- History
- Location
- Radiation
- What makes the pain better or worse
- Quality
- Severity
- Timing
- Patient’s understanding of the pain
- Examination
- Investigations
- Outcome assessments
- Documentation
- When the patient cannot give a pain history
- What to do when the practitioner cannot understand the clinical situation
Nonpharmacological pain management techniques
- Physical techniques
- Physiotherapy
- Manual therapies
- Hyperstimulation analgesia
- Acupuncture
- Transcutaneous electrical nerve stimulation
- Percutaneous electrical nerve stimulation
- Biofeedback
- Psychological techniques
- Cognitive behavioural therapy
- Education
- Family or relationship therapy
- Hypnosis
- Relaxation/meditation techniques
- Attentional techniques
- Psychotherapy
- Occupational therapy
- Social/environmental interventions
- Community support groups
- Self-help groups
- Statutory benefits advice
- Work retraining/modification
Interventional techniques for chronic pain
- Injection techniques
- Precautions, contraindications and adverse effects
- Local
- Intralesional and intra-articular
- Trigger point injections
- Botulinum toxin type A injections
- Medial branch blocks
- Sacroiliac joint
- Peripheral nerve blocks
- Regional
- Nerve root sleeve injection
- Epidural
- Sympathetic blockade
- Stellate ganglion blockade
- Lumbar sympathetic blockade
- Coeliac plexus / splanchnic nerve blockade
- Systemic
- Other techniques
- Percutaneous radiofrequency neurotomy
- Pulsed radiofrequency neurotomy
- Spinal cord stimulation
- Intrathecal therapy
- Surgery
The pain clinic
- Types of pain clinic
- Referral to a pain clinic
- Who to refer
- When to refer
- Preparing the patient to attend the pain clinic
Perioperative pain
- Drugs used perioperatively
- Preoperative phase
- Intraoperative phase
- Postoperative phase
- Parenteral opioid and local anaesthetic administration
- Intravenous administration
- Patient controlled analgesia (PCA)
- Subcutaneous administration
- Intramuscular administration
- Regional and local administration
- Epidural administration
- Intrathecal administration
- Continuous peripheral nerve blockade
- Paravertebral and extrapleural infusion
- Brachial plexus infusion
- Intra-articular infusion
- Surgical wound infiltration and infusion
- Choosing an infusion device
- Nonsurgical postoperative pain
- Bladder distension
- Muscle spasm
- Flatulence
- Persistent postsurgical pain
Procedure-related pain
- Sedation and general anaesthesia
- Minimal sedation
- Moderate sedation
- Deep sedation and general anaesthesia
Trauma pain
- Minor trauma
- Wounds and lacerations
- Sprains and strains
- Dislocations and fractures
- Simple
- Complicated
- Chest injuries
- Burns
- Major trauma
- Chest injuries
- Abdominal injuries
- Fractured hip
- Head injuries
- Isolated closed head injuries
- Nonsignificant and mild head injuries
- Moderate to severe head injuries
- Isolated penetrating head injuries
- Multiple injuries
Burn pain
- First aid treatment
- Assessment
- Minor burns
- Acute phase (first 24 to 48 hours)
- Continuing pain (after 48 hours)
- Major burns
- Acute phase
- Continuing pain
- Procedures—dressings and debridement
- Short procedures (less than 15 minutes)
- Long procedures (greater than 15 minutes)
- Dysaesthesia and neuropathic pain
Obstetric pain
- Pain during pregnancy
- Labour pain
- Nonpharmacological analgesic techniques
- Relaxation and breathing techniques
- Positioning and movement
- Transcutaneous electrical nerve stimulation
- Heat and cold, showering, massage
- Hypnosis
- Acupuncture
- Intradermal sterile water
- Other techniques
- Pharmacological analgesic techniques
- Inhalational analgesia
- Parenteral opioids
- Neuraxial blockade using local anaesthetics and/or opioids
- Caesarean section
- Puerperal pain
- Perineal pain
- Breast pain
- Uterine pain
Pain in children
- Pain assessment
- Analgesics and adjuvants in children
- Drug dosing in children
- Nonopioid analgesics
- Oral opioids
- Inhalational agents
- Local anaesthetics
- Routes of analgesic and adjuvant administration
- Acute pain
- Perioperative pain
- Preoperative phase
- Intraoperative phase
- Postoperative phase
- Procedure-related pain
- Nonpharmacological techniques
- Pharmacological techniques
- Wounds and lacerations
- Neonatal circumcision
- Medical conditions
- Chronic pain
- Cancer pain / palliative care
Special considerations for older people
- Introduction
- Ageing and pain
- Clinical assessment
- Burden of pathology
- Drug-related issues
- Factors that contribute to the need for increased care
- Adherence
- Adverse effects
- Nonpharmacological approaches
- Physical approaches
- Psychological and social approaches
Complex regional pain syndromes
- Introduction
- Clinical features
- Diagnosis
- Management
- Physiotherapy
- Pharmacological treatment
- Psychological treatment
- Nerve blocks
- Other treatments
- CRPS and children
Miscellaneous conditions requiring analgesia
- Chest pain
- Costochondritis and Teitze’s syndrome
- Discogenic pain
- Zygapophyseal joint pain (facet joint pain)
- Vertebral body pain
- Mastalgia
- Abdominal pain
- Renal colic
- Biliary colic
- Acute pancreatitis
- Recurrent biliary pain
- Pelvic pain
- Proctalgia
- Proctalgia fugax
- Prostatic pain
- Dysmenorrhoea and endometriosis
- Primary dysmenorrhoea
- Secondary dysmenorrhoea
- Endometriosis
- Pelvic inflammatory disease
- Acute infection with pelvic peritonitis
- Recurrent pelvic inflammation
- Nonspecific pelvic pain
Legal aspects of prescribing opioids
- Prescribing for nonaddicted persons
- Prescribing for addicted persons
- Notification of suspected addicted persons
- ‘Prescription shopping’ information service
Appendix
- Analgesics and adjuvants in pregnancy and breastfeeding
- Pregnancy and the use of drugs
- Analgesics
- Categorisation of drugs in pregnancy
- Category A
- Category B1
- Category B2
- Category B3
- Category C
- Category D
- Category X
- Breastfeeding and the use of drugs
Glossary
Electronic version
Therapeutic Guidelines: Analgesic is available in electronic format as part of eTG complete.
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