Drug Route of admin Dose Uses MOA Advantages Disadvantages

Paracetamol Oral 60-80mg/kg/day - Monotherapy for Direct + indirect - Easy to use - Toxicity
Rectal Up to 4g/day mild-mod pain central cox - OTC - Drug interaction
IV - Multimodal inhibition. - Cheap - IV form more
therapy - Reduces adverse expensive
- Anti-pyretic: Inhibits central events of NSAIDs,
Inhibits prostaglandin opioids
hypothalamic heat synthesis - Well tolerated
regulating centre, - Safe in children
peripheral
vasodilation,
increased
dissivation of heat
NSAIDS - Inhibits PGE - Decreases SE - Expensive
- Aspirin: 300-600mg 4-6/24, max 4 doses daily, orally synthesis in - Offers protection - Increased risk of
- Indomethacin: 50mg TDS orally, 100mg BD PR response to tissue against colorectal AMI or CVA
- Diclofenac: 50mg TDS orally, 100mg 18/24 PR injury -> less cancer and - No change in
- Ibuprofen: 400mg 6/24 orally hyperalgesia, dementia incidence of gastric
- Ketorolac: 10mg 6/24 orally, 10-30mg 6/25 IM. 30mg IM ketorolac produces analgesia inflammation and irritation or
equivalent to 10mg morphine pain ulceration (only
- Parecoxib: pro-drug of valdecoxib - COX 1: GI, renal, bleeding) compared
platelet side effect to non-specific
Contraindications - COX 2: - Increased risk of
- CKD inflammation and anaphylaxis with
- Peptic ulcer disease/GI bleeding pain sulphonamide
- Known hypersensitivity allergy (celecoxib,
- Uncontrolled HTN parecoxib)
- 3rd trimester pregnancy
- Asthma
- On anticoagulants
- CCF, cirrhosis, ACEi, ARBs  can precipitate renal failure
Oxycodone Oral IR and SR 5-10mg Q2H PRN - 1.5x more - Need dose
- JMO most IV dose of oxycodone potent than adjust for renal &
commonly Subcut IR for a sedation morphine hepatic failure
prescribed PR score <2 - Sedation
- For standard - Pruritis
appendix post-op - N/V
patient - Slowing Gi fn
Targin Oral 5/2.5mg up to First pass - Urinary
- SR oxycodone and 40/20mg BD metabolism in retention
naloxone liver, no reversal of - Resp depression
analgesia. - Hypoxia
Supposedly - CNS – e.g.
reduces dysphoria
constipation
through blocking
opioid receptors in
the gut
PCA S/C Patient controlled.
Epidural Dosage controlled
Intrathecal when patient too
sedated to press
button, preventing
patient from receiving
needless doses,
reduces overdose
Other opioids Not commonly used Never use Non-opioids Procedural
- Morphine - Alfentanil - Pethidine - Gabapentinoids - LA
- Oxycodone - Remifentanyl - Codeine - Antidepressants - Regional
- Fentanyl - Hydromorphone - Anticonvulsants blocks
- Tramadol - Buprenorphine - Ketamine - Substance P
- Tapentadol - Methadone - Clonidine inhibitors
Paracetamol toxicity
- 300mg/kg (ideal body weight) or 10-15g single dose
- 20-25g single dose = fatal
- More at risk
o Pre-existing liver disease (less hepatic reserve)
o Malnutrition
o Prolonged fasting (depleted glutathione stores)
o Systemic sepsis
- Management
o ABC/supportive therapy/regular LFT monitoring
o Activated charcoal
 1g/kg up to 50g within 1-2h of ingestion
o Treat with N-acetylcysteine
 This increases glutathione stores
 Rummack Matthew normogram
o Methionine
 Increases glutathione synthesis
o Early consideration of transplant
 High risk factors include:
 INR >5
 Metabolic acidosis
Hypoglycaemia
 Renal failure
o Psychiatry involvement necessary

Opioid tolerance
- Progressive increases in dose required to maintain desired pharmacological effect
- Will dramatically increase doses of opioid you might need
- Often these patients are on huge doses
o 1g of heroin is equivalent to 800-1000mg of PO morphine
- Physical dependence
o When you stop opioid, withdrawal occurs
- Psychological dependence/addiction
o Drug seeking behaviour
o Impaired control, craving, compulsive use and continued use despite harm
 - Management
o Contact pain team

What should I discharge the patient on?

- Panadol and NSAIDS are fine
- All long-term opioids should be prescribed with a stop date on the patient’s chart
- Post-op patients should not go home with more than 1/52 worth of PRN opioids
o Not more than 10 tablets of oxynorm IR
 High street value
- Liaise with GP

Pain service
- Labour
- Rib fractures
o All rib fractures require pain service review
 Because rib fractures prevent deep breathing, increasing risk of pneumonia
- Regional anaesthesia
o Can facilitate rapid recovery and early mobilisation after surgery or injury