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PAIN AND ANALGESICS LADDER

ANALGESICSOpioid / Narcotic / Morphinelike analgesics

Non opioid / Non-narcotic /Aspirin like analgesics

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PAIN MOA INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS INTERACTIONS

N S A I D S

SalicylateASPIRIN

blocks prostaglandinsynthesis at thethermoregulatorycentres in thehypothalamus and atperipheral target sites

Aspirin may also supresspain stimuli at sub-cortical sites (thalamusand hypothalamus).

anti-inflammatory, anti-pyreticand analgesics effects

Chronic Inflammation RA Severe OA Chronic back pain

Acute injury with Inflammation Dysmenorrhoea Pain from lytic bone

metastases

GI symptoms /peptic ulcer disease

Liver or renalimpairment

Asthmatic withaspirin sensitivity

Coagulationdisorders /treatment

Aspirin should beavoided in pregnancyand during lactation

GI disturbances Skin reactions Fluid retention

worsening of CF Renal effects

Less intense thanaspirin in term of GIeffects propionic acid

Oral anticoagulants Lithium antiHPT digoxin phenytoin with

ibuprofen MTA Insulin with

salicylates Antacids with

naproxen sodium orsalicylates

Probenecid withnaproxen

Propionic acidIBUPROFENNAPROXEN blocking cyclo-

oxygenase (COX) andhence prostaglandinsynthesis

Heteroarylacetic acidDiclofenac

RA, OA and AnkylosingSpondylitisOphthalmic preparation

O P I O D S

MORPHINE

Acts at receptors whichcause spinal analgesia,psychotomimetic effects,slow GI transit

Relef of Pain Ischaemicpain, visceral pain, palliativepain

Pre-anaesthetic medication Symptomatic treatment of

Diarrhoea Acute Left ventricular

failure

5H Hypotension Hepatic disease BPH

Head injury

3B Bronchial asthma Biliary colic Babies & elderly

Respiratorydepression

Sedation Euphoria Pupil constriction Nausea & vomiting Reduced gut

motility Constipation Pruritis Hypotension Bronchospasm Urinary retention

TCA,Phenothiazines,MAO Inhibitorspotentiatemorphine

Morphine retardsabsorption of manyorally administereddrugs by delayinggastric emptying

CODEINE exert their effects by bindingto and activating the -opioid receptor

Cough

DIAMORPHINE/HEROIN

Severe pain of cancer

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WEEK 3 - PAIN

N - O

P I A T E

O P I O I D Tramadol

exert their effects by bindingto and activating the -opioid receptor

Moderate to moderatelysevere pain

Patients on MAOi SSRITCA

PARACETAMOL

Inhibits prostaglandinsynthesis in the CNS

Metabolized by Liver can cause hepatictoxicity

Analgesic / Antipyretic Substitute aspirin for those

with gastric complaints Children w/ viral infection

or chickenpox

Hepatic disease,viral hepatitis

Alcoholism

Renal tubular necrosis

Virtually free of anysignificant adverseeffects

Alcohol

GABAPENTINActs on Ca channels

Neuropathic painBenign side effectprofile

STEP 1 STEP 2 STEP 3 STEP 4 STEP 5PRN/Regular paracetamol andPRN/regular NSAID (if safe)

Regular paracetamol andregular NSAID (if safe)

Regular paracetamol and regularNSAID (if safe)

Regular paracetamol andregular NSAID (if safe)

REFER TO ACUTE PAIN SERVICE

PRN weak opiate i.e. Codeine Regular weak opiate i.e. Codeine Regular opiate i.e. OramorphPRN opiate for breakthrough paini.e. Oramorph

PRN opiate for breakthroughpain i.e. Oramorph