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*Include limitations of the pharmacological management of chronic pain and barriers such as social and professional stigma/stereoypes associated with medication use and prescription<br>
*Include limitations of the pharmacological management of chronic pain and barriers such as social and professional stigma/stereoypes associated with medication use and prescription<br>
*The role of AHP and Physiotherapy prescribing
*The role of AHP and Physiotherapy prescribing
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</div>
</div>
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'''Introduction:''' A wide range of drugs are used to
help
manage pain
which may result
from inflammation in response to tissue damage, chemical agents
or
pathogens (nociceptive pain) or nerve damage ( neuropathic pain ). Most drugs act by binding to protein targets on
the
cell
membrane
and
affect
the biochemical processes of the body. Protein targets are specific to specific tissues allowing drugs to be precisely targeted at organs or cells
(specificity)
. Drugs exhibiting high specificity require lower doses and have fewer side effects than those with lower specificity.<ref name="McFadden">McFadden R. The physiological framework of pharmacology.Birmingham City University 2009.</ref> <br>Originally developed by the World Health Organisation (WHO)
as an attempt
to improve
the
management of cancer pain; the 3 step WHO analgesic ladder<ref name="WHO">World Health Organisation. Pain relief ladder for cancer pain relief.1986 Geneva. Switzerland Available at: www.who.int/cancer/palliative/painladder/en</ref> is also
widely
used
as the framework
for providing stepwise pain relief for pain due to other causes.
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<u>
'''Introduction:'''
</u>
A wide range of drugs are used to manage pain
resulting
from inflammation in response to tissue damage, chemical agents
/
pathogens (
[http://www.physio-pedia.com/Nociception
nociceptive pain
]
) or nerve damage (
[http://www.physio-pedia.com/Neuropathic_pain
neuropathic pain
]
). Most drugs act by binding to protein targets on cell
membranes
and
affecting
the biochemical processes of the body. Protein targets are specific to specific tissues allowing drugs to be precisely targeted at
individual
organs or cells. Drugs exhibiting high specificity require lower doses and have fewer side effects than those with lower specificity.<ref name="McFadden">McFadden R. The physiological framework of pharmacology.Birmingham City University 2009.</ref> <br>
+
+
Originally developed by the World Health Organisation (WHO) to improve management of cancer pain; the 3 step WHO analgesic ladder<ref name="WHO">World Health Organisation. Pain relief ladder for cancer pain relief.1986 Geneva. Switzerland Available at: www.who.int/cancer/palliative/painladder/en</ref> is also used for providing stepwise pain relief for pain due to other causes.
THE AIM OF THIS WIKKI IS TO >>>>>>
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== '''Non opioid medications: (step 1 WHO Analgesic ladder – mild to moderate pain.<ref name="WHO" />)'''
== '''Non opioid medications: (step 1 WHO Analgesic ladder – mild to moderate pain.<ref name="WHO" />)'''
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Non steroidal anti inflammatory drugs (NSAIDs) such as '''asprin, ibuprofen, naproxen, diclofenac '''weaken and reduce the levels of chemical mediators (prostaglandins) produced during inflammation, relieving symptoms of pain, swelling and redness. They inhibit the enzyme cyclo-oxygenase (COX 2) which is integral in the synthesis of prostaglandins. During infection the effect of prostaglandins on the hypothalamus results in a higher body temperature (pyrexia). NSAIDs weaken the production of prostaglandins enabling the temperature to reduce towards normal. NSAIDS do not just inhibit prostaglandin production
at the site if pain
but throughout the body producing side effects
including
in the gastrointestinal tract(GIT). GIT side effects are explained by NSAIDs interference with the normal homeostasis role of prostaglandins (mediated by COX 1 enzyme) in maintaining gastric mucosa and regulating stomach acids.<ref name="McFadden">McFadden</ref> Side effects affecting GIT may include indigestion, nausea and vomiting, and diarrhoea and can result in ulceration and bleeding.. Other side effects include rashes, photosensitivity, bronchospasm, dizziness and haematuria.<ref name="BNF">Joint Formulary Committee. British National Formulary. 67ed. London: BMJ Group and Pharmaceutical Press;2014</ref> <br>NSAIDs must be used with caution in the elderly, and people with diabetes, asthma and impaired renal or cardiac function.<ref name="BNF" /><br>NSAIDs are contraindicated for people with a previous history of adverse reaction, a history of peptic ulcer or clotting disorders and those taking anticoagulants or another NSAID medication.<ref name="BNF" />
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Non steroidal anti inflammatory drugs (NSAIDs) such as '''asprin, ibuprofen, naproxen, diclofenac '''weaken and reduce the levels of chemical mediators (prostaglandins) produced during inflammation, relieving symptoms of pain, swelling and redness. They inhibit the enzyme cyclo-oxygenase (COX 2) which is integral in the synthesis of prostaglandins. During infection the effect of prostaglandins on the hypothalamus results in a higher body temperature (pyrexia). NSAIDs weaken the production of prostaglandins enabling the temperature to reduce towards normal. NSAIDS do not just inhibit
local
prostaglandin production
,
but
also
throughout the body
,
producing side effects in
other boy tissues/systems such as
the gastrointestinal tract(GIT). GIT side effects are explained by NSAIDs interference with the normal homeostasis role of prostaglandins (mediated by COX 1 enzyme) in maintaining gastric mucosa and regulating stomach acids.<ref name="McFadden">McFadden</ref> Side effects affecting GIT may include indigestion, nausea and vomiting, and diarrhoea and can result in ulceration and bleeding.. Other side effects include rashes, photosensitivity, bronchospasm, dizziness and haematuria.<ref name="BNF">Joint Formulary Committee. British National Formulary. 67ed. London: BMJ Group and Pharmaceutical Press;2014</ref> <br>NSAIDs must be used with caution in the elderly, and people with diabetes, asthma and impaired renal or cardiac function.<ref name="BNF" /><br>NSAIDs are contraindicated for people with a previous history of adverse reaction, a history of peptic ulcer or clotting disorders and those taking anticoagulants or another NSAID medication.<ref name="BNF" />
<br>'''Paracetamol'''. Although it is the most widely used pain relieving medication the exact mechanism of action of paracetamol is relatively poorly understood. It is thought to act on the COX 3, a recently discovered type of COX present in the brain and spinal cord. Paracetamol has mainly anti-pyretic (reducing the levels of prostaglandins in the hypothalamus) and analgesic properties; it does not interfere with COX 2 and does not affect the other components of inflammation ( swelling and redness). As paracetamol has no action on COX 1 at a therapeutic dose it has few side effects.<ref name="McFadden" /> The maximum recommended daily therapeutic dose of paracetamol for adults is 4g ( 8 x500mg tablets). It is hepatotoxic at only 2-3 times the therapeutic dose causing necrosis of the liver and resulting in 226 deaths in 2013 in England and Wales <ref name="ONS">Office for National Statistics. Deaths related to drug poisoning in England and Wales, 2013 (accessed 10 Jan 2014)fckLRhttp://www.ons.gov.uk/ons/rel/subnational-health3/deaths-related-to-drug-poisoning/england-and-wales---2013/stb---deaths-related-to-drug-poisoning-in-england-and-wales--2013.html#tab-Paracetamol-and-Other-Analgesics</ref>
<br>'''Paracetamol'''. Although it is the most widely used pain relieving medication the exact mechanism of action of paracetamol is relatively poorly understood. It is thought to act on the COX 3, a recently discovered type of COX present in the brain and spinal cord. Paracetamol has mainly anti-pyretic (reducing the levels of prostaglandins in the hypothalamus) and analgesic properties; it does not interfere with COX 2 and does not affect the other components of inflammation ( swelling and redness). As paracetamol has no action on COX 1 at a therapeutic dose it has few side effects.<ref name="McFadden" /> The maximum recommended daily therapeutic dose of paracetamol for adults is 4g ( 8 x500mg tablets). It is hepatotoxic at only 2-3 times the therapeutic dose causing necrosis of the liver and resulting in 226 deaths in 2013 in England and Wales <ref name="ONS">Office for National Statistics. Deaths related to drug poisoning in England and Wales, 2013 (accessed 10 Jan 2014)fckLRhttp://www.ons.gov.uk/ons/rel/subnational-health3/deaths-related-to-drug-poisoning/england-and-wales---2013/stb---deaths-related-to-drug-poisoning-in-england-and-wales--2013.html#tab-Paracetamol-and-Other-Analgesics</ref>
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<br>Opioid receptors are present in tissues throughout the body and the interaction of the drugs with these receptors is responsible for the side effects associated with opioid medications. In the GIT these include nausea and vomiting and, as a result of decreased gut motility, constipation. Opioids also reduce the sensitivity of the respiratory centres in the brain stem to CO2 leading to respiratory depression. Other effects include drowsiness and dizziness and prolonged use can lead to hormonal changes which can lead to reduced libido, infertility and depression <ref name="BPS">The British Pain Society. Opioids for persistent pain:good practice. The British Pain Society 2010</ref>.<ref name="Ballantyne">Ballantyne JC, Mao J. Opioid therapy for chronic pain. New England Journal of Medicine 2003. 349:1943-53</ref><ref name="McFadden" />Accidental overdose is a signifcant risk; the drug naloxone is used to reverse the effects of opioids and is used to treat narcotic overdose.<ref name="BNF" /> To avoid withdrawal symptoms opioid medications should be reduced slowly under medical guidance and not stopped abruptly<ref name="BPS" />
<br>Opioid receptors are present in tissues throughout the body and the interaction of the drugs with these receptors is responsible for the side effects associated with opioid medications. In the GIT these include nausea and vomiting and, as a result of decreased gut motility, constipation. Opioids also reduce the sensitivity of the respiratory centres in the brain stem to CO2 leading to respiratory depression. Other effects include drowsiness and dizziness and prolonged use can lead to hormonal changes which can lead to reduced libido, infertility and depression <ref name="BPS">The British Pain Society. Opioids for persistent pain:good practice. The British Pain Society 2010</ref>.<ref name="Ballantyne">Ballantyne JC, Mao J. Opioid therapy for chronic pain. New England Journal of Medicine 2003. 349:1943-53</ref><ref name="McFadden" />Accidental overdose is a signifcant risk; the drug naloxone is used to reverse the effects of opioids and is used to treat narcotic overdose.<ref name="BNF" /> To avoid withdrawal symptoms opioid medications should be reduced slowly under medical guidance and not stopped abruptly<ref name="BPS" />
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<br>The use of opioids for chronic non-cancer pain is controversial. Pain is rarely abolished and the use of analgesoa is to enable the individual to particpate in rehabilitation to restore function and maximise quality of life.<ref name="BPS" /> Prolonged use of opioids can result in tolerance (where an increased dose of a drug is required to produce the same analgesic effect), psychological dependence and sometimes addiction and abuse. There is evidence that people with chronic pain may not benefit from opioid use. People who use opioids for a prolonged time may develop hyperalagesia which is disinct from their original pain problem and may present as a more diffuse less defined pain<ref name="BPS" /> A Danish study reported significant associations between opioid use and an increase in moderate to severe pain as well as a reduction in quality of life scores and poorer self rated health in people with chronic pain taking opioid medication versus those who were not. Using opioids was also linked to low levels of exercise , unemployment and higher healthcare usage.<ref>Eriksen J,Sjogren P, Bruera E, Ekholm O,Rasmussen NK. Critical issues on opioids in chronic non-cancer pain. An epidemiological study.Pain 2006;125:172-9</ref> The Cochrane review <ref name="Cochrane review">Deshpande A, Furlan AD, Mailis-Gagnon A, Atlas S, Turk D. Opioids for chronic low-back pain. Cochrane Database of Systematic Reviews 2007(3)</ref> found that there was no statisically significant difference in pain relief and functional improvement beween strong opioids and NSAIDS fpr people with chronic low back pain. <br>
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<br>The use of opioids for chronic non-cancer pain is controversial. Pain is rarely abolished and the use of analgesoa is to enable the individual to particpate in rehabilitation to restore function and maximise quality of life.<ref name="BPS" /> Prolonged use of opioids can result in tolerance (where an increased dose of a drug is required to produce the same analgesic effect), psychological dependence and sometimes addiction and abuse. There is evidence that people with chronic pain may not benefit from opioid use. People who use opioids for a prolonged time may develop hyperalagesia which is disinct from their original pain problem and may present as a more diffuse less defined pain<ref name="BPS" /> A Danish study reported significant associations between opioid use and an increase in moderate to severe pain as well as a reduction in quality of life scores and poorer self rated health in people with chronic pain taking opioid medication versus those who were not. Using opioids was also linked to low levels of exercise , unemployment and higher healthcare usage.<ref>Eriksen J,Sjogren P, Bruera E, Ekholm O,Rasmussen NK. Critical issues on opioids in chronic non-cancer pain. An epidemiological study.Pain 2006;125:172-9</ref> The Cochrane review <ref name="Cochrane review">Deshpande A, Furlan AD, Mailis-Gagnon A, Atlas S, Turk D. Opioids for chronic low-back pain. Cochrane Database of Systematic Reviews 2007(3)</ref> found that there was no statisically significant difference in pain relief and functional improvement beween strong opioids and NSAIDS fpr people with chronic low back pain. <br>
== Adjuvants ==
== Adjuvants ==