Drugs (Pain Management)

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Real name for Aspirin?

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Acetylsalicyclic acid

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What is Acetylsalicyclic acid?

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Aspirin

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Presentation of Aspirin?

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Tablet - Dispersible or chewable

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Indications for Aspirin

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Back (Definition)

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What does Aspirin do? (Actions)

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Back (Definition)

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Aspirin contra-indications

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Back (Definition)

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Aspirin cautions

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Back (Definition)

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Aspirin side effects

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Back (Definition)

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Why is Aspirin contra-indicated in under 16 years?

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Back (Definition)

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Aspirin - Initial dose

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300Mg

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Aspirin - Max dose

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300Mg

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Aspirin - Repeat dose

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None

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Ibuprofen - Presentation

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Ibuprofen - Indications

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Back (Definition)

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Ibuprofen - Actions

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Back (Definition)

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Ibuprofen - Contra-indications

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Do NOT administer if the patient is:

Dehydrated.

Hypovolaemic.

Known to have renal insufficiency.

Patients with active upper gastrointestinal disturbance (e.g. oesophagitis, peptic ulcer, dyspepsia).

A woman in the last trimester of pregnancy.

A child with chickenpox.

A patient who has previously shown hypersensitivity reactions (e.g. asthma, rhinitis, angioedema or urticaria), in response to ibuprofen, aspirin or other non-steroidal anti-inflammatory drugs.

A patient with active peptic ulcer/haemorrhage.

Patient with severe heart failure (NYHA Class IV), renal failure or hepatic failure.

Patients on anticoagulant drugs, e.g. warfarin, direct oral anticoagulants (DOACs).

Avoid giving further non-steroidal anti-inflammatory drugs (NSAIDs) (i.e. ibuprofen), if an NSAID containing product (e.g. diclofenac, naproxen) has been used within the previous 4 hours or if the maximum cumulative daily dose has already been given.

Do NOT offer non-steroidal anti-inflammatory drugs (NSAIDs) to frail or older adults with fractures.

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Ibuprofen - Cautions

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Back (Definition)

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Ibuprofen - Side effects

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Back (Definition)

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Ibuprofen - Initial dose, interval & max dose (12+ years)

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Back (Definition)

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Morphine Sulphate - Presentation

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Back (Definition)

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Morphine Sulphate - Indications

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Pain associated with suspected myocardial infarction (analgesic of first choice).

Severe pain as a component of a balanced analgesia regimen.

Oral morphine can be used as a component of managing moderate pain.

The decision about which analgesia and which route should be guided by clinical judgement. Refer to Pain Management in Adults and Pain Management in Children.

Indications specific to Adults at the End of Life

Using ambulance service issue morphine for end of life should only be followed in situations where:

A patient's own medication for pain or breathlessness has not been prescribed.

The patient's own medication is not yet available or has run out.

Medicines are in place without a patient-specific document signed by an independent prescriber.

Wherever possible, liaison should occur with palliative care/nursing teams in line with local pathways, particularly if ‘anticipatory’ or ‘just in case’ medicines are prescribed and are available.

Consider discussing with a senior clinician for advice and support, preferably a clinician with expertise in end of life care before administering morphine. Follow local pathways to access senior clinician support.

If a patient has their own prescribed morphine, use this.

For both breathlessness and pain management in adults, refer to the End of Life Care guideline.

Breathlessness

Patient is at end of life, and is distressed and breathless.

Reversible causes of breathlessness should always be considered first.

If you are unable to access rapid community/palliative care, morphine should be administered.

Pain

Patient is at end of life and is in pain.

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Morphine Sulphate - Actions

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Back (Definition)

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Morphine Sulphate - Contra-Indications

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Do NOT administer morphine in the following circumstances:

Children under 1 year of age.

Respiratory depression (adult <10 breaths per minute, child <20 breaths per minute).

Hypotension (actual, not estimated, systolic blood pressure <90 mmHg in adults, <80 mmHg in school children, <70 mmHg in pre-school children).

Head injury with significantly impaired level of consciousness (e.g. below P on the AVPU scale or below 9 on the GCS).

Known hypersensitivity to morphine.

Contra-indications specific to Adults at the End of Life

Once the clinician has confirmed the patient has pain and/or breathlessness, and is at the end of life, then the benefits of morphine clearly outweigh treatment-related adverse effects. Cautions and contra-indications do not generally apply; the focus should be on symptom control for the patient to ensure a peaceful and dignified death. It is important that palliative care specialists involved in the patient’s care should be consulted as part of the assessment process. The use of the subcutaneous route also reduces the likelihood of some of these adverse effects.

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Morphine Sulphate - Cautions

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Known severe renal or hepatic impairment – smaller doses may be used carefully and titrated to effect.

Use with extreme caution (minimal doses) during pregnancy. NB Not to be used for labour pain where Nitrous Oxide (Entonox®) is the analgesic of choice.

Use morphine WITH GREAT CAUTION in patients with chest injuries, particularly those with any respiratory difficulty, although if respiration is inhibited by pain, analgesia may actually improve respiratory status.

Any patients with other respiratory problems (e.g. asthma, COPD).

Head injury. Agitation following head injury may be due to acute brain injury, hypoxia or pain. The decision to administer analgesia to an agitated head injured patient is a clinical one. It is vital that if such a patient receives opioids they are closely monitored since opioids can cause disproportionate respiratory depression, which may ultimately lead to an elevated intracranial pressure through a raised arterial pCO2.

Acute alcohol intoxication. All opioid drugs potentiate the central nervous system depressant effects of alcohol and they should therefore be used with great caution in patients who have consumed significant quantities of alcohol.

Medications. Prescribed antidepressants, sedatives or major tranquillisers may potentiate the respiratory and cardiovascular depressant effects of morphine.

Morphine may not be the appropriate treatment for a headache when the cause for the headache is uncertain, for example, a possible migraine.

Smaller doses should be considered for patients weighing less than 50kg, and for frail and/or older patients who may be more susceptible to complications.

Cautions specific to Adults at the End of Life

For pain in the last days or hours of life when the patient is in the dying phase, morphine may be given with caution for patients with a systolic blood pressure of 90mmHg or less.

If the patient has been prescribed their own ‘anticipatory’ or ‘just in case’ medications for pain, and this medicine is available, then administer the medication from the patient’s own supply, in liaison with the palliative care or nursing team.

Check for prior opioid use before administration to avoid overdosing the patient.

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Morphine sulphate - Side effects

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Back (Definition)

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Morphine Sulphate - Special precautions

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Naloxone can be used to reverse morphine related respiratory or cardiovascular depression. It should be carefully titrated after assessment and appropriate management of ABC for that particular patient and situation, refer to Naloxone Hydrochloride.

Morphine frequently induces nausea or vomiting which may be potentiated by the movement of the ambulance. Titrating to the lowest dose to achieve analgesia will reduce the risk of vomiting. The use of an anti-emetic should also be considered whenever administering any opioid analgesic, refer to Ondansetron and Metoclopramide Hydrochloride.

Special Precautions specific to Adults at the End of Life

The use of Naloxone in palliative care is not routinely practised and is only indicated in circumstances where a clinician suspects opioid induced toxicity, from intentional or unintentional overdose. The aim is to reverse life-threatening respiratory depression only i.e. if the respiratory rate is <8 breaths per minute and the patient is unconscious and or cyanosed.

Refer to the End of Life Care guideline opioid administration in the last hours of life and for death after drug administration.

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Morphine sulphate - Initial dose, interval & max dose (>50Kg, IV)

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Back (Definition)