Analgesia and Anti-emetics

ANALGESIA
COMMON DRUGS:
Paracetamol 1g QID PO
Ibuprofen 400mg TDS PO
Endone 5-10mg q3hrly PO
Oxycontin 10mg BD PO
Morphine 2.5-5mg q3hrly IV
Fentanyl 20microg q30mins IV

STEP-W ISE ANALGESIA AND ORAL VS. IM VS. IV VS. SL VS. INTRATHECAL
Mainly just discussing acute pain chronic pain shouldnt be your sole responsibility (needs
referral to HIPS)

Paracetamol there is no reason why a patient should be getting the strong stuff without
getting the basic stuff (except allergies/deranged LFTs etc!) It doesnt do anything for me.. is
a common complaint
Ibuprofen caution in renal failure (terrible triad) and pregnancy (closure of PDA)
+/- Codeine
+/- Tramadol
Oxycodone - Endone (short acting) Oxynorm is 10mg dose
Oxycodone - Oxycontin (long acting)
Morphine Sulphate - Morphine elixir/Morphine sulphate/Ordine (short
acting)
Morphine Sulphate MS Contin (long acting)
Morphine SC or IV
Fentanyl short acting
Need anaesthetic consult/Acute Pain Service re:
blocks/epidurals etc.

*Always beware of need for apperients (another talk in itself, but Movicol is gentle but tastes
gross 1-2 sachets BD, or Coloxyl with Senna is another commonly used aperient tablet
before bed is helpful 1-2 tabs BD)

OPOID ROTATION
Rationale for opioid rotation individual opioids have different structures/receptor
mechanisms cross-tolerance is incomplete (as are adverse effects)
- start at a dose equivalent of 20-30% lower
- withdrawal features can be treated with a modest dose of a short acting opioid for
several days
- Clonidine 50-150microg BD to TDS can be used to reduce sympathetically mediated
withdrawal effects (particularly if oral morphine equivalent of >300mg is used)

DOSE EQUIVALENCE
Oral conversion everything gets compared to Morphine

OPIOIDS CONVERSION RATIO Examples

Morphine: Codeine
Morphine: Tramadol
Morphine: Oxycodone
1:6 Morphine 10mg: Codeine
60mg (Panadeine forte has
30mg)
1:5 Morphine 10mg: Tramadol
50mg (Comes in 50mg. 50-
100mg is a common dose)
1.5:1 Morphine 30mg: Oxycodone
20mg
Morphine: Fentanyl
Transdermal
Morphine: Methadone
Morphine: Hydromorphone
Morphine: Buprenorphine
Transdermal
150:1 Morphine 90mg: Fentanyl
25microg/hr (Durgoesic
patch 12, 25, 50, 75 &
100mcg/hr)
3:1 Morphine 30mg: Methadone
10mg (Physeptone 10mg)
5:1 Morphine 20mg:
Hydromorphone 4mg
(Jurnista 4, 8,16, 32, 64mg)
75:1 Morphine 18mg:
Buprenorphine 10mg
(Norspan 5, 10, 20mcg/hr)

ANTI-EMETICS
COMMON DRUGS:
Metoclopramide/Maxalon 10mg TDS PO/IV (can be used up to 20mg). Cheap as chips.
Ondansetron/Zofran 4-8mg TDS SL/IV. Works better my first line.
Prochlorperazine/Stemetil 10mg PO/IV, 12.5mg IM

Metoclopramide dopamine receptor antagonist (particularly D2 in GI tract). Gastrokinetic

secondary to release of Ach in myenteric plexus dont use with other cholinergics and can
change rate of absorption. Caution in Parkinsons, bowel obstructions, severe renal failure.
Adverse effects: extrapyramidal side effects (acute dystonic reactions facial and skeletal
mm space and oculogyric crisis, tardive dyskinesia involuntary/repetitive movements),
Parkinsonian reactions (tremor, rigidity, bradykinesia). Additive sedative effects with ETOH,
benzos and opioids.

Ondansetron selective 5HT3 antagonist in CNS (important in emesis stimulated by cytotoxic

drugs) and GI tract (local initiation of the vomiting reflex). Particularly in PONV. Adverse
effects: Headaches, constipation, rarely dystonic reactions.
- Related drugs are Granisetron, Dolasetron etc. Seen used in haematology post chemo.

Prochlorperazine phenothiazine derivative, action due to dopamine blockade. Adverse

effects postural hypotension and sedation. Particularly good for vertiginous symptoms.
Acute EPS is uncommon but most important side effect can happen after one dose in
children.

Domperidone dopamine antagonist, blocks receptors in CTZ. Direct stimulant of gastric

motility. Not as effective as metoclopramide. Adverse effects: abdo cramps, dry mouth,
galactorrhoea (using it currently in O&G to stimulate milk production).

Dexamethasone good for PONV. Generally only 4-8mg. Unsure how corticosteroids control
emesis.

Droperidol - potent D2 (dopamine receptor) antagonist with some histamine and serotonin
antagonist activity. It has a central antiemetic action and effectively prevents postoperative
nausea and vomiting in adults using doses as low as 0.625 mg (antipsychotic doses range
from 5 to 10 mg IM).

May see Aprepitant at the Mater for chemo substance P (neurokinin-1) antagonist

Promethazine (Phenergan) sedating antihistamine with antimuscarinic effects. Used in

motion sickness, PONV (will contribute to post-op sedation).