Pain, Neurology and Mental Health Prescribing

This module covers drug treatment of pain in UK practice: multimodal analgesia and the stepwise analgesic ladder, safe use of paracetamol and NSAIDs, opioid choice, titration, conversion and adverse effects including constipation, analgesia after surgery, and first-line treatment of neuropathic pain. It prepares learners for prescribing scenarios on postoperative pain, osteoarthritis, diabetic peripheral neuropathy and opioid-induced constipation.

1. Multimodal Analgesia and the Analgesic Ladder: Paracetamol, NSAIDs and When to Step UpPreview

   This lesson explains the stepwise analgesic ladder and the principle of multimodal analgesia, then focuses on the two foundation drugs: paracetamol and the non-steroidal anti-inflammatory drugs. You will work through paracetamol dosing and hepatotoxicity risk, and the gastrointestinal, renal and cardiovascular hazards of NSAIDs in older adults, in renal impairment and in patients already taking aspirin. Gastroprotection, relevant interactions and regional formulary variation are covered, with clear signposting to the opioid lesson that follows. Teaching doses are examples only; safety decisions in practice rest on local protocols, current formularies and the prescriber's clinical judgment.

   10 min
2. Opioid Analgesia: Choice, Titration, Conversion and Managing Adverse Effects Including Constipation

   This lesson covers the safe and effective use of opioid analgesics in UK practice. It explores weak and strong opioids such as codeine, tramadol, morphine and oxycodone, including modified-release and transdermal preparations. Key topics include titration, oral morphine equivalence, route conversion, and dose adjustment in renal or hepatic impairment. It also addresses prevention and treatment of constipation, nausea, sedation and respiratory depression, with reference to British National Formulary dosing and NICE-style guidance.

   10 min
3. Neuropathic Pain: Recognition, First-Line Drug Choice, Titration and Review

   This lesson covers how to recognise neuropathic pain and distinguish it from nociceptive pain, then choose and use first-line drug treatment in UK practice. It uses amitriptyline, duloxetine, gabapentin and pregabalin as teaching examples, with BNF-style dosing for illustration only. It covers titration, expected time to benefit, review points, common adverse effects, cautions in older adults and renal impairment, gabapentinoid dependence and withdrawal, switching between agents, and topical options such as lidocaine 5% plaster and capsaicin. The lesson is for final-year medical and pharmacy students and foundation doctors preparing for finals and the Prescribing Safety Assessment. It does not replace local formularies, institutional protocols or clinical judgment.

   10 min
4. Prescribing: Postoperative Pain After Laparotomy
   15 min
5. Prescribing: Prescribing Analgesia for Knee Osteoarthritis in an Older Woman on Aspirin
   15 min
6. Prescribing: Prescribing for Painful Diabetic Peripheral Neuropathy
   15 min
7. Prescribing: Constipation on Opioid Therapy: Prescribing a Laxative Regimen
   15 min
8. OSCE station: Prescribing Postoperative Analgesia after Laparoscopic Cholecystectomy
   11 min
9. Quiz: Analgesia and Pain Management: The Analgesic Ladder, Opioid Safety and Neuropathic Pain
   9 min

Module 2 of Pain, Neurology and Mental Health Prescribing. Covers antiepileptic drug selection with attention to valproate in women of childbearing potential and enzyme-inducing interactions, acute and prophylactic treatment of migraine, and Parkinson's disease drugs alongside antiemetics that are safe to use. Dosing follows the British National Formulary; local formularies and specialist guidance may differ. Content is for education and training, not a substitute for clinical judgment.

1. Antiepileptic Drug Choice: Seizure Type, Valproate Risk in Women of Childbearing Potential, and Enzyme-Inducing Interactions

   Antiepileptic drug choice starts with the seizure type, not with habit. This lesson sets out first-line options for focal seizures and for the main generalised seizure types, and flags the drugs that can worsen myoclonic and absence seizures. It then examines sodium valproate in girls and women who could become pregnant: the risks to the fetus, the conditions of the pregnancy prevention programme, and the conversations that must happen before it is prescribed. The final section covers enzyme induction and inhibition, showing how carbamazepine, phenytoin, phenobarbital, primidone and topiramate alter the concentrations of other antiepileptics, hormonal contraceptives and commonly co-prescribed medicines, and how valproate raises lamotrigine concentrations. Switching between products, gradual withdrawal and monitoring, including when plasma concentrations are useful, are covered. Practice varies by region and formulary.

   10 min
2. Migraine: Matching Acute Treatment to the Attack, Choosing Prophylaxis, and the Contraception Decision

   This lesson covers the practical prescribing decisions in migraine. It starts with acute treatment: which analgesic, when to add a triptan, and which antiemetic to use, taking account of attack severity, timing and cardiovascular risk. It then covers medication overuse headache, when prophylaxis is indicated, and how to choose and review propranolol, amitriptyline, topiramate or candesartan, including the restrictions on topiramate and valproate in women who could become pregnant. The third strand is the interaction between migraine with aura and combined hormonal contraception, where the added stroke risk makes progestogen-only or non-hormonal options preferable. It ends with the point at which specialist advice is needed. Doses quoted are teaching examples only.

   10 min
3. Parkinson's Disease: Drug Treatment and Choosing an Antiemetic That Does Not Worsen Motor Control

   This lesson covers the drug treatment of Parkinson's disease, then tackles a common prescribing problem: nausea in a patient who is already taking levodopa. It sets out the dopaminergic and adjunctive drug classes and what each is used for, then explains why antiemetics that block dopamine D2 receptors, such as metoclopramide and prochlorperazine, can worsen parkinsonism or precipitate an akinetic crisis. It describes which antiemetics are usually preferred, including domperidone and ondansetron, together with the cautions and monitoring each requires, and how nausea and vomiting are managed in advanced disease when swallowing and absorption are unreliable. Teaching doses are illustrative only; local formularies, prescribing information and specialist advice govern actual practice.

   10 min
4. Prescribing: Newly Diagnosed Generalised Epilepsy in a Woman of Childbearing Potential
   15 min
5. Prescribing: Smoking Cessation in a Patient with Epilepsy
   15 min
6. Prescribing: Migraine with aura in a 28-year-old woman on a combined oral contraceptive
   15 min
7. Prescribing: Nausea in a Patient with Parkinson's Disease on Co-beneldopa
   15 min
8. OSCE station: Focused History: 35-Year-Old Woman with Worsening Headache
   11 min
9. OSCE station: Cranial Nerve Examination for Left Facial Weakness
   11 min
10. Quiz: Epilepsy, Headache and Parkinson's Disease: Antiepileptic, Migraine and Antiparkinsonian Prescribing
    9 min

This module covers the pharmacological management of depression, anxiety and insomnia in UK practice. It moves from structured assessment and risk in low mood, through choosing and switching antidepressants with attention to SSRIs in older adults (hyponatraemia, bleeding, falls), to lithium and mood stabilisers, and the safe, time-limited use of anxiolytics and hypnotics.

1. Assessing Low Mood and Starting an Antidepressant: Risk, Sertraline Counselling and Review

   Low mood is common and most presentations are managed outside secondary care, but safe prescribing depends on a structured assessment before any drug is chosen. This lesson covers severity, duration and functional impairment; direct questioning about self-harm and suicide; and the medical, substance-related and drug causes that mimic or worsen depression. It then applies stepped care and British National Formulary dosing to select a first-line antidepressant, using sertraline as the worked example, and sets out what to tell a patient starting it: the delayed onset of benefit, early adverse effects, adherence, interactions and when to seek urgent help. Review intervals, response monitoring and duration of treatment are covered. Doses given are teaching examples; local formularies and guidelines vary by region.

   10 min
2. Choosing and Switching Antidepressants: SSRIs in Older Adults, Hyponatraemia, Bleeding, Falls and Safe Switching

   This lesson covers the extra care needed when using SSRIs in older adults and the practical methods for switching antidepressants. It explains why age-related changes and polypharmacy increase risk, then focuses on four safety concerns: hyponatraemia and SIADH, bleeding risk with antiplatelets, anticoagulants and NSAIDs, falls and fractures, and QT prolongation. The lesson then describes cross-tapering, direct switching and washout periods, and highlights interactions that must be avoided. Teaching examples use British National Formulary dosing and NICE-style guidance. Regional and formulary differences are noted where practice varies. The content supports safe prescribing and monitoring decisions in UK practice for medical, pharmacy and nursing learners.

   10 min
3. Lithium, Mood Stabilisers, Anxiolytics and Hypnotics: Monitoring, Toxicity and Dependence

   This lesson covers the safe use of lithium, other mood stabilisers, benzodiazepines, Z-drugs and non-benzodiazepine anxiolytics and hypnotics. It sets out why lithium needs baseline and repeated monitoring of renal, thyroid and calcium parameters, how the therapeutic range is used in practice, and how toxicity presents and is managed. It then examines the interacting drugs that raise lithium levels and the monitoring requirements of alternative mood stabilisers. The final sections cover short-term prescribing of benzodiazepines and Z-drugs, the mechanisms and recognition of dependence and withdrawal, and the non-drug options that should be offered first for anxiety and insomnia. Doses quoted are teaching examples only; local formularies and current prescribing information govern practice, and all content is for education and training rather than a substitute for clinical judgment.

   10 min
4. Prescribing: Moderate Depression in a 70-Year-Old Man with Recent Hip Fracture: Prescribing an Antidepressant
   15 min
5. OSCE station: Psychiatric History and Risk Assessment for Low Mood
   11 min
6. OSCE station: Counselling a Patient Starting Sertraline for Depression
   11 min
7. Quiz: Depression, Anxiety and Sleep: Antidepressants, SSRIs in Older Adults, Lithium and Anxiolytics
   9 min

This module covers the safe prescribing of antipsychotics and the management of acute disturbed behaviour. It begins with antipsychotic choice and the adverse effects that drive monitoring, then moves to the assessment and drug treatment of acute psychosis including rapid tranquillisation, and ends with delirium: recognition, reversible causes, drugs that precipitate or worsen it, and non-drug and drug management. Doses are teaching examples only; always check the current British National Formulary.

1. Choosing an Antipsychotic and Monitoring for Metabolic, Movement, Cardiac and Prolactin Effects

   Antipsychotics differ more within classes than between them, so choice rests on indication, comorbidity, prior response and tolerability rather than on the first- versus second-generation label. This lesson covers how to select a drug for psychosis and how to monitor for the harms that change decisions: extrapyramidal symptoms and tardive dyskinesia, neuroleptic malignant syndrome, weight gain and hyperglycaemia, QT prolongation and hyperprolactinaemia. It sets out baseline and follow-up physical health checks, what to record before starting, what to repeat and when, and which findings should prompt a review of treatment. Doses mentioned are teaching examples; local formularies and current prescribing information govern practice.

   10 min
2. Assessing Acute Psychosis and Prescribing for Rapid Tranquillisation

   Acute psychosis and severe agitation are emergencies in which treatable physical and drug-related causes must be excluded before a psychiatric label is applied. This lesson covers the immediate assessment of the agitated or psychotic patient, structured risk assessment, and de-escalation before any drug is given. It then works through oral and intramuscular options for acute psychosis and rapid tranquillisation, using British National Formulary doses as teaching examples, and identifies the patients in whom antipsychotics need caution because of cardiac, metabolic or neurological risk. Monitoring of sedation, pulse, blood pressure and ECG is described, together with the UK legal and consent framework, including the Mental Health Act and the Mental Capacity Act. Practice varies by region and formulary.

   10 min
3. Delirium: Recognition, Reversible Causes and Drugs That Cause or Worsen It

   Delirium is a common, fluctuating disturbance of attention and awareness that is often missed in older adults, particularly when the presentation is quiet rather than agitated. This lesson covers how delirium presents, how it differs from dementia and depression, and how to search systematically for reversible precipitants including infection, pain, constipation, dehydration, hypoxia, alcohol or benzodiazepine withdrawal, and culprit medicines. It reviews drugs that commonly cause or worsen delirium, such as anticholinergics, opioids, benzodiazepines and steroids, then sets out non-drug management as first-line treatment, the narrow situations in which drug treatment is justified, and the extra caution required in Parkinson's disease and Lewy body dementia.

   10 min
4. Case: Acute Psychosis in a Young Man: Assessment and Immediate Management
   20 min
5. Case: Delirium on the Acute Medical Unit: An Elderly Woman with a Urinary Tract Infection
   20 min
6. Quiz: Psychosis and Delirium: Antipsychotic Prescribing, Rapid Tranquillisation and Delirium Management
   8 min