Lecture 2: Pain treatment and pain research

Question 1

What did trephination consist of in Antiquity?

Answer 1

Relieving pain by cutting a whole in the scalp to let the evils spirits out of your head.
Trephination did not work.

Question 2

How was theriac able to relieve pain?

Answer 2

The active ingredient in Theriac is opium poppy.

Question 3

What were the two main ingredients used in antiquity that are still used in pain medication today?

Answer 3

• Willow bark for aspirin

- Opium poppy for morphine

Question 4

How did morphine evolve when it was discovered?

Answer 4

• 1600’s: chemists found how to turn opium into morphine.
• But the problem was that you didn’t really know how big the dose was, too little wasn’t effective and too much could kill you.
• Merck in Darmstadt, were the first to standardize the doses

Question 5

How did anesthesia evolve?

Answer 5

• Before, the only way to operate people was to get them blackout drunk.
• Then a drug called Ether was discovered which was used to do general anesthetia.
• It is not used today anymore.

Question 6

What are opiates made from?

Answer 6

Opiates are a subdivision of opioids. They are either natural or synthetic derivates of opium.

Question 7

What are the different ways of administering drugs ?

Answer 7

• Injection: subcutaneous, intramuscular, intravenous.
• Transdermal (patch)
• Implantation
• Intrasynoval (joints)
• Intracardiac
• Intrathecal

Question 8

What are the major differences between the routes?

Answer 8

• Some of these routes will work better than others

- Some of these routes are faster acting than others (intravenous is the fastest, the slowest is oral)

Question 9

What would the advantage of topical (transdermal) administration be?

Answer 9

Fewer side effect, because you can use a much lower dose of the drug.

Question 10

What is the difference between pharmacodynamics and pharmacokinetics?

Answer 10

Pharmacodynamics: what the drug does to body once it gets were it has to go

Pharmacokinetics: What the body does to the drug

Question 11

What is patient-controlled analgesia? (PCA)

Answer 11

A method of pain relief in which the patient controls the amount of pain medicine that is used.

Question 12

What are the main opiate side effects and what do they mean?

Answer 12

• constipation
• nausea or vomiting
• sedation (sleepiness)
• confusion or hallucinations
• myoclonic jerks (Sudden uncontrollable contraction of muscles)
• respiratory depression
• xerostomia (dry mouth)
• urine retention
• pruritis (severe itching of skin)

Question 13

What are over-the-counter (OTC) analgesics?

Answer 13

• Analgesics you can have without prescription
• Usually there are several components in these analgesics: one analgesics, and other things that can treat cough or running nose for example.

Question 14

What does dextromethorpan treat?

Answer 14

cough

Question 15

What are the 3 steps to treating cancer pain?

Answer 15

• non-opioid
• opioid for mild to moderate pain (codeine)
• opioid for moderate to severe pain (morphine)

-Additional drugs called adjuvants for fear and anxiety can also be used.

Question 16

What other type of analgesics are used to treat pain?

Answer 16

anti-depressants, convulsants, botox.

Question 17

What is a “first line” treatment?

Answer 17

The initial, or first treatment recommended. (for example for a headache, tylenol or doliprane.)

Question 18

What are the three ways of treating pain?

Answer 18

• surgically (by otomy or ectomy which consists in removing a specific part of the body)
• anesthesiologically
• psychologically
• others (ex: physical therapy, acupuncture)

Question 19

What is complementary or alternative medicine? (CAM)

Answer 19

• Also called holistic or integrative medicine
• They can be individual practices like mindfulness
• They can be systems of medicine like homeopathy, osteopathy.
• They can be World medicine systems like Chinese medicine
• these sometimes have some evidence of efficacy, not everything is proved, some might just be placebo, or actually work.

Question 20

What is the best type of self-management of pain?

Answer 20

• Exercise

- Pain patient might not like the idea of self-management of pain

Question 21

What were the beliefs in the 1900’s about pain and babies?

Answer 21

-Doctors thought babies didn’t feel any pain. An open heart surgery was performed on Jeffrey Lawson without analgesia which was a scandal and changed the outlook on pain and babies

Question 22

What is the easiest way to draw blood on babies?

Answer 22

With a heel needle, this is performed without analgesic which is painful for the baby.

Question 23

What are different types of natural analgesics for babies?

Answer 23

• sugar
• suckling
• skin to skin with mother

Question 24

What did John J.Bonica do?

Answer 24

• wrote the first textbook on the management of pain

- He put in place a new pain management organization in hospitals

Question 25

What is palliative care?

Answer 25

Palliation is when you know you're not gonna be able to cure the cancer so you are just trying to make the patient more comfortable, with or without ongoing curative care

Question 26

What is hospice care?

Answer 26

Hospice care is when curative intent has been given up and you are just trying to make the patient comfortable

Question 27

What are some objections to setting pain as the 5th vital sign?

Answer 27

- all other signs are objective but pain isn't | - the necessity to measure pain has led to increased pressure to treat it, leading to overtreatment

Question 28

What are the different levels of evidence in medicine?(from less accurate to more accurate)

Answer 28

- Personal opinion - expert opinion - case reports - case series (series of case reports) - case control studies - cohort studies - randomized controlled double blind studies - systematic reviews and meta-analysis

Question 29

How does a RCT (Randomized Controlled Trial) work?

Answer 29

Subjects are randomly assigned to one of two groups: - experimental (receive the drug) - control (don't receive anything)

Question 30

In what case could someone be excluded from an RCT when assessed for eligibility?

Answer 30

Someone who has other pain conditions than the one being studied

Question 31

What are the 4 phases of RCT?

Answer 31

- enrollment: assessing participants for eligibility (inclusion criteria: you are diagnosed with the thing that is being studied) - allocation: allocated to intervention (2 ways of doing this: control with placebo or other type pf drug (active control)) - follow up (few hours, days or weeks later): participants either discontinue, or are lost to follow up

Question 32

What does the parallel design consist of?

Answer 32

- 1 group assigned with experimental treatment, 1 group assigned with active control, 1 group assigned with placebo - They all end the trial at the same time

Question 33

What does the crossover design consist of?

Answer 33

- 2 groups, 2 periods, 2 drugs | - group 1 takes drug A in period 1 and drug B in period 2 and vice versa for group B

Question 34

What is the advantage to the crossover design and its potential confound?

Answer 34

- you need fewer people | - it might actually matter what drug you get first

Question 35

What does the enriched design consist of ?

Answer 35

- First phase is screening, everybody gets the drug | - Then people are assigned to placebo or real drug after having the drug in the first place.

Question 36

How does odds ratio work ?

Answer 36

- produit en croix | - serves for example to figure out if toxins in the environment cause cancer

Question 37

What is a forest plot?

Answer 37

- 1D graph of relative risk - List of papers the author thinks are relevant - If the relative risk is 1, the treatment doesn't make things better or worse, lower than one= lower negative risks, higher than 1= higher negative risks - size of square is the weight of the study

Question 38

What are l'abbe plots?

Answer 38

- 2D graph with a dot for the result of each study | - compares the effect of placebo with the effect of treatment.

Question 39

What is the relevance of NNT and how do you calculate it?

Answer 39

- How many people you need to treat to get a success result (NNT=1 means the drug works on everyone) - At least 50% of people means the drug is a "success" - 1/proportion benefiting from experimental intervention - proportion benefiting from a control intervention.

Question 40

According to NNT's, what drugs are the best for treating neuropathic pain?

Answer 40

-TCA's and Opioids are the best treatments

Question 41

What are the odds of NNTs?

Answer 41

- It isn't everything, you have to consider side effects | - One drug may be better for one kind of specific pain over another.

Question 42

What is the NNH?

Answer 42

- Number Needed to Harm | - Same thing than NNT but the harm condition is defined, not the success.

Question 43

How are consensus guideline decided and what are the odds of them?

Answer 43

- Experts in specific types of illness but consensus guidelines in place. - They are "guide" lines but your doctor can prescribe you anything they want (at risk of getting in trouble with their superior if they have one)

Question 44

How do doctors decide which drugs to prescribe to their patients with the consensus guidelines?

Answer 44

- starts with first line, if it doesn't work or has side effects, go to 2nd line, same thing, if not they go to 3rd line as last resort- - Have to consider cost, side effects, quality of evidence...

Question 45

Why aren't there more neurologists and rheumatologists in IASP?

Answer 45

Because they have their own pain association

Question 46

Why are there more papers on neuropathic pain?

Answer 46

Because we have better models for neuropathic pain so there are more studies on it?