Week 6- Pain and post operative analgesia

Question 1

what is pain?

Answer 1

An unpleasant sensory and emotional experience associated with, or
resembling that associated with, actual or potential tissue damage,

Question 2

how is pain measured?

Answer 2

• Usually measured on a scale, typically 1-10
• For younger children pictorial scales with faces are used to depict the level of pain
-In very young children and babies and patient unresponsive in critical
care behavioral and physiological signs are used to determine the level of pain

Question 3

what is the WHO analgesic ladder?

Answer 3

step one- is mild pain use non-opioid
step 2- for pain increasing/persistent use non-opioid or opioid for mild to moderate pain
step 3- for increasing pain/persistent use opiodid

Question 4

what are the non-opioid analgesic?

Answer 4

• Paracetamol
- Weight, hepatic function
• NSAIDs/COX-2 inhibitors
• Topical treatments
- NSAIDs
- Capsaicin
- Lidocaine

Question 5

what are some opioids? strong and mild

Answer 5

• Opioids for mild/moderate pain – weak opioids – limited potency at mu receptor
-Codeine
- Dihydrocodeine
• Opioids for moderate/severe pain – strong opioids – high potency at mu receptor
- Morphine
- Diamorphine
- Oxycodone
- Fentanyl

Question 6

what are some considerations surround opioids analgesia?

Answer 6

• Metabolism
- Several opioids, including codeine, tramadol and oxycodone, are affected by
variations in CYP2D6 metabolism
• Side effects
- Constipation
- Nausea/vomiting
- Drowsiness
- Sedation
- Respiratory depression
• Renal function
• Dependance/addiction

Question 7

what are some adjuvant therapies opioids be used with?

Answer 7

• Anti-epileptic drugs
• Antidepressants
• Other
- Dexamethasone for bone pain in palliative care
• Non pharmaceutical strategies
- Physiotherapy
- Exercise
- Psychological therapy
- Acupuncture

Question 8

what is chronic pain? types?

Answer 8

• One of the most common reasons for GP consultation
• May be classified as per type
- Musculoskeletal
- Neuropathic
- Non-specific persistent pain
- Chronic headache syndrome

Question 9

what can musculoskeltal pain be broken down into?

Answer 9

Mechanical pain
• Osteoarthritis
• Lower back pain
• Rheumatoid arthritis

Question 10

what is lower back pain/ sciatica?

Answer 10

• Low back pain that is not associated with serious or potentially serious causes
• Sciatica - leg pain secondary to lumbosacral nerve root pathology
• Worldwide lower back pain causes more disability than any other condition

Question 11

what is the treatment for lower back pain/ sciatica?

Answer 11

• Treatment
• Continue normal activities
• Group exercise programs
• Manual therapies
• Psychological therapy
• Oral NSAID
• If NSAID contraindicated or not tolerated weak opioid +/- paracetamol for ACUTE pain
only
• Sciatica specific – epidural injections (local anaesthetic + corticosteroid), spinal
decompression surgery
• Surgical treatments
• Radiofrequency denervation
• Spinal cord stimulation

Question 12

what is osteoarthritis? symptoms

Answer 12

• Most common form of arthritis
• Breakdown of the cartilage in the joints, most commonly hips,
knees, hands, lower back and neck
- Symptoms
• Joint pain during and after activity
• Joint stiffness in the morning or after rest
• Initial limited range of motion
• Clicking or cracking in joints
• Swelling around joints
• Muscle weakness around the joint
• Instability of the joint

Question 13

what is osteoarthritis treatment?

Answer 13

- Treatment
• Exercise and manual therapy
• Weight loss if overweight/obese
• Paracetamol +/- topical NSAID
• Topical capsaicin
• If the above are ineffective or insufficient oral NSAID/COX-2 inhibitor may be
considered
• Intra-articular corticosteroid

Question 14

what is rheumatoid arthritis?

Answer 14

• Autoimmune disease causing inflammation of the synovium
• Can lead to erosion and deformation of the affected joints
• Other tissues may be affected in more advanced disease
- Symptoms
• Symmetrical pain and swelling of the small joints in the hands and feet lasting
>6 weeks
• Spread to the larger joints
• Joints may be warm and tender
• Stiffness on waking or following inactivity
• Fatigue, fever and loss of appetite

Question 15

what can be used for musculoskeletal pain?

Answer 15

• Corticosteroids or NSAIDs may be used for symptomatic control of
an acute flare
• Physiotherapy
• Hand exercise program
• 'Treat to target strategy'
• Surgical treatment

Question 16

what is treat to target?

Answer 16

• Initial therapy
• Monotherapy
• Methotrexate/leflunomoide/ sulfasalazine
• Hydroxychloroquine as alternative in those with mild or palindromic (periodic) disease
• Step Up Strategy
• Additional DMARD (methotrexate/ leflunomide/ sulfasalazine /hydroxychloroquine) in combination where dose titration has not achieved remission/low disease activity
• Inadequate response to conventional DMARDs
• Biological DMARDs
• Upadacitinib/sarilumb/ adalimumab/ etanercept/infliximab…..
• Inadequate response to biological DMARDs
• Rituximab

Question 17

what is neuropathic pain? diff types

Answer 17

• Definition - ‘Central neuropathic pain is defined as ‘pain caused by a
lesion or disease of the central somatosensory nervous system’, and
peripheral neuropathic pain is defined as ‘pain caused by a lesion or
disease of the peripheral somatosensory nervous system’.IASP 2011
• Types
• Peripheral neuropathy
• Complex regional pain syndrome
• Central pain

Question 18

how is neuropathic pain? how is the pain exerted? treatment?

Answer 18

• Can be difficult to manage due to heterogeneity of its aetiologies, symptoms and underlying mechanisms
• Can be intermittent or constant, spontaneous or provoked pain
• Treatment
• Amitriptyline/duloxetine/gabapentin (or pregabalin)
• If initial drug ineffective try one of the others
• Tramadol may be considered for acute rescue therapy
• Consider capsaicin cream for people with localised neuropathic pain who wish
to avoid, or who cannot tolerate, oral treatments
• Carbamazepine should be offered for management of trigeminal neuralgia

Question 19

what is included in non-specific persistence pain?

Answer 19

• Includes conditions that may be recorded as
• fibromyalgia
• complex regional pain syndrome
• myofascial pain
• somatoform disorder
• functional syndromes
• chronic widespread pain
• pelvic pain of unknown origin

Question 20

what is the treatment for non-specific persistent pain

Answer 20

• Treatment
• Supervised group exercise program
• Psychological therapy
• Acupuncture
• Antidepressants
• Duloxetine/fluoxetine/paroxetine/ citalopram/sertraline/amitriptyline
• Several pharmacological therapies are not recommended for use in the
treatment of persistent pain including paracetamol, opioids, NSAIDS,
antiepileptic drugs, benzodiazepines….

Question 21

what are chronic headaches?

Answer 21

• Cluster-type (idiopathic, intermittent, unilateral eye, lasting less than
2 hours, occurring more than 3 days per week)
• Analgesic overuse (bilateral, constant, lasting 8 to 24 hours)
• Tension-type (primary headache, bilateral, constant, lasting 8 to 24
hours, 7 to 9 days per month)
• Post-trauma (bilateral, constant, lasting 8 to 24 hours, 7 to 9 days per
month)
• Chronic migraine (primary headache, bilateral, lasting 1 to 4 hours)

Question 22

what is acute pain?

Answer 22

• Sudden onset and result of something specific
• Usually <6 months duration
• Typically can be split into spontaneous insult/trauma and planned – surgery
• Spontaneous/trauma
• Broken bones
• Burns and cuts
• Toothache
• Headache
• Childbirth

Question 23

what is the treatment for acute pain?

Answer 23

• Minor causes of acute pain
• OTC analgesia
• Paracetamol
• NSAIDs – PO/topical
• Low dose weak opioids
• Non-pharmacological
• More significant pain, where medical treatment is necessary, may
necessitate higher levels of analgesia and additional therapies
• The WHO pain ladder can be used as a basis for acute pain
management

Question 24

what is palliative care?

Answer 24

• Palliative care is an approach that improves the quality of life of
patients and their families facing the problems associated with lifethreatening illness (World Health Organisation [WHO] )
• Recognised by the World Health Organisation as a priority are for
standardisation of care
• Development of the WHO analgesic ladder
• Adequate analgesia combined with other symptomatic control to
ensure patients are comfortable
• Palliative care ≠ end of life

Question 25

what pain control is used in palliative care?

Answer 25

The WHO pain ladder should be adapted to the needs of individuals
• Basic principle of starting at the bottom may not be suitable for all
• Adjuvants should be considered at each step
• If pain control is not achieved move up a step
• Morphine is the most commonly used strong opioid analgesic, the
availability of prolonged and immediate release preparations allows
maintenance and breakthrough analgesia
• No maximum dose of morphine

Question 26

what are some long-acting and breakthrough for palliative care?

Answer 26

• One long-acting opioid (prolonged release formulation) should be
used with a short acting opioid (immediate release formulation) for
breakthrough pain
• The breakthrough analgesia dose should be 1/10 to 1/6 of the daily
long-acting dose
• Example
• Zomorph 60mg BD
• Total daily dose = 120mg
• Breakthrough – oramorph 12 - 20mg 2 - 4 hourly
• Be aware of opioid equivalences when switching from one drug to
another

Question 27

what are syringe drivers? how do they work? biggest concern

Answer 27

• If frequent doses of analgesics or other medications for symptom control
are required a constant subcutaneous infusion can be administered via a
syringe driver
• Drugs and diluent added to a syringe which is set to infuse over a defined
time period, usually 24 hours
• Major concern is stability of the contents of the driver, multiple drugs are
often combined and infused over a prolonged period of time
• Some resources to determine the compatibility of syringe driver contents
and other information surrounding palliative care