essential pain management

Question 1

what is pain

Answer 1

an unpleasant sensory and emotional experience associated with or resembling that associated with acute or potential tissue damage or described in terms of such damage

Question 2

benefits of treating pain: physical

Answer 2

improved sleep
better appetite
fewer medical complications
better mobility

Question 3

benefits of treating pain: psychological

Answer 3

reduced suffering

less depression, anxiety

Question 4

benefits of treating pain: for society

Answer 4

lower health costs e.g. shorter hospital stay

able to contribute to community

Question 5

classification of pain: acute pain

Answer 5

recent onset, probable limited duration

Question 6

classification of pain: chronic pain

Answer 6

> 3 months

often no identifiable cause

Question 7

classification of pain: cancer pain

Answer 7

progressive

may be mixture of acute and chronic

Question 8

classification of pain: nociceptive pain

Answer 8

obvious tissue injury or illness
aka physiological or inflammatory pain
protective function

Question 9

classification of pain: neuropathic pain

Answer 9

nervous system damage or abnormality

does not have protective function - pain ongoing after original injury (if there has been one)

Question 10

pain physiology: periphery

Answer 10

tissue injury that results in release of chemicals - prostaglandins, substance p

stimulation of nociceptors

signals travel in A-delta or C fibres to spinal cord (dorsal root ganglion)

Question 11

pain physiology: spinal cord

Answer 11

dorsal horn is first relay station

second nerve travels up opposite site of spinal cord into thalamus

Question 12

pain physiology: brain

Answer 12

thalamus is second relay station

connections to many parts of brain - cortex, limbic system, brainstem

pain perception occurs in cortex

Question 13

pain physiology: modulation

Answer 13

descending pathway from brain to dorsal horn

usually decreases pain signal - neurotransmitters

Question 14

neuropathic pain pathological mechanisms

Answer 14

increased receptor numbers - enhance pain signal and keeps it going

abnormal sensitisation of nerves - peripheral, central

chemical changes in dorsal horn

loss of normal inhibitory modulation

Question 15

simple analgesics

Answer 15

paracetamol (acetaminophen)

NSAIDs - ibuprofen, diclofenac

Question 16

opioids

Answer 16

weak: codeine, tramadol
strong: morphine, oxycofone, fentanyl

potential for addiction

Question 17

treatments: periphery

Answer 17

non-drug: rest, ice, elevation

NSAIDs - reduce amount of prostaglandins

local anaesthetics - reduce nociceptive afferent triggering

Question 18

treatments: spinal cord

Answer 18

non-drug: acupuncture, massage, TENS

local anaesthetics: epidural, nerve blockade

opioids

ketamine (modulates pain signal in descending pathways)

Question 19

treatments; brain

Answer 19

non-drug: psychological

drug:
paracetamol
opioids
amitriptyline 
clonidine

Question 20

paracetamol: advantages

Answer 20

cheap, safe
can be given orally, rectally or IV
good for mild pain (itself) or mod-severe (used w other drugs)

Question 21

paracetamol: disadvantages

Answer 21

liver damage in overdose

max dose related to patient weight

Question 22

NSAIDs advantages

Answer 22

cheap, gen safe

good for nociceptive pain

Question 23

NSAIDs disadvantages

Answer 23

GI and renal (reduced renal blood flow) side effects plus bronchospasm in some patients with asthma

Question 24

codeine advantages

Answer 24

cheap
sage
good for mild-moderate acute nociceptive pain

Question 25

codeine disadvantages

Answer 25

constipation | not good for neuropathic pain

Question 26

tramadol advantages

Answer 26

less respiratory depression can be used with opioids and simple analgesics less constipating

Question 27

tramadol disadvantages

Answer 27

nausea + vomiting | controlled drug

Question 28

morphine advantages

Answer 28

cheap, generally safe can be given orally, IV, IM, SC, PR, intrathecally effective if given regulaly

Question 29

morphine disadvantages

Answer 29

constipation resp depression in high dose controlled drug addiction/avoidance due to fear of addiction

Question 30

amitriptyline advantages

Answer 30

cheap, safe in low dose good for neuropathic pain also treats depression, poor sleep

Question 31

amitriptyline disadvantages

Answer 31

anti-cholinergic side effects (e.g. glaucoma, urinary retention) long term use may be linked with cognitive decline and dementia

Question 32

pain assessment

Answer 32

``` verbal rating score numerical rating score visual analogue scale smiling faces abbey pain scale (for confused patients) functional assessments ```

Question 33

WHO pain ladder: step one

Answer 33

non-opioids - NSAIDs or paracetamol

Question 34

WHO pain ladder: step 2

Answer 34

mild opioids (e.g. codeine) with or without non-opioids

Question 35

WHO pain ladder: step 3

Answer 35

strong opioids (e.g. morphine) with or without non-opioids

Question 36

WHO pain ladder: mild pain

Answer 36

bottom rung of ladder

Question 37

WHO pain ladder: moderate pain

Answer 37

bottom and middle rungs

Question 38

WHO pain ladder: severe pain

Answer 38

bottom and top rungs

Question 39

WHO pain ladder: as pain resolves

Answer 39

move from top to middle rung continue bottom rung lastly,, stop NSAIDs first then paracetamol

Question 40

RAT approach to pain management

Answer 40

recognise pain assess pain - severity, type, other factors treat - non-drug, drugs

Question 41

drugs for neuropathic pain

Answer 41

amitryptiline gabapentin duloxetine