16 - Chronic Non-Cancer Pain

Question 1

Contrast acute pain to chronic pain

Answer 1

Acute pain - is a symptom that plays a functional role in body defences and resolves with tissue recovery

Chronic pain - has no such functional role, does not resolve with tissue recovery, and can be a primary diagnosis. Chronic pain involves complex CNS signalling that can be amplified by stressors

Question 2

Define sensitization

Answer 2

Activity is generated by nociceptors during inflammation - increase excitability of nerve cells in the dorsal horn of the spinal cord (central sensitization) or increase excitability of nociceptor terminals and decrease threshold for activation by mechanical, thermal and chemical stimuli (peripheral sensitization)

Question 3

Allodynia

Answer 3

normally non-painful stimulus is perceived as pain

Question 4

Hyperalgesia

Answer 4

increase pain intensity in response to the same noxious stimulus (ex. moderate pressure causes severe pain)

Question 5

What are some misconceptions of the patient of chronic pain?

Answer 5

• The origin of the pain is biological
• Their pain problem can be solved
• A pill can solve all pain problems
• Feels questioned and develops strategies to be perceived as credible

Question 6

What are some misconceptions of the clinical of chronic pain?

Answer 6

• The origin of the pain is psychosomatic
• Feels suspicious when patina benefits from being ill
• Biomedical explanations do not match patients’ experience
• Doctors fear failure when neither cure, improvement, or consolation is achieved.

Question 7

List 3 things that all contribute to functional impairment

Answer 7

• pain
• sleep issues
• depression, anxiety, inability to cope

Question 8

Goals of therapy that all work to improve function

Answer 8

• pain reduction
• increased mobility
• exercise
• sleep
• QOL
• improved mood
• minimal side effects
• minimal cost
• minimal pill burden

Question 9

Medications are only a ____ part of the chronic pain management picture

Answer 9

small

Question 10

What can we do for subacute pain (2-12 weeks) ?

Answer 10

• reinforce self care and return to usual activities/exercise
• reassess response to pharm and non-pharm therapies
• if opioid continuation considered, assess abuse risk of potential
• assess for comorbidities that cause of increase pain

Question 11

What are the 6 A’s of opioid therapy ?

Answer 11

1) Analgesia
2) Activity
3) Adverse effects
4) Affect (cognitively, emotionally, mentally)
5) Accurate records
6) Aberrant behaviour/Abuse risk

Question 12

Opioids for ___-term management should be done with extreme caution, especially after a comprehensive assessment of potential risks..

Answer 12

long

Question 13

There are few brief pain inventory questionnaires that exist. What are the benefits of these?

Answer 13

• Helps define what makes up patient’s pain experience
• Shows you care about what goes on day-to-day
• Acts as a non-pain intensity parameter for follow-up

Question 14

What can we do to minimize abuse and diversion of opioids?

Answer 14

1) Utilize an opioid risk assessment tool +/- an opioid contract/agreement

2) Be patient-cantered and firm from the start (pharmacist and physician):
- a visit does not equal a refill
- inform patient to exit strategy if goals aren’t achieved
- a breach of contract is serious

3) Be the reliable local pharmacist
4) Use Mb Rx profiles (DPIN/eChart)
5) Small fills at shorter durations
6) Urine drug screen ?
7) Inquire about recovery and disposal if opioid no longer used

Question 15

What are possible pharmacological options that we have for chronic low back pain?

Answer 15

• Muscle relaxant (cyclobenzaprine): If spasms involved - 7-14 days max
• Acetaminophen: likely hasn’t helped the patient tin example - no better than placebo
• NSAIDs (oral):
• very few but not great studies
• TCA’s vs placebo: equivocal
• Gabapentin: if sciatica? Caution with substance abuse history?
• Epidural corticosteroids: if sciatica?