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Palliative Medicine > 2. Assessment and Management of Cancer and Chronic Pain > Flashcards

2. Assessment and Management of Cancer and Chronic Pain Flashcards

1
Q

Define pain.

A

It is an unpleasant sensory and emotional experience associated with or resembling actual or potential tissue damage

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2
Q

State 3 criteria used to classify pain?

A
  1. Duration (Acute/Chronic)
  2. Pathophysiology (Nociceptive/Neuropathic)
  3. Etiology (Cancer/Non-cancer)
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3
Q

Define Acute Pain.

A

A pain felt for a short duration (hours to days)

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4
Q

Define Chronic Pain.

A

A pain felt for a long duration (more than 3 months)

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5
Q

Define Physiological Pain.

A

Physiological pain is a warning signal of tissue injury. It’s intensity is proportionate to clinical findings. It is a biological function. It’s intensity reduces with healing. The treatment of the disease cures the pain and it is self-limiting. It is usually seen with acute pain.

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6
Q

Define Pathological Pain.

A

Pathological pain is a disease in itself, of the nervous system. It’s intensity is disproportionate to clinical findings. It has no biological function. It’s intensity is unremitting and progressive. It is difficult to treat and is usually sustaining in nature. It is usually seen with chronic pain.

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7
Q

Define Nociceptive Pain.

A

Nociceptive Pain is the pain felt due to physical damage or potential damage to the body.

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8
Q

Classify Nociceptive Pain.

A
  1. Somatic Pain

2. Visceral Pain

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9
Q

Somatic Pain arises from?

A

The musculoskeletal system (Skin, Bones, Soft Tissues)

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10
Q

Visceral Pain arises from?

A

The visceral organs (GIT, Pancreas, Stomach)

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11
Q

Describe the pain felt in Somatic Pain.

A

Achy, dull, throbbing, sore, localized pain.

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12
Q

Describe the pain felt in Visceral Pain.

A

Gnawing, squeezing, cramping, diffuse and poorly localized pain. (often referred pain)

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13
Q

Define Neuropathic Pain.

A

Neuropathic Pain is the pain felt due to damage/injury to the central/peripheral nervous system.

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14
Q

Describe the pain felt in Neuropathic Pain.

A

Shooting, burning, electric-like sensation, tingling, stabbing pain which can follow a nerve path or be poorly diffused.

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15
Q

State examples for each type of pain.

A
  1. Somatic Pain : Fractures, Infection, Post-op. pain
  2. Visceral Pain : Pancreatitis, Gastroenteritis
  3. Neuropathic Pain : Phantom pain, Complex Regional Pain Syndrome
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16
Q

State the different types of aetiologies for pain.

A

AETIOLOGY OF PAIN

  1. Tumour (causes nerve compression/metastasis)
  2. Iatrogenic (post-surgery,chemotherapy/radiotherapy induced neuropathic pain)
  3. Debility (bed sores, constipation, bladder spasm)
  4. Unrelated (osteoarthritis)
  5. Total Pain
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17
Q

Describe Total Pain.

A

It is the pain felt physically, psychologically, socially and spiritually.

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18
Q

State some factors that reduce pain intensity.

A
  1. Distraction
  2. Relaxation
  3. Creative Thinking
  4. Good Mood
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19
Q

State some factors that increase pain intensity.

A
  1. Depression
  2. Attention
  3. Chronic Pain
  4. Sleep disturbance
  5. Past experiences
  6. Fatigue
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20
Q

What are the basic guidelines for treating a patient with pain?

A

TREATMENT GUIDELINES (PAIN)

  1. Come to a diagnosis by identifying a treatable cause
  2. Identify the type of pain
  3. Pick a choice of treatment
  4. Assess the effects of the treatment
  5. Monitor the progress of the patient
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21
Q

What are the main criteria for assessing pain?

A
  1. Onset of pain
  2. Provoking/Palliating factors
  3. Quality of pain
  4. Region and Radiation of pain
  5. Severity of pain
  6. Understanding and Impact of the Pain
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22
Q

How do you elicit the history of onset of pain?

A
  1. When did it began?
  2. How long did it last?
  3. How often does it occur?
  4. What were you doing when it started?
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23
Q

How do you elicit the history of provoking/palliating factors of pain?

A
  1. What initiates the pain?

2. What makes it worse

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24
Q

What does pain upon movement indicate?

A

It indicates a likely fracture/inflammation/peritonitis/pleurisy.

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25
Q

What does pain upon eating indicate?

A

Ulcers/Oesophagitis

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26
Q

What does pain upon passing urine/stools indicate?

A

Fissures/Renal Calculi/Constipation

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27
Q

How do you elicit the history of quality of pain?

A
  1. What does it feel like?

2. Can you describe it?

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28
Q

How do you elicit the history of region and radiation of pain?

A
  1. Can you point to where it hurts most?
  2. Where does your pain go from there?
  3. Does the pain radiate?
  4. Where does it spread to?
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29
Q

When is Glove-and Stocking pain commonly seen in?

A

Diabetics

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30
Q

How do you elicit the history of severity of pain?

A
  1. What is the intensity of pain?

2. What is the pain severity now and at it’s worst?

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31
Q

What is the importance of history of severity of pain?

A

To help decide which analgesic to prescribe for the patient.

32
Q

State the different ways to grade the severity of pain.

A
  1. Verbal Scale (None, Mild, Moderate, Severe, Very severe, Worst possible pain)
  2. Numerical Scale (0-10)
  3. Visual Analog Scale
  4. Coin Percentage Scale
  5. Wong-Baker FACES Pain Scale
  6. Universal Pain Assessment Scale
33
Q

How do you elicit the history of treatment of pain?

A
  1. What medications are you on for the pain?

2. How effective are they and is there any side effects?

34
Q

How do you elicit the history of understanding and the impact of the pain?

A
  1. What do you believe is causing this pain?

2. How is affecting your daily life and relationships?

35
Q

What are the main principles of pain management?

A
  1. Diagnosing the cause of pain
  2. Full assessment of all contributing factors
  3. Explain the mechanism of the underlying pain to the patient
  4. Use the WHO Analgesic Ladder to guide systematic pain-relief
  5. Consider the roles of treatments and non-drug treatments in the treatment of pain
36
Q

What is the Multimodal Approach to Pain Management?

A

It is the various approaches to treat pain.

  1. Pharmacological Treatment (NSAID, Opioids, Adjuvants)
  2. Physical Therapy (Exercises, Physiotherapy)
  3. Interventional Therapy (Procedures, Surgeries)
  4. Psychological Therapy (Counselling)
  5. Patient Education (Knowledge on pain, goals)
37
Q

Describe the WHO Analgesic Ladder.

A
  1. Mild Pain : Non-opioids (paracetamol, aspirin, NSAIDS) +/- adjuvants
  2. Mild-Moderate Pain : Weak opioids (codeine, tramadol) +/- non-opioids +/- adjuvants
  3. Severe Pain : Strong opioids (morphine/fentanyl) +/- non-opioid +/- adjuvants
38
Q

When is a patient given drugs via oral administration?

A

If everything is normal and under control, oral route is preferred.

39
Q

When is a patient given drugs via ‘around the clock’ administration?

A

When a patient has continous pains or cancer pains

40
Q

What are the important factors which should be considered before prescribing a drug?

A
  1. Age
  2. Organ function
  3. Metabolism
  4. Allergy
  5. Toxicity
  6. Dependance
  7. Misuse/Diversion
  8. Access/Availability
  9. Legal
  10. Non-pharmalogical
41
Q

What is the mode of action of Paracetamol (Acetaminophen) and NSAIDS?

A
  • Inhibition of Central Cyclo-oxygenase - COX 1 and 2 (Prostaglandin Synthesis)
  • Potentiation of descending inhibitory serotonergic pathway.
42
Q

What is the normal dose to be prescribed for Paracetamol?

A

500 mg - 1 g every 4-6 hourly

43
Q

What is the max. recommended dose for Paracetamol?

A

4 g per day

44
Q

What are the advantages of Paracetamol?

A
  • No gastritis
  • No renal dysfunction
  • No platelet dysfunction
45
Q

Paracetamol can be safely used in …… ?

A
  • Elderly patients
  • Cachectic subjects with occult gastric bleeding
  • Renal dysfunction patients
  • Bone Marrow suppression
46
Q

What are the disadvantages of Paracetamol?

A
  • Use carefully in Liver damage patients
  • Hepatotoxicity if dose is >4g per day
  • Dyspepsia
47
Q

What are the different types of NSAIDS?

A
  1. Non-selective NSAIDS

2. Selective NSAIDS (COX-1 or COX-2 Selective)

48
Q

State some drugs which are Non-selective NSAIDS.

A
  1. Aspirin
  2. Salicylates
  3. Ibuprofen (200mg - 400mg TDS)
  4. Fenamates
  5. Naproxen (250mg - 500mg BD)
  6. Nabumetone
49
Q

State some drugs which are COX-1 Selective NSAIDS.

A
  1. Indomethacin
  2. Ketorolac (10 mg - 30 mg QID)
  3. Flurbiprofen
  4. Ketoprofen
50
Q

State some drugs which are COX-2 Selective NSAIDS.

A
  1. Diclofenac (50 mg TDS)
  2. Nimesulide
  3. Etodolac
  4. Meloxicam
  5. Etoricoxib
51
Q

State the side effects commonly seen upon administration of NSAIDS.

A
  • GI Irritation
  • Renal Dysfunction
  • Platelet Dysfunction
  • Bronchoconstriction
  • Reye’s Syndrome
  • Salicylism
52
Q

Name some weak opioids.

A
  1. Codeine
  2. Tramadol
  3. Tapentadol
53
Q

State the dose and properties of Codeine.

A
  • Dose : 30-60 mg Q4H
  • Properties : CYP2D6 mutations in patients leads ineffectiveness to in poor metabolizers and toxicity in ultrarapid metabolizers.
54
Q

State the dose and properties of Tramadol.

A
  • Dose : 50-100 mg Q6H
  • Properties : It has a dual MOA (useful in nociceptive and neuropathic pain), causes less constipation and respiratory depression than Morphine. However, it has to be used with caution in patients on TCAs, SSRIs and Elderly patients with Brain mets. It is contraindicated in patients on MAOI.
55
Q

State the dose and properties of Tapentadol.

A
  • Dose : 50-100 mg Q4-6H

- Properties : It has a dual MOA (useful in nociceptive and neuropathic pain).

56
Q

What is the Gold Standard Drug used in treatment of pain and why?

A

Morphine, because it has no ceiling effect

57
Q

State the various preparations that Morphine comes in.

A
  1. Immediate Release (Given every 4 hourly) : 10mg, 20mg, 30mg, 60mg
  2. Morphine Solutions
  3. Sustained Release (Given every 12 hourly) : 10, 30, 60 SR
58
Q

What is the oral bio-availability of Morphine?

A

approx. 33%

59
Q

State the metabolites of Morphine.

A
  1. Morphine-6-Glucuronide

2. Morphine-3-Glucuronide

60
Q

Which the following metabolites causes side effects in a patient?

A

Morphine-3-Glucuronide

61
Q

How do you achieve steady state dose in a patient with constant pain?

A

For oral morphine, the half-life is 4 hours. Hence, it is administered every 4th hourly to achieve steady state plasma concentration.

62
Q

Define breakthrough pain.

A

It is the increased spikes of pain felt by a patient who is already in constant pain.

63
Q

How do you handle a patient with breakthrough pain?

A

Ask the patient if he/she would like an extra dose of medication to relieve the breakthrough pains, whilst administering round-the-clock medication for the constant pain.

64
Q

The EAPC recommended opioid for moderate-severe cancer pain is ……… ?

A

Morphine

65
Q

The EAPC recommended optimal route of administration of morphine is ……… ?

A
  • Orally

- Alternative : Subcutaneous

66
Q

The EAPC recommended treatment method for moderate-severe cancer pain is ……… ?

A
  1. Start with I.R. Morphine
    - If patient is opioid naive : 5 mg Q4H
    - If patient was on weak opioid : 10 mg Q4H
  2. For breakthrough pains, administer 1/6th of the Total Daily Dose.
67
Q

How do we avoid causing a patient with cancer pains to be woken up by pain at night?

A

By administering a double dose at bedtime.

68
Q

When do we convert to S.R. Morphine?

A

When the pain has stabilized or if I.R. is not available.

69
Q

What drugs do we have to prescribe along with Morphine?

A

An anti-emetic (Haloperidol) and a laxative

70
Q

If a patient requires continous parenteral morphine, the preferred method of administration is ……… ?

A

Subcutaneous infusion

71
Q

Which is most common? Pseudo-addiction or True Addiction?

A

Pseudo Addiction

72
Q

What is the mode of action of Adjuvants in Neuropathic Pain?

A
  1. Blockade of Sodium channels
  2. Enhanced descending inhibition of serotogenic pathways
  3. Activation of GABA inhibitory systems
  4. Inhibition of Glutamate excitatory system
73
Q

Name some adjuvants that cause blockade of Sodium Channels.

A
  1. Lidocaine
  2. Mexiletine
  3. Flecainide
  4. Carbamazepine
  5. Lamotrigine
  6. Phenytoin
74
Q

Name some adjuvants that enhances the descending inhibition of serotogenic pathways.

A
  1. TCAs
  2. SSRIs
  3. Methadone
  4. Tramadol
75
Q

Name some adjuvants that activates GABA inhibitory system.

A
  1. Baclofen
  2. BZDs
  3. Gabapentin
  4. Pregabalin
  5. Valproate
  6. Vigabatrin
  7. Phenobarbital
76
Q

Name some adjuvants that inhibits the Glutamate excitatory system.

A
  1. Carbamazepine
  2. Lamotrigine
  3. Phenytoin
  4. Valproate
  5. Ketamine
  6. Methadone
  7. Dextromethorphan

Palliative Medicine (4 decks)

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