B-18. Treatment strategy of pain.

Question 1

What is non-pathological pain

Answer 1

Mostly caused by tissue damage

• Acute- cut from surgery, brusies, fracture, burns, MI, breakthrough pain
• Chronic- osteoarthritis, muscle spasms, RA chronic pain
• Somatic or visceral
• Inflammatory or non-inflammatory
• cancer pain

Question 2

What is pathological pain?

Answer 2

Pain caused by nerve injury or abnormal neuronal function and may be associated with hyperalgesia and/or allodynia

Question 3

Types of pathological pain

Answer 3

• Neuralgia (e.g. trigeminal)- feels like needle punch series or lightning
• Neuropathy (e.g. diabetic, postherpatic)-fells like burning
• Phantom pain
• Pain syndromes
  
  • Central pain syndrome (caused by stroke, tumors, MS)
  • Complex regional pain syndrome (large area feels constant burning sensation
• Fibromyalgia
• IBS
• Headache syndrome- migraine, cluster, tension headache

Question 4

How to scale pain?

Answer 4

You really can’t because pain depends on the individual

Question 5

Types of analgesics

Answer 5

• NSAIDs
• Minor analgesics (paracetamol)
• Opiods
  
  • Weak (tramadol, tapentadol, codein)
  • Strong (morphine, hydromorphone, oxymorphone, oxycodone, fentanyl, buprenorphine)
• Alternative analgesics
  
  • TCA (amitryptiline)
  • Antiepileptics (carbamazepine, gabapentin, pregabalin)
  • Capsaicin (given locally)

Question 6

Difference between NSAIDs and Opiods

Answer 6

Question 7

Ten universal precautions in pain medicine

Answer 7

Question 8

Analgesic ladder for non-cancer pain

Answer 8

• Mild pain is treated with non pharmacolgic modalities and/or acetaminophen (up to 4000 mg/d)
• Moderate pain is treated with low-dose ibuprofen or nonacetylated salicylates
• Severe pain with weak opiods +/- adjuvant
• Severe pain with strong opiods +/- adjuvant

Question 9

Administration of strong opiods

Answer 9

• Enteral
  
  • Oral
  • Transmucosal
  • Nasal spray
  • Sublingual/buccal
  • Rectal
• Skin
  
  • Topical (e.g. joints)
  • Transdermal
• Inhalation
• Parental
  
  • IV/SC/IM/Epidural/Intrathecal

Question 10

Side effecs of strong opiods

Answer 10

Question 11

Opiod bowel syndrome symptoms

Answer 11

• Symptoms: severe constipation, chronic or recurrent abdominal pain (cramping, spasm), decreased gastric emptying, bloating, delayed GI transit, formation of hard dry stools

Question 12

Opiod bowel syndrome causes

Answer 12

1. Activation of excitatory anti-analgesic pathways
2. Descending facilitation of pain
3. Pain facilitation via dynorphin and CCK activation
4. Glial cell activation that produces morphine tolerance and enhances opiod induced pain

Question 13

Opiod bowel syndrome treatment

Answer 13

• Treatment
  
  • Laxatives (stool softeners, salt laxatives)
  • H2-blockers or PPIs against reflux
  • N-methyl-naltrexone s.c. or naloxone per os (quaternary N-containing opiods do not enter the brain, naloxone has 100% first pass hepatic metabolism)

Question 14

Breakthrough pain defintion and treatment

Answer 14

• Defintion: strong acute pain despite the regular administration of a strong opiod in cancer patients
• Treatmnet: ultra-rapid opiod add-on therapy for short time (sublingual/buccal fentanyl)

Question 15

General rules of analgesic drug development (This flashcard I’m not sure needs much review)

Answer 15

Question 16

Confirmatory efficacy studies (also a bit extra of a flashcard)

Answer 16

Question 17

Additional pain relief in clincal sutdies

Answer 17

• Rescue medication
  
  • In case of the ineffectiveness of the test drug the patient is allowed to use a known analegesic
• Supplemental medication
  
  • In case of a decreased efficacy of the test drug (for example moving, ambulation , walking may enhance pain) a known analgesic is allowed to be added