Chronic non cancer pain

Question 1

describe acute pain

Answer 1

<2weeks

palys a functional role in bodys defenses and resolves with tissue recovery

Question 2

describe chronic pain

Answer 2

no function role, doesnt resolve with tissue recoery and can be a primary diagnosis
involves complex cns signaling that can be amplified bystressors
increased excitatory mechanisma dn decreased inhibitory

Question 3

what is sensitization

Answer 3

increased excitability of nerve cells in dorsal horn of spinal cord (central)
or increased excitability of nociceptor terminal and decreased threshold for actiovation by stimuli (peripheral)

Question 4

what is allodynia

Answer 4

normally nn painful stimulus percieved as pain

Question 5

what is hyperalgesia

Answer 5

increased pain intensity in response to the same noxious stimulus

Question 6

on a scale of 1-10 how much do most agents improve chronic non cancer pain

Answer 6

1

NNT for 50% improvement =5

Question 7

on a scale of 1-10 how much do most agents improve function

Answer 7

none or .5

Question 8

6 A’s of opioids hterapy

Answer 8

analgesio 
activity 
adverse effects
affect
accurate records
aberrant behaviour/abuse risk

Question 9

efficacy of opioids in chronic low back pain

Answer 9

not great outcomes
min effect on disability
no placebo RCT to support the effectiveness and safety of long term opioid therapy
short term may be ok

Question 10

ways to minimize abuse and diversion risk

Answer 10

form from the start
visit doesnt mean arefill
inform patient of exit strategy if goals arent achieved
use dpin or echart
small fills at shorter duration
urine drug screen
use opioid risk assessment tool or opioid contract

Question 11

what do we do with results from the opiod risk tool

Answer 11

low risk 0-3 safe to give
moderat 4-7 give limited amount
high >8 dont use opioids

Question 12

evidence for benefit of chronic low back pain for which non drug measures

Answer 12

heat
cbt
acupuncture
physio
massage
yoga
exercise
multidisciplinary programs

Question 13

what to move from passive modalities to

Answer 13

active rehabilitation

Question 14

what is multimodal care

Answer 14

behaviourl, physical and integrated medical approaches

primary goal of reducing pain related distress, disability, and suffering

Question 15

describe exercise prescriptions

Answer 15

therapy options such as biking, walking, yoga
dose options in minutes
frequency in # of days per week

Question 16

does dose escalation reduce pain or increase function

Answer 16

not proven

Question 17

short term opioid AE

Answer 17

nausea
sedation
dizziness
cognitive impairment
eventually goes away

Question 18

long term opioid AE

Answer 18

constipation 
tolerance, dependence, abuse
dental problems due to dry mouth
hypogonadism (erectile dysfunction)
may paradoxially induce abnormal pain sensitivity

Question 19

at what doses of opioids do we start to see serious effects

Answer 19

> 100mg MEQ daily

shouldnt need to get close to these doses in chronic non cancer pain

Question 20

an adequate therapeutic trial

Answer 20

codiene or tramadol x 2weeks

if no/min improvement then can stop all together or consider a short trial fo a strogn opioid

Question 21

describe the graded analgesic response

Answer 21

patient expereinces the great benefits at lower doses and plateauing of analgesic response at higher doses

Question 22

response less likely if min improvement after ____

Answer 22

2-3 dose increases

Question 23

patients who receive high opioid doses and remain incapacitated by pain should be

Answer 23

considered treatment failures

even if it takes the edge off the pain

Question 24

why do opioid tapering

Answer 24

eliminate source of abuse
reduce withdrawal mediated pain at higher doses
reduce hyperalgesia
healthier perception of pain experience due to improved mood and energy

Question 25

how fast should we taper opioids

Answer 25

decrease 10% of original dose every 1-2 weeks

once 1/3 of original dose is reached may slow to taper to half of the previous rate

Question 26

how often should we see an opioid patient

Answer 26

every1-2 week withsimilar dispensing interval

Question 27

what should we monitor with opioid tapering

Answer 27

pain
withdrawal symptoms (sweating, diarrhea, agitation)
beenfits - improved mood and energy