Chronic Pain Flashcards
Chronic Pain:
How many Australians adequately address chronic pain?
1 in 20 (5%)
Chronic Pain:
How many Australian suffer chronic pain?
20%
Chronic Pain:
Non Pharmacological options?
- physical
- psychological
- interventional
Chronic Pain:
Forms of physical non pharmacological options?
- compression/splints
- exercise/posture changes
- hot/cold
- hydrotherapy, massage therapy, physiotherapy, occupational therapy
Chronic Pain:
Forms of psychological non pharmacological options?
- biofeedback
- CBT
- desensitisation
- distraction
- attention control exercises
- hypnosis
- education
- psychotherapy for co-morbid affective disorders
Chronic Pain:
Forms of interventional non pharmacological options?
- radiation therapy
- nerve blocks
- neurodestructive surgical techniques
- Transcutaneous Electrical Nerve Stimulation (TENS)
- implantable stimulation
- vertebroplasty
Chronic Pain:
What type of pain does the WHO recommend opioids for?
moderate to severe or out of control pain
Chronic Pain:
Historically what are the two types of chronic pain?
1) Nociceptive (pain in response to ongoing tissue damage)
2) neuropathic (due to damage or dysfunction of nervous system)
Chronic Pain:
What factors does the old model of chronic pain not take into account?
- conditioning factors
- cognitive behavioural factors
- psychosocial
- psychiatric disturbances
- cultural influences
- social support
Chronic Pain:
Types of pain and opioid effectiveness?
- Nociceptive - small to moderate benefit for ≤3 months
- Neuropathic - small to moderate with higher opioid doses (improved in combination with TCA’s or anticonvulsants)
- Widespread soft tissue pain eg. fibromyalgia - small
- headache/functional GIT pain - rarely indicated
Chronic Pain:
When to initiate opioids?
-functional gains unsuccessful with non opioid therapy AND opioids will likely help with pain type
Chronic Pain:
How compliant are chronic pain patients with opioids?
Poor - 1/3rd may not use them as prescribed or abuse them
Chronic Pain:
Can combination therapy be effective with opioids?
Yes
Not well studied but evidence suggests a lower dose of both agents in combination eg. opioids and neuropathic agent result in more effective pain control then single agent of either drug alone
Chronic Pain:
When to be concerned about opioid doses?
50mg of oral morphine equivalent per day as it is connected with overdoses and deaths
Chronic Pain:
Pertinent pain history and examinations?
History
- WWQQAAB
- investigations and interventions/medications
- functional impairment (typical day, most active activity, exercise)
Examination
- gait
- seated to standing
- flexion and extension of back
Chronic Pain:
Other important history when assessing chronic pain?
- sleep health
- mental health
- social/family support
- employment
- family history/current/past substance or gambling use
- double check with the Prescription Shopping Information Service (PSIS) 1800 631 181
- urine drug screen
Chronic pain:
What treatment goals should be established prior to prescription of opioids?
- goal is improved function or reduction in pain intensity by at least 30%
- goal towards realistic activity of choice
Chronic pain:
What type of patients tend to have uncontrolled pain?
- passive
- those who catastrophise
- those with external locus of control
Chronic pain:
What yard stick is appropriate to assess and measure chronic pain?
Brief Pain Inventory (BPI) or PEG screening tool.
*both best over time for a pattern to emerge.
Chronic pain:
How to predict aberrant opioid behaviour?
Opioid Risk Tool (ORT)
- family history and personal history of substance and prescribed use
- age
- Child sexual abuse
- mental health history
Chronic pain:
What are universal precautions with chronic pain?
1) Diagnosis with appropriate differential
2) Psychological assessment including addiction screening and urine Drug Screening (Opioid Risk Tool, DASS21 screening)
3) Informed Consent (plan, benefits, risks, weaning and deprescribing)
4) Written Agreement
5) Review 4 A’s of pain medicine (Analgesia, Activity, Adverse effects, Aberrant behaviour)
6) Appropriate opioid use
7) Documentation
Chronic pain:
Best approach to opioid dose titration and why?
- start low
- up-titrate gradually (eg. no quicker than 3 daily)
- the greatest analgesic effects are at lower doses and they plateau at higher doses
- typically if there is no response at low to medium doses then a high dose will be unsuccessful
Chronic pain:
What seems to be a common observation in higher opioid dose patients?
- reported greater pain severity
- catastrophising behaviour
- use of health care is higher
- activity levels are lower
Chronic pain:
How many people using opioids will have adverse effects?
80%
