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Pain > Chronic Pain > Flashcards

Chronic Pain Flashcards

1
Q

Chronic Pain:

How many Australians adequately address chronic pain?

A

1 in 20 (5%)

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2
Q

Chronic Pain:

How many Australian suffer chronic pain?

A

20%

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3
Q

Chronic Pain:

Non Pharmacological options?

A
  • physical
  • psychological
  • interventional
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4
Q

Chronic Pain:

Forms of physical non pharmacological options?

A
  • compression/splints
  • exercise/posture changes
  • hot/cold
  • hydrotherapy, massage therapy, physiotherapy, occupational therapy
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5
Q

Chronic Pain:

Forms of psychological non pharmacological options?

A
  • biofeedback
  • CBT
  • desensitisation
  • distraction
  • attention control exercises
  • hypnosis
  • education
  • psychotherapy for co-morbid affective disorders
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6
Q

Chronic Pain:

Forms of interventional non pharmacological options?

A
  • radiation therapy
  • nerve blocks
  • neurodestructive surgical techniques
  • Transcutaneous Electrical Nerve Stimulation (TENS)
  • implantable stimulation
  • vertebroplasty
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7
Q

Chronic Pain:

What type of pain does the WHO recommend opioids for?

A

moderate to severe or out of control pain

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8
Q

Chronic Pain:

Historically what are the two types of chronic pain?

A

1) Nociceptive (pain in response to ongoing tissue damage)

2) neuropathic (due to damage or dysfunction of nervous system)

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9
Q

Chronic Pain:

What factors does the old model of chronic pain not take into account?

A
  • conditioning factors
  • cognitive behavioural factors
  • psychosocial
  • psychiatric disturbances
  • cultural influences
  • social support
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10
Q

Chronic Pain:

Types of pain and opioid effectiveness?

A
  • 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
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11
Q

Chronic Pain:

When to initiate opioids?

A

-functional gains unsuccessful with non opioid therapy AND opioids will likely help with pain type

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12
Q

Chronic Pain:

How compliant are chronic pain patients with opioids?

A

Poor - 1/3rd may not use them as prescribed or abuse them

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13
Q

Chronic Pain:

Can combination therapy be effective with opioids?

A

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

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14
Q

Chronic Pain:

When to be concerned about opioid doses?

A

50mg of oral morphine equivalent per day as it is connected with overdoses and deaths

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15
Q

Chronic Pain:

Pertinent pain history and examinations?

A

History

  • WWQQAAB
  • investigations and interventions/medications
  • functional impairment (typical day, most active activity, exercise)

Examination

  • gait
  • seated to standing
  • flexion and extension of back
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16
Q

Chronic Pain:

Other important history when assessing chronic pain?

A
  • 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
17
Q

Chronic pain:

What treatment goals should be established prior to prescription of opioids?

A
  • goal is improved function or reduction in pain intensity by at least 30%
  • goal towards realistic activity of choice
18
Q

Chronic pain:

What type of patients tend to have uncontrolled pain?

A
  • passive
  • those who catastrophise
  • those with external locus of control
19
Q

Chronic pain:

What yard stick is appropriate to assess and measure chronic pain?

A

Brief Pain Inventory (BPI) or PEG screening tool.

*both best over time for a pattern to emerge.

20
Q

Chronic pain:

How to predict aberrant opioid behaviour?

A

Opioid Risk Tool (ORT)

  • family history and personal history of substance and prescribed use
  • age
  • Child sexual abuse
  • mental health history
21
Q

Chronic pain:

What are universal precautions with chronic pain?

A

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

22
Q

Chronic pain:

Best approach to opioid dose titration and why?

A
  • 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
23
Q

Chronic pain:

What seems to be a common observation in higher opioid dose patients?

A
  • reported greater pain severity
  • catastrophising behaviour
  • use of health care is higher
  • activity levels are lower
24
Q

Chronic pain:

How many people using opioids will have adverse effects?

A

80%

25
Q

Chronic pain:

Top 3 most common opioid adverse effects?

A

1) nausea
2) constipation
3) drowsiness

26
Q

Chronic pain:

Proven long term effects of opioids?

A
  • Tolerance
  • Dependence
  • Hyperalgesia
27
Q

Chronic pain:

Concerning associations with long term opioids?

A

1) Endocrine
- low testosterone
- Opioid induced androgen deficiency (low FSH, LH, oestrogen and testosterone) = sexual dysfunction, hot flushes and depression
2) Immune
- increased morbidity and mortality due to infection and cancer exacerbation in animal models
3) Hyperalgesia

28
Q

Chronic Pain:

How to distinguish hyperalgesia from disease progression or opioid tolerance?

A
  • typically diffuse, less defined quality that extends to other areas from pre-existing pain
  • mimics opioid withdrawal
  • pain thresholds may change
  • will worsen with increasing opioid use
29
Q

Chronic Pain:

How to manage hyperalgesia?

A
  • lower the dose of opioid
  • opioid rotation
  • drug holiday
30
Q

Chronic Pain:

Which opioid does not seem to exhibit the endocrine and immunological side effects with long term use?

A

Buprenorphine

31
Q

Chronic pain:

What is the concern regarding codeine and breastfeeding?

A

These women can rapidly metabolise the codeine increasing the risk of morphine toxicity to infant

32
Q

Chronic pain:

Important tramadol considerations?

A

1) caution in patients with high seizure risk or in combination with higher serotonin level
2) risk of serotonin syndrome when combined with some other medications eg SSRI’s

33
Q

Chronic pain:

Main consideration in morphine based opioids?

A

Renal function due to risk of accumulation

34
Q

Chronic pain:

Do aberrant behaviours suggest inadequate pain relief?

A

No - studies have found that the common factor is previous substance abuse and it tends to happen regardless of success of treatment for pain

35
Q

Chronic pain:

What is the new concept for the cause of chronic pain?

A

a complex combination of brain interpretation, central sensitisation, descending modulation and immune/endocrine activation

36
Q

Chronic pain:

Key aspects of the new concept for chronic pain cause

A
  • pain is more likely the interpretation by the brain when there is a perceived threat/danger
  • pain is dampened or amplified by emotions, motivations, learning, memory
  • chronic pain severity does not equate to severity of tissue damage

Pain (9 decks)

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