IMPACT OF DRUGS AND PAIN ON SLEEP

Question 1

NOCICEPTION?

Answer 1

THE NEURAL PROCESS OF ENCODING NOXIOUS STIMULI

Nociception is the detection of painful stimuli. Specialized neurons in the dorsal root ganglia (DRG) or the trigeminal ganglia project into skin and soft tissue to detect mechanical, chemical and thermal stimuli. These stimuli are mostly picked up with C fibres (slower and unmyelinated) and A delta fibres (myelinated, fast). They then reach the spinal cord (might lead to reflex actions) and the brain, where they are process.

Question 2

PAIN?

Answer 2

AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE ASSOCIATED WITH, OR RESEMBLING THAT ASSOCIATED WITH ACTUAL OR POTENTIAL TISSUE DAMAGE

Question 3

WHAT ARE RESPONSES TO UNPLEASENT STIMULI GUIDED BY?

Answer 3

• RESPONSE IS BOTH A SENSORY AND AN EMOTINAL EXPERIENCE
  GUIDED BY:
• PREVIOUS EXPERIENCE
• BELIEFS (PERSONAL, CULTURAL)
• ENVIRONMENT
• PSYCHOLOGICAL FACTORS (E.G. ANXIETY, DEPRESSION..)
• SOCIAL FACTORS (E.G. IMPACT OF PAIN ON EMPLOYMENT, RELATIONSHIPS..)

Question 4

CLASSIFICATION OF PAIN ACCORDING TO DURATION

Answer 4

• ACUTE
• CHRONIC
• ACUTE ON CHRONIC (NEW PAIN ON THE BACKGROUND OF CHRONIC PAIN OR A FLARE UP OF A KNOWN CONDITION)

Question 5

CLASSIFICATION OF PAIN ACCORDING TO CAUSE?

Answer 5

• PRIMARY VS SECONDARY (In chronic primary pain there is no clear underlying condition that adequately accounts for the pain or its impact; chronic secondary pain is pain linked to an underlying condition.)
• NOCICEPTIVE VS NEUROPATHIC VS CENTRAL SENSITISATION
• CANCER VS NON CANCER

Question 6

ACUTE PAIN?

Answer 6

• LASTING LESS THAN 6 WEEKS
• NORMAL RESPONSE TO A STIMULUS (MECHANICAL, CHEMIAL OR THERMAL!!!)
• OFTEN PROTECTIVE (REMOVE HAND FROM HOT SURFACE, REDUCE MOVEMENT OF BROKEN ARM ALLOWING HEALING..)
• USUALLY RESPONS TO TREATMENT

Question 7

CHRONIC PAIN?

Answer 7

• PERSISTS OR RECURS FOR >3 MONTHS
• OFTEN DIFFICULT TO TREAT
• MAY HAVE SIGNIFICANT SOCIAL AND PSYCHOLOGICAL IMPLICATIONS 9REDUCE QOL, FUNCTIONAL DISABILITY…)
• DIVISION TO CHRONIC PRIMARY (NO ALTERNATIVE DIAGNOSIS, SIGNIFICANT EMOTIONAL DISTRESS AND FUNCTIONAL DISABILITY) AND CHRONIC SECONDARY PAIN (UNDERLYING DISEASE, PAIN A SYMPTOM, E.G. CANCER, NERVE DAMAGE, PROBLEMS WITH ORGANS..)

Question 8

ASSESSMENT OF PAIN?

Answer 8

TAKING HISTORY (CHARACTERISTICS, INTENSITY, DURATION, ALLEVIATING AND EXACERBATING FACTORS, ‘RED FLAGS’, TREATMENT HISTORY, CO-MORBIDITIES, PSYCHO-SOCIAL HISTORY..)

EXAMINATION

INVESTIGATIONS

Question 9

BIO-PSYCHO-SOCIAL MODEL IN PAIN ASSESSMENT?

Answer 9

BIO

• PHYSIOLOGY
• PATHOLOGY

PSYCHO

• EMOTIONS
• BEHVAIOURS
• BELIEFS

SOCIAL

• ECONOMICS
• ENVIRONMENT
• CULTURE
• EMPLOYMENT

(CAN INDICATE RISK OF A PATIENT WITH ACUTE PAIN PROGRESSING TO CHRONIC PAIN, BARRIERS FOR SOMEONE WITH CHRONIC PAIN TO IMPROVE ETC)

Question 10

‘YELLOW FLAGS’ IN PAIN ASSESSMENT?

Answer 10

• INDICATE INCREASED RISK OF DEVELOPING CHRONICITY OR POOR PROGNOSIS
• SHOULD BE ADDRESSED DURING MANAGEMENT)

BELIEFS/JUDGEMENTS (UNHELPFUL BELIEFS, EXPECTATIONS OF POOR OUTCOMES OR DELAYED ABILITY TO WORK)

EMOTIONAL RESPONSES (DISTRESS, WORRY, FEAR, ANXIETY)

PAIN BEHAVIOUR (PAIN AVOIDANCE, OVER-RELIANCE ON PASSIVE TREATMENT)

Question 11

DIVISION OF ANALGESIA?

Answer 11

SIMPLE ANALGESICS

• PARACETAMOL
• NON STEROIDAL ANTI-INFLAMMATORY DRUGS

OPIOID ANALGESICS

• WEAK OPIOIDS (E.G. CODEINE PHOSPHATE)
• STRONG OPIOIDS (E.G. MORPHIN, FENTANYL, OXYCODONE, BUPRENORPHINE)

Question 12

ANTI-DEPRESSANT MEDICATION USED AGAINST PAIN?

Answer 12

• IN CASE OF NEUROPATHIC PAIN, ANTIDEPRESSANTS CAN BE PRESCRIBED FOR ANALGESIC EFFECTS
• ANALGSIC DOSE USUALLY LOWER THAN ANTIDEPRESSANT DOSE
• UNCERTAIN MECHANISM OF ACTION IN PAIN
• THE DRUGS BLOCK CENTRAL REUPTAKE OF NEUROTRANSMITTERS ALLOWING INCREASED DESCENDING INHIBITORY INPUT (SEROTONIN, NORADRENALINE)

Tricyclic antidepressants e.g. amitriptyline, nortriptyline
Noradrenaline reuptake inhibitors e.g. duloxetine

Question 13

ANTI-EPILEPTIC DRUG USE FOR PAIN MANAGEMENT?

Answer 13

• USED IN NEUROPATHIC PAIN (MECHANISM THOUGHT TO WORK THROUGH REDUCTION OF NEURONAL ACTIVITY)
• DRUGS USED: GABAPENTIN, PREGABALIN, CARBEMAZEPINE, LAMOTRIGINE

Question 14

HOW MANY TIMES PER NIGHT TO CYCLES BETWEEN REM AND NREM SLEEP OCCUR?

Answer 14

4-6 TIMES A NIGHT

Question 15

PURPOSE OF SLEEP IS THOUGHT TO INVOLVE:

Answer 15

• HOMEOSTASIS
• PROTEIN SYNTHESIS
• CELL GROWTH AND PROLIFERATION
• METABOLISM
• IMMUNE FUNCTION
• CLEARING FREE RADICALS (SLEEP DEPRIVATION INCREASES OXIDATIVE STRESS)

Question 16

WHAT IS CONSIDERED SLEEP DISTURBANCE?

Answer 16

• SLEEP ONSET LATENCY OF >30 MINS
• DURATION OF WAKING AFTER SLEEP ONSET >30MINS
• SHORT TOTAL SLEEP TIME (<6.5HRS)
• LOW QUALITY/NON REFRESHING SLEEP (SLEEP EFFICIENCY <85%; PROPORTION OF TIME IN BED SPENT ASLEEP)

Question 17

% OF BURN PATIENTS REPORTING SLEEP DISTURBANCES?

Answer 17

75%

Question 18

% OF HOSPITAL POST SURGICAL INPATIENT REPORTING SLEEP DISTURBANCES?

Answer 18

22-61%

Question 19

ACUTE PAIN AND SLEEP

Answer 19

• POLYSOMNOGRAPHY SHOWS FREQUENT AWAKENINGS

- SLEEP DISTURBANCES IN PATIENTS WITH ACUTE PAIN ARE SHORT TERM

Question 20

% OF THOSE IN PAIN CLINIC REPORTING SLEEP DISTURBANCE?

Answer 20

90%

PAIN IS A RISK FACTOR FOR DEVELOPING INSOMNIA

Question 21

OPIOID DRUGS AND SLEEP?

Answer 21

• OPIOID DRUGS DISRUPT SLEEP ARCHITECTURE, REDUCING REM SLEEP

Question 22

EXAMPLES OF DIAGNOSES ASSOCIATED WITH BOTH PAIN AND SLEEP DISTURBANCE?

Answer 22

• CANCER
• RA
• OA
• FIBROMYALGIA

Question 23

ASSOCIATION BETWEEN SLEEP AND PAIN + PAIN DRUGS?

Answer 23

BIDIRECTIONAL!!!!

PAIN DISTURBS SLEEP, BUT SLEEP DEPRIVATION ALSO INCREASES PAIN INTENSITY

• PRIMARY SLEEP DISORDERS (Primary sleep disorders include those not attributable to another medical or psychiatric condition) INCIDENCE HIGHER IN CHRONIC PAIN POPULATION
• SOME MEDICATION USED AGAINST PAIN (E.G. SELECTIVE SEROTONIN REUPTAKE INHIBITORS) MAY CAUSE INSOMNIA, OPIOIDS MAY DISRUPT BOTH SLEEP AND RESPIRATION, DROWSINESS OF SOME ANTIDEPRESSANTS CAN BE USEFUL FOR FALLING ASLEEP

Question 24

DRUGS USED TO TREAT SLEEP DISTURBANCES?

Answer 24

• BENZODIAZEPINES
• Z-DRUGS (ZOPLICLONE, ZOLPIDEM)

CAUTION TO POLYPHARMACY!!!, INTERACTIONS WITH OTHER DRUGS CAN BE DANGEOUS, DEPENDENCE ON THESE DRUGS SHOULD BE AVOIDED

Question 25

NON PHARMACOLOGICAL MANAGEMENT OF SLEEP DISTURBANCE - PSYCHOLOGICAL TECHNIQUESWHAT

Answer 25

• COGNITIVE BEHAVIOURAL THERAPY
• ACCEPTANCE AND COMMITMENT THERAPY
• PAIN MANAGEMENT PROGRAMMES

Question 26

NON PHARMACOLOGICAL MANAGEMENT OF SLEEP DISTURBANCE - LIFESTYLE MODIFICATION

Answer 26

• INCREASEING ACTIVITY LEVELS
• REDUCE/STOP ALCOHOL, DRUGS, CAFFEINE
• MANAGING STRESS, ANXIETY, DEPRESSION
• EDUCATION ABOUT SLEEP HYGIENE (SCREEN USE, ROUTINE..)

Question 27

GOOD SLEEP HYGIENE?

Answer 27

Good sleep hygiene is all about putting yourself in the best position to sleep well each and every night.

Optimizing your sleep schedule, pre-bed routine, and daily routines is part of harnessing habits to make quality sleep feel more automatic. At the same time, creating a pleasant bedroom environment can be an invitation to relax and doze off.

• Set Your Sleep Schedule
• Have a Fixed Wake-Up Time
• Prioritize Sleep
• Make Gradual Adjustments
• Don’t Overdo It With Naps

Question 28

WHAT IS THE DIFFERENCE BETWEEN PAIN AND NOCICEPTION?

Answer 28

While nociception refers to neural encoding of impending or actual tissue damage (ie, noxious stimulation), pain refers to the subjective experience of actual or impending harm.