IMPACT OF DRUGS AND PAIN ON SLEEP Flashcards
NOCICEPTION?
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.
PAIN?
AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE ASSOCIATED WITH, OR RESEMBLING THAT ASSOCIATED WITH ACTUAL OR POTENTIAL TISSUE DAMAGE
WHAT ARE RESPONSES TO UNPLEASENT STIMULI GUIDED BY?
- 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..)
CLASSIFICATION OF PAIN ACCORDING TO DURATION
- ACUTE
- CHRONIC
- ACUTE ON CHRONIC (NEW PAIN ON THE BACKGROUND OF CHRONIC PAIN OR A FLARE UP OF A KNOWN CONDITION)
CLASSIFICATION OF PAIN ACCORDING TO CAUSE?
- 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
ACUTE PAIN?
- 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
CHRONIC PAIN?
- 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..)
ASSESSMENT OF PAIN?
TAKING HISTORY (CHARACTERISTICS, INTENSITY, DURATION, ALLEVIATING AND EXACERBATING FACTORS, ‘RED FLAGS’, TREATMENT HISTORY, CO-MORBIDITIES, PSYCHO-SOCIAL HISTORY..)
EXAMINATION
INVESTIGATIONS
BIO-PSYCHO-SOCIAL MODEL IN PAIN ASSESSMENT?
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)
‘YELLOW FLAGS’ IN PAIN ASSESSMENT?
- 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)
DIVISION OF ANALGESIA?
SIMPLE ANALGESICS
- PARACETAMOL
- NON STEROIDAL ANTI-INFLAMMATORY DRUGS
OPIOID ANALGESICS
- WEAK OPIOIDS (E.G. CODEINE PHOSPHATE)
- STRONG OPIOIDS (E.G. MORPHIN, FENTANYL, OXYCODONE, BUPRENORPHINE)
ANTI-DEPRESSANT MEDICATION USED AGAINST PAIN?
- 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
ANTI-EPILEPTIC DRUG USE FOR PAIN MANAGEMENT?
- USED IN NEUROPATHIC PAIN (MECHANISM THOUGHT TO WORK THROUGH REDUCTION OF NEURONAL ACTIVITY)
- DRUGS USED: GABAPENTIN, PREGABALIN, CARBEMAZEPINE, LAMOTRIGINE
HOW MANY TIMES PER NIGHT TO CYCLES BETWEEN REM AND NREM SLEEP OCCUR?
4-6 TIMES A NIGHT
PURPOSE OF SLEEP IS THOUGHT TO INVOLVE:
- HOMEOSTASIS
- PROTEIN SYNTHESIS
- CELL GROWTH AND PROLIFERATION
- METABOLISM
- IMMUNE FUNCTION
- CLEARING FREE RADICALS (SLEEP DEPRIVATION INCREASES OXIDATIVE STRESS)
WHAT IS CONSIDERED SLEEP DISTURBANCE?
- 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)
% OF BURN PATIENTS REPORTING SLEEP DISTURBANCES?
75%
% OF HOSPITAL POST SURGICAL INPATIENT REPORTING SLEEP DISTURBANCES?
22-61%
ACUTE PAIN AND SLEEP
- POLYSOMNOGRAPHY SHOWS FREQUENT AWAKENINGS
- SLEEP DISTURBANCES IN PATIENTS WITH ACUTE PAIN ARE SHORT TERM
% OF THOSE IN PAIN CLINIC REPORTING SLEEP DISTURBANCE?
90%
PAIN IS A RISK FACTOR FOR DEVELOPING INSOMNIA
OPIOID DRUGS AND SLEEP?
- OPIOID DRUGS DISRUPT SLEEP ARCHITECTURE, REDUCING REM SLEEP
EXAMPLES OF DIAGNOSES ASSOCIATED WITH BOTH PAIN AND SLEEP DISTURBANCE?
- CANCER
- RA
- OA
- FIBROMYALGIA
ASSOCIATION BETWEEN SLEEP AND PAIN + PAIN DRUGS?
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
DRUGS USED TO TREAT SLEEP DISTURBANCES?
- BENZODIAZEPINES
- Z-DRUGS (ZOPLICLONE, ZOLPIDEM)
CAUTION TO POLYPHARMACY!!!, INTERACTIONS WITH OTHER DRUGS CAN BE DANGEOUS, DEPENDENCE ON THESE DRUGS SHOULD BE AVOIDED
NON PHARMACOLOGICAL MANAGEMENT OF SLEEP DISTURBANCE - PSYCHOLOGICAL TECHNIQUESWHAT
- COGNITIVE BEHAVIOURAL THERAPY
- ACCEPTANCE AND COMMITMENT THERAPY
- PAIN MANAGEMENT PROGRAMMES
NON PHARMACOLOGICAL MANAGEMENT OF SLEEP DISTURBANCE - LIFESTYLE MODIFICATION
- INCREASEING ACTIVITY LEVELS
- REDUCE/STOP ALCOHOL, DRUGS, CAFFEINE
- MANAGING STRESS, ANXIETY, DEPRESSION
- EDUCATION ABOUT SLEEP HYGIENE (SCREEN USE, ROUTINE..)
GOOD SLEEP HYGIENE?
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
WHAT IS THE DIFFERENCE BETWEEN PAIN AND NOCICEPTION?
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.
