Lecture 14 & 15 : Social Aspects And Clinical Assessments & Pharmaceutical care of Pain

Question 1

What are the different medications given for pain based on the WHO ladder?

Answer 1

1. Mild Pain: Non-opioid (paracetamol) + adjuvant therapy (additional to usual)
2. Mild to moderate Pain: Weak opioid (codeine/ tramadol) + non-opioid + adjuvant therapy
3. Moderate pain: Strong opioid + non-opiod + adjuvant

Question 2

What is Fibromyalgia?

Answer 2

• Chronic primary pain: Widespread pain across the whole body (esp back and neck)
• Causes severe fatigue, poor sleep, aching and stiffness and flare ups
• Sensitisation - lower pain threshold

Question 3

What is the difference between primary and secondary chronic pain?

Answer 3

• Primary - no underlying condition that explains pain e.g. Fibromylagia
• Secondary - Underlying condition that explains pain e.g. cancer, osteoarthritis

Question 4

What are things that should happen when a flare up in pain occurs?

Answer 4

• Offer re-assessment if change in symptoms
• Review
• Can consider investigations to identify source of new pain

Question 5

What non-drug therapies are recommended for Chronic primary pain?

Answer 5

• Group excerise programmes
• Acceptance and commitment therapy or cognitive behavioural therapy
• Single course of acupunture

Question 6

What are some pharmacological treatments that can be given for chronic primary pain?

Answer 6

• Antidepressant
• Amitrytiline, Citalopram, Duloxetine, Fluoxetine

Question 7

What are some medicines to not start in Chronic primary pain for a patient?

Answer 7

• Anti epileptics - Gabapentinoids
• Anti-psychotics
• Benzodiazepines - addicting
• NSAIDs
• Opioid

Question 8

What is the evidence against some analgesics: Cannabis based, opioids, Benzodiazepines, NSAIDs

Answer 8

• Cannabis based: No evidence, short term ADRs
• Opioids: No evidence w/ over 6 months, increased risk of dependence
• Benzodiazepines: Dont work and are addictive
• NSAIDs: no difference to QoL, pain. Worse physical function e.g. GI bleeds

Question 9

What is the advice on Pregabalin and Valporate on pregnancy?

Answer 9

• Pregabalin: Risk of major congenital malformations
• Valporate: Risk of malformations

Question 10

What is neuropathic pain?

Answer 10

• Pain caused by lesions in the central or peripheral somatosensory nervous system

Question 11

What are examples of neuropathic pain?

Answer 11

• Diabetic neuropathy
• Trigeminal neuralgia
• Neuropathic cancer pain
• Post surgical chronic neuropathic pain

Question 12

What are some drugs used to treat neuropathic pain?

Answer 12

• TCAs
• SSRIs
• SNRIs
• Anti epileptics
• Topical
• Opiods (not preferred)

Question 13

What does the guildlines say on treating neuropathic pain?

Answer 13

• Either amitriptyline, duloxetine, gabapentin or pregabalin
• Consider tramadol only if acute rescue therapy is needed

Question 14

What are some opioids risks?

Answer 14

• Long term: risk of falls and fractures
• Addiction, misuse, withdrawal symptoms
• Co prescription of opioids and benzo - impaired resp control
• Tolearance and hyperalgesia

Question 15

What are signs of opioid overdose?

Answer 15

• Confusion or hallucinations
• Slurred speech
• Lips/ fingernails - blue/purple
• Unresponsive
• Heavy snoring
• Difficulty breathing
• Very small pupils

Question 16

Why would an xray or scan not find the cause of pain?

Answer 16

• If there is no injury or sensitisation of receptors and fibres and not shown on scan

Question 17

What are the main standards in pain consultations?

Answer 17

• Good general care
• Adequate assessment
• Effective communication
• Shared decision making
• Trust
• Documentation

Question 18

What types of pain are there in neuropathic pain?

Answer 18

• Shooting
• Tingling
• Numb
• Electric Shocks
• Burning

Question 19

What types of pain are there in somatic pain (pain that originates from injuries to the body’s soft tissues, such as muscles, skin) ?

Answer 19

• Aching
• Dull
• Throbbing
• Well localised
• Stabbing

Question 20

What type of pain is there in visceral pain? (originates in the internal organs)

Answer 20

• Cramping
• Pressure
• Distension
• Deep
• Pulling

Question 21

What do the letters in Socrates stand for in pain consultations?

Answer 21

• Site
• Onset
• Cause
• Radiation
• Associations - what makes it better/worse
• Time Course
• Exacerbating factors
• Severity

Question 22

What is referred pain?

Answer 22

• Referred pain is when you feel pain in one part of your body, but the pain originates from another part of your body
• Irritation of visceral organs not felt at site but as some somatic structures

Question 23

What are some examples of neuropathic pain?

Answer 23

• Nerve injury following spinal surgery
• Pain after infection such as shingles
• Pain associated w/ diabetes (diabetic neuropathy)
• Pain after amputation
• Pain after stroke

Question 24

What are some clinical history questions for pain?

Answer 24

• Medical History: Pain, treatment, current meds, other conditions, mental health, alcohol, allergies
• Psychological: Home, social support, education, finance, on QoL
• Other: Suicide, complete ADLs, signposting

Question 25

What are some examples of pain assessment tools?

Answer 25

• Brief pain inventory
• Verbal rating scale
• Numerical rating scale

Question 26

What are some things that should be observed in the patient in pain assessment?

Answer 26

• Vocalisation
• Facial grimace
• Behaviour
• Skin damage
• Fracture