Mx Pain Older people and malignant disorders

Question 1

What are the dimensions of pain?

Answer 1

• Sensory discriminative (location, intensity, quality, duration)
• Affective-motivational (unpleasant, desire to avoid)
• Cognitive evaluative (feelings of distress and despair)

Question 2

What is the lateral pain transmission system?

Answer 2

-Spinothalamic tracts

Location, intensity and quality of pain

Question 3

What is the medial pain transmission system?

Answer 3

-Medulla
-Medial thalamus
-Hypothalamic nuclei
-Limbic
-Insula cortex
Emotion, arousal, attentions (i.e. unpleasant, affective dimensions)

Question 4

What is adaptive v maladaptive pain?

Answer 4

Adaptive: contributes to survival by protecting organism from injury / promoting healing
Maladaptive: i.e. chronic pain = pain as a disease

Question 5

What is chronic pain?

Answer 5

• Generally pain >3 months
• Persists longer than expected period of healing of tissue damage
• May be unprovoked
• Severity not correlated with degree of tissue damage
• may be considered disease in own right

Question 6

Emotional problems associated with chronic pain?

Answer 6

Depression, anxiety, secondary gain

Question 7

What is nociceptive pain?

Answer 7

• Most common mechanism e.g. injury, surgery
• Somatic and visceral
• Responsive to analgesia

Question 8

What is neuropathic pain?

Answer 8

• Poster herpetic neuralgia, painful peripheral neuropathies, central post stroke pain
• Less responsive to conventional analgesia
• may respond to adjuvant strategies

Question 9

What is functional pain?

Answer 9

• Fibro, IBS, interstitial cystitis, tension HAs
• Unclear aetiology
• Difficult to treat

Question 10

What is psychological pain?

Answer 10

• Chronic pain frequently a/w depression, anxiety, anger

- Purely psychogenic pain rare

Question 11

What are examples of pain intensity scales?

Answer 11

• Visual analogue scale
• Numerical rating scale
• Wong Baker Faces Scale
• Verbal rating scale
• Brief pain inventory (short form)

Question 12

What are issues associated with opioid use?

Answer 12

• Physical tolerance
• Physical dependence
• Opioid dependence

Question 13

What is physical tolerance?

Answer 13

• physiologic adaptation to the drug

- manifestation: increased disease required to produced same pharmacologic efffects

Question 14

What is physical dependence?

Answer 14

• Physiologic adaptation to continuous presence of a substance
• Manifested by withdrawal syndrome if dose significantly lowers or stops

Question 15

What is opioid dependence?

Answer 15

• Preoccupation with desire to obtain and take the drug
• persistent drug seeking behaviour
• Impairment of function and harm

Question 16

What is pseudo addiction?

Answer 16

• Pain is poorly controlled
• Patient makes attempts to obtain analgesia that resembles drug seeking behaviour
• staff misinterpret as addictive behaviours thereby compromising pain management and undermining trust

Question 17

What is breakthrough pain?

Answer 17

Exacerbation of chronic pain otherwise stable on continuous analgesia; manage with PRN analgesia

Question 18

What is incident pain?

Answer 18

Pain occurring with or exacerbated by physical activity e.g. wound dressing. Manage with analgesia prior to the incident.

Question 19

What are adjutant analgesics?

Answer 19

Drugs with primary indication other that pain that have analgesic properties in some painful conditions

e. g. -antidepressants
- anticonvulsants
- corticosteroids
- local anaesthetics
- NMDA antagonists
- calcitonin
- bisphosphonates

Question 20

Which conditions are TCAs useful in?

Answer 20

TCA e.g. amitriptyline

• neuropathic pain
• fibromyalgia
• low back pain
• headaches
• IBS

Question 21

SNRI usefulness in pain Mx?

Answer 21

• Neuropathic pain esp diabetic peripheral neuropathy

- fibro

Question 22

What is the action of gabapentin and pregabalin?

Answer 22

a2y subunit of Ca++ channels: brain and dorsal horn.

Question 23

What is the evidence for gabapentin and pregabalin in pain conditions?

Answer 23

Good: neuropathic pain, fibro
Some: low back pain with radiculopathy
No: non specific low back pain

Question 24

What are non pharmacologic approaches to pain Mx?

Answer 24

• heat or cold
• PT
• Massage
• accupuncture
• relaxation and stress Mx
• TENS
• CBT

Question 25

Services offered by PTs for management pain?

Answer 25

• therapeutic exercise
• TENS
• CT mobilisation techniques
• relaxation techniques
• gait aids/ techniques
• accupuncture

Question 26

What are indications for a syringe driver?

Answer 26

• Inability to swallow
• Persistent nausea and vomiting
• Dysphagia
• Persistent fits
• Profound weakness
• Poor absorption

Question 27

What are examples of non-drug treatments for cancer pain?

Answer 27

• TENS
• {T
• Accupuncture
• Relaxation therapy

Question 28

What are common adjuvant analgesics for cancer pain?

Answer 28

• NSAIDs
• Corticosteroids
• Antidepressants / convulsants / antiarrhythmics
• Bisphosphonates

Question 29

What are the indications for NSAIDs as adjuvants in cancer analgesia?

Answer 29

• Bone pain
• Soft tissue infiltration
• Hepatomegaly

Question 30

What are the indications for corticosteroids as adjuvants in cancer analgesia?

Answer 30

• raised ICP
• Soft tissue infiltration
• Nerve compression
• Hepatomegaly

Question 31

What are the indications for antidepressants / anti convulsants / antiarrhythmics as adjuvants in cancer analgesia?

Answer 31

• Nerve compression or infiltration

- Paraneoplastic neuropathies