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PALLIATIVE CARE > PAIN > Flashcards

PAIN Flashcards

1
Q

Effect of pain on life?

A

Impairs physical and social function
Reduces QOL
Decreases patient autonomy
Makes pt think they have a poor prognosis and may actually affect prognosis

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2
Q

Common causes of pain in life limiting conditions e.g. cancer?

A

Mass pressing on tissues, nerves, bone, organ
Cancer blocking a part of the body e.g. bowel
Surgery, radiotherapy, side effects of anti-cancer drugs
Procedures e.g. dressing changes

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3
Q

General ascending pain pathway structure:

A

First order neuron - nociceptors are activated and signals are transmitted to the dorsal horn of the spinal cord
Second order neuron: neurone synapses with another neuron using substance P as a neurotransmitter, crosses to other side of spinal cord and enters the spinal tract. It will ascend up the spinal cord and terminate in the thalamus
Third order neuron: neurones synapse and this neuron will carry the impulse to the region of the brain related to the body part affected. Perception of pain is received here

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4
Q

General descending pain pathway structure:

A

Neurones from the periaqueductal gray matter go down and synapse with a second order neuron at the nucleus raphe Magnus. This second neurone is a serotonergic noradrenergic neurone and travels down to the dorsal horn of the spinal cord
Here it inhibits the communication between first order and second order neuron of the ascending pathway = controls pain signals going up
It also stimulates an interneurone in the substantia gelatinosa which releases enkephalin (an endogenous opioid). Enkephalin inhibits the presynaptic neurone from releasing substance P and inhibits the postsynaptic neuron from depolarising = stops impulse

Overall = descending pathway of pain inhibits ascending pathway

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5
Q

How to assess pain severity in palliative care?

A

Numerical rating scales
Visual analogue scales
Differentiate between the persons usual level of pain
If near end of life investigtaions are not appropriate

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6
Q

Social aspects of pain?

A

Culture can influence perception and expression of pain
Pain can impact on relationships
Social support can influence pain
Social/economic status can influence pain
Education can influence pain

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7
Q

Psychological aspects of pain?

A

The following modulate the perception of pain:
Expectancy
Perceived controllability
Fear and anxiety
Perceived self-efficacy

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8
Q

WHO analgesic ladder?

A

Non-opioid e.g. paracetemol or NSAIDs
Weak opioids e.g. codeine, dihydrocodeiene, Tramadol
Strong opioids e.g. morphine

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9
Q

Weak opioid drug options?

A

Codeine
Dihydrocodeiene
Tramadol

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10
Q

What shpould you prescribe alongside weak opioids and why?

A

A stimulant laxative and a softening laxative (senna + docusate)
To prevent constipation

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11
Q

What should you prescribe alongside strong opioids?

A

If IV morphine or otherwise if symptomatic…Antiemetics e.g. metoclopramide for gastric stasis or low-dose haloperidol

Give ALL Stimulant and softening laxative e.g. senna = docusate

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12
Q

How do you manage breakthrough pain in a person taking regular paracetemol or NSAIDs?

A

Treat with an additional dose of regular analgesic provided it does not exceed the maximum dose
Or add a weak opioid on for PRN

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13
Q

How do you manage breakthrough pain in a person taking regular paracetemol/NSAIDs and weak opioids?

A

Treating with an additional dose of the regular analgesic as long as it does not exceed the maximum licensed dose, or
Switching to a strong opioid.

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14
Q

How do you manage breakthrough pain in a person taking oral morphine?

A

Immediate-release oral morphine at a dose of 1/6th - 1/10th of the total daily oral morphine dose
To be taken as required but not repeated more than 2-hourly or >6 times in 24 hours

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15
Q

How do you manage breakthrough pain in a person on subcutanous infusion of morphine?

A

Treat with a subcutaneous bolus dose at 1/6th-1/10th the 24 hour infusion dose PRN but don’t repeat sooner than 2 hourly

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16
Q

Options for strong opioids for pain in palliative patients?

A

Morphine
Oxycodone
Buprenorphine
Fentanyl

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17
Q

Opioid side effects?

A

Constipation - usually persistent
Nausea and vomiting - usually transient
Drowsiness and poor concentration
Delirium
Myoclonus
Dry mouth
Hallucinations
Confusion/delirium
Myoclonus
Respiratory depression - uncommon: only if incorrect use
Urinary retention, bradycardia, hypotension, reduced sexual function
Hyperalgesia
Pin point pupils

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18
Q

Adjuvant analgesic options for pain in palliative care pts?

A

TCAs e.g. amitriptyline
Antiepileptics e.g. gabapentin or pregabalin
SNRI e.g. duloxetine

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19
Q

What drug is preferred to morphine in palliative patients with mild-moderate renal impairment?

A

Oxycodone

20
Q

What drug is preferred to morphine in palliative patients with severe renal impairment?

A

Alfentanil
Buprenorphine
Fentanyl

21
Q

What analgesia will metastatic bone pain respond best to?

A

Strong opioids
Bisphosphonates
Radiotherapy

Denosumab can also be used

22
Q

When you increase the dose of opioids, what % increase should the next dose be?

A

30-50%

23
Q

Side effect differences between morphine and Oxycodone?

A

Oxycodone causes sedation, vomiting and pruritus
But morphine causes less constipation than Oxycodone

24
Q

What is the mechanism of action of pregabalin for reducing pain?

A

Blocks the presynaptic voltage-gated calcium channels in the CNS to modulate the release of several excitatory neurotransmitters into the synaptic cleft = reduces neuronal excitability
It does this by binding to the alpha2-delta subunits

25
Q

What is the mechanism of action of lidocaine for reducing pain?

A

It blocks Na+ channels which prevents nerve depolarisation
This prevents the action potential transmission

26
Q

What is the mechanism of action of carbamazepine for reducing pain?

A

Inhibits Na+ channels = no depolarisation = no action potential transmission

27
Q

What is the mechanism of action of opioids for reducing pain?

A

Agonists of mu, delta and kappa opioid receptors which promotes K+ conductance and inhibit Ca2+ conductance = neurone less likely to fire an action potential and release neurotransmitters = prevents ascending pain pathway

28
Q

What is the mechanism of action of ketamine for reducing pain?

A

NMDA receptor antagonist

29
Q

Moa for duloxetine and TCAs for providing analgesia?

A

Increases the concentration of serotonin and norepinephrine in the dorsal horn of the spinal cord which increases the descending pathway = inhibition of pain

30
Q

Potential harms of opioids?

A

Excessive side effects
Toxic by products
Opioid-induced hyperalgesia

31
Q

How do opioids affect the GI tract?

A

They inhibit inter neurones of circular muscle = increase circular mucle contraction
They inhibit interneurons of longitudinal msucle causing a reduction in coordinated peristalsis
They inhibit interneurones causing reduced secretion of fluids and electrolytes

= faeces spend longer in bowel and more fluid is absorbed = cramps, slow bowel transit and dry hard stool

32
Q

How does opiate-induced respiratory depresson present?

A

Decreased respiratory rate which subsequently causes decreased oxygen saturations
(Note this is so important to remmeber because if RR is high and sats are low it’s more likely to be anther pathology e.g. PE)

33
Q

Treating opioid-induced respiratory depression?

A

Stimulate pt e.g. shake
Give high flow oxygen
You may do an ABG but not necessary

Only give naloxone if recent fall in RR and sats <90% and you can’t stimulate their breathing non-pharmacologically

34
Q

How do we titrate naloxone to a pt with opioid-induced respiratory depresson?

A

Titrate to RR not pain
E.g. 20mcg IV every 2 mins until RR is normal

(This is very different to if they are an IV drug user and come to you with opioids resp depression where they need 400mcg!)

35
Q

What might have caused opioid-induced respiratory depression?

A

Renal failure?
Have they been given the wrong dose?
Have they recently started another drug that is suppressing respiratory drive?
Etc

36
Q

What is allodynia?

A

pain due to a stimulus that does not normally provoke pain e.g. light touch

37
Q

What is hyperalgesia?

A

increased pain from a stimulus that usually provokes pain

38
Q

What is opioid induced-hyperalgesia?

A

a state of nociceptive sensitization caused by exposure to opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli.

39
Q

What is zomorph?

A

Modified/slow release oral morphine

40
Q

How fast does oromorph kick in and how long does it last?

A

Works in 30-60 mins
Lasts 4-6 hours

41
Q

Opiate withdrawal symptoms?

A

Lacrimation
Rhinorrhoea
Piloerection - hairs on end
Myalgia
Diarrhoea
N&V
Pupillary dilation
Photophobia
Insomnia
Autonomic hyperactivity e.g. tachypnoea, hyperreflexia, tachycardia, sweating, hypertensive, hyperthermia
Yawning

42
Q

What % of cancer pts relieving palliative care have pain?

A

Up to 70%

43
Q

Factors that can affect pain?

A

Cognitive level and level of consciousness - dementia or drowsiness may reduce expression of pain
Mood disturbances e.g. depression may increase pain
Other symptoms being present will impact the patient’s expression of pain
Life experience and the meaning the pt attributes to pain and suffering e.g. fear of what pain means such as is it spread of cancer can worsen it
Cultural and religious beliefs

44
Q

Transdermal opioid options?

A

Fentanyl
Buprenorphine

45
Q

What number of episodes of breakthrough pain a. Day should indicate that current management of baseline pain should very reviewed?

A

When >4 episodes

PALLIATIVE CARE (8 decks)

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