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Year 2 C&M Clinical Symposia > Pain 2 > Flashcards

Pain 2 Flashcards

1
Q

What are the 2 types of pain as classified by duration?

A

1) Acute

2) Chronic

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2
Q

What are the 2 types of pain as classified by pathophysiology?

A

1) Nociceptive

2) Neuropathic

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3
Q

What are the main differences between acute and chronic pain?

A

Acute pain is associated with injury and resolves with healing of the underlying injury, it serves a protective function and assists wound repair
Chronic pain persists beyond the normal type of healing and is dissociated from tissue damage, it ceases to perform a protective function and is associated with considerable suffering

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4
Q

What is nociceptive pain?

A

Pain which is caused by actual tissue damage and painful stimuli at nociceptors

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5
Q

How is nociceptive pain regulated?

A

By the opioidergic system

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6
Q

Is it possible to get chronic nociceptive pain?

A

Yes - for example osteoarthritis, but chronic nociceptive pain may lead to neuropathic and mixed pain

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7
Q

What are the 2 main beneficial aspects of acute pain?

A

1) protective - avoid further damage
2) Learning experience
It is part of the trauma response

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8
Q

What are the 4 main adverse effects of acute pain?

A

1) Humanitarian issue
2) Cardiovascular stress
3) Respiratory compromise
4) Hypercoagulation

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9
Q

For what 2 reasons is it very difficult to measure pain?

A

1) It is a synthesis of several observations eg. intensity, quality etc
2) How it is perceived is relative to distress of person eg. acid reflux in normal 43 year old compared to in a 43 yr old with strong family history of IHD may be perceived as more severe in latter

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10
Q

What are the 5 factors associated with changes in pain perception?

A

1) Anxiety
2) Depressed affect - if depressed pain is felt more strongly
3) Gender - socialisation/gonadotrophins
4) Circadian variation - pain worse in middle of night
5) Climatic conditions - MSK pain thought to be worse in cold

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11
Q

How can pain be assessed in patients?

A

Self reported - visual analogue score

Assess at rest and during movement

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12
Q

What are the 3 main steps in the analgesic ladder, when do you progress through the ladder?

A

Start at the bottom and progress if pain persists or is increasing

1) Non-opioid +/- adjuvant
2) Opioid for mild to moderate pain + non opioid +/- adjuvant
3) Opioid for moderate to severe pain + non opioid +/- adjuvant

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13
Q

Name 4 non opioid drugs?

A

1) Acetaminophen
2) Aspirin
3) NSAIDs
4) Cox-2 inhibitors

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14
Q

Name 3 opioids for mild to moderate pain?

A

1) Codeine
2) Dihydrocodeine
3) Tramadol

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15
Q

Name 5 opioids for moderate to severe pain?

A

1) Morphine
2) Fentanyl
3) Hydromorphone
4) Buprenorphine
5) Methadone

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16
Q

In what way do opioids act at 2 sites in the spinal cord?

A

1) Presynaptically pain signal transmission is reduced

2) Post synaptic membrane is hyperpolarised, decreasing the probability of an action potential being generated

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17
Q

NSAIDs and COX-2 inhibitors act mainly peripherally, which non opioid has central acitivity?

A

Paracetemol

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18
Q

What is the mode of action of NSAIDs?

A

Inhibition of cyclo-oxygenase - prostaglandin synthesis decreases

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19
Q

What are the 4 main side effects of NSAIDs?

A

1) GI irritation/bleeding
2) Renal toxicity
3) Potential drug-drug interactions
4) CV side effects (COX2)

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20
Q

What is the efficacy of NSAIDs?

A

Mainly act on nociceptive pain

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21
Q

What is the efficacy of opioids?

A

Mainly nociceptive pain - less effective in chronic states, only partially effective in neuropathic pain

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22
Q

What is the efficacy of paracetemol?

A

Analgesic and antipyretic effects, no anti inflammatory action

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23
Q

What is the mode of action of paracetamol?

A

Not fully understood - inhibits central prostaglandin synthesis

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24
Q

What is the main side effect of paracetamol?

A

Risk of toxic liver damage

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25
Q

What is the mode of action of opioid analgesics?

A
  • Activate the endogenous analgesic system
  • Stimulate receptors in the limbic system to eliminate the subjective feeling of pain
  • Affect descending pathways that modulate pain perception
  • Reduce ascending pain signal transmission in the spinal cord
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26
Q

What is the problem with large bolus analgesia?

A

Narrow range in which get analgesia without side effects - when only given as a large bolus then the plasma level fluctuates from pain to a level at which side effects occur rather than staying constantly within the plasma level range which has only analgesic effects

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27
Q

Name a method of avoiding large bolus analgesia and maintaining opioids within the optimum therapeutic range?

A

Patient controlled analgesia - small bolus and 5 minute lockout

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28
Q

What are the 6 main side effects of opioids?

A

1) Nausea
2) Vomiting
3) Constipation
4) Dizziness or vertigo
5) Somnolence
6) Dry skin, pruritus

29
Q

What is the most serious potential adverse affect of systemic opioid analgesia?

A

Respiratory depression and hypoxia

30
Q

What is the best early warning sign of respiratory depression with systemic opioids?

A

Progressive sedation

- not respiratory rate, not SpO2

31
Q

What 2 opioids should not be used in patients with renal failure and why?

A

Morphine or codeine
Sedative metabolites accumulate
(Fentanyl or oxycodone are OK)

32
Q

In patients with a history of substance abuse how should opioids be used?

A

Give what is required - use balanced analgesia

33
Q

What is epidural anaesthesia?

A

Drugs administered directly into the epidural space

34
Q

What are the 3 common uses of epidural anaesthesia?

A

1) Postoperatively: thoracic, abdominal, groin/perineal, lower limb surgery
2) Labour pain
3) Chronic pain

35
Q

What are the 6 benefits of epidural anaesthesia?

A

1) High quality pain relief
2) Improved pulmonary function
3) Reduced sepsis and chest infection
4) Reduced cardiac morbidity
5) Reduced vascular graft failure
6) Reduced incidence of DVT

36
Q

Where is the epidural space?

A

Between dura mater and the wall of the vertebral canal

37
Q

What are the 5 areas of block in epidural anaesthesia?

A

1) High thoracic - upper chest
2) Low thoracic - middle trunk
3) Low thoracic/high lumbar - lower trunk and groin area
4) Lumbar - legs
5) Caudal - saddle region

38
Q

What percentage of people with advanced cancer experience pain?

A

75%

39
Q

What percentage of cancer patients control their pain with oral or sub cut opioids?

A

90% -the other 10% require complex management

40
Q

What are the rough guidelines for use of morphine correctly?

A

1) begin with regular immediate release morphine (provide access morphine for breakthrough pain)
2) Review regular requirement by incorporating breakthrough dose into new 4 hourly dose
3) When stable convert to sustained release morphine (but still provide for breakthrough pain)

41
Q

What type of cancer is a celiac plexus block used in?

A

Pancreatic carcinoma and upper abdominal neoplasia

42
Q

At what part of the spinal cord do spinal opioids act at?

A

Dorsal horn of the cord

43
Q

Which type of spinal opioid reaches the brainstem?

A

Lipophobic morphine

44
Q

Which type of spinal opioid remains segmentally localised?

A

Lipophilic fentanyl

45
Q

In what 5 ways can morphine be administered?

A

1) PO
2) IV
3) Epidural
4) Intrathecal
5) Intraventricular

46
Q

What is neuropathic pain?

A

Spontaneous pain and hypersensitivity to pain in association with damage to or a lesion of, the nervous system, it is intense and may be accompanied by another pain phenomenon, often persistent and associated with severe comorbidity and poor quality of life

47
Q

Give 5 examples of conditions which cause neuropathic pain?

A

1) Post herpetic neuralgia
2) Painful diabetic neuropathy
3) Trigeminal neuralgia
4) Pain after CVA
5) Post traumatic/post operative

48
Q

What is thought to be the spinal mechanism behind neuropathic pain following surgery/ trauma?

A

Hyperexcitable spinal cord
Previously silent nociceptors start signalling following trauma
Have an expanded hyperexcitable dorsal horn with ne inputs

49
Q

What is the supraspinal mechanism involved in neuropathic pain following surgery/trauma?

A

Remapping of the thalamus and cortex - this is associated with more pain
Regions of the cortex which prior to the surgery were receiving input and now are not, get confused by this and start manifesting pain

50
Q

WHat are the 7 features suggesting neuropathic pain?

A

1) Pain different from normal everyday pain
2) Pain in the absence of ongoing tissue damage
3) Pain in an area of sensory loss
4) Paroxysmal or spontaneous pain
5) Allodynia (pain in response to non painful stimuli)
6) Hyperalgesia (increased pain in response to painful stimuli)
7) Dysaesthesia (unpleasant abnormal sensations - eg ants crawling on the skin)

51
Q

What is the prevalence of neuropathic pain?

A

2-4% of population

52
Q

What 3 psychiatric conditions are associated with neuropathic pain?

A

1) Depression
2) Anxiety
3) Insomnia

53
Q

Name a questionnaire designed to measure pain quality?

A

McGill Pain questionnaire

54
Q

What are the 2 advantages and 2 problems with the McGill Pain questionnaire?

A 
Advantages = Well validated and quality assessed
Problems = Time consuming, Insensitive to small change in intensity
55
Q

Which type of pain medication acts on the brain?

A

Opioids

56
Q

Which 4 types of pain medication act on the dorsal grey horn?

A

1) Opioids
2) Antidepressants
3) Anticonvulsants
4) Non-opioid analgesics

57
Q

Name 2 types of pain medication which act in the periphery?

A

1) Topical analgesics

2) Non-opioid analgesics

58
Q

What are the 5 possible drug therapies for neuropathic pain?

A

1) Antidepressants
2) Anticonvulsants
3) Opioids
4) Membrane stabilising drugs
5) Topical drugs

59
Q

For what 3 types of pain are antidepressants (TCAs) effective?

A

1) Neuropathic pain
2) Complex regional pain syndrome
3) Tension headache

60
Q

What is the mode of action of antidepressants - TCAs?

A

Inhibition of neuronal re-uptake of noradrenaline and serotonin 5-HT

61
Q

What are the 6 side effects of TCAs?

A

1) Constipation
2) Dry mouth
3) Somnolence
4) Abnormalities in heart rate and rhythm
5) Insomnia
6) Increased appetite

62
Q

Can antidepressants other than tri-cyclic agents be used for neuropathic pain?

A

No - serotonin uptake inhibitors are relatively ineffective

63
Q

What are the modes of action of the anticonvulsants Gabapentin, Pregabalin, Carbamazepine in the treatment of neuropathic pain?

A

Gabapentin - binds to pre-synaptic voltage-dependent calcium channels
Pregabalin - interacts with special N-type calcium channels
Carbamazepine - blocks Na+ and Ca2+ channels

64
Q

What are the 6 main side effects of anticonvulsants?

A

1) Sedation
2) Dizziness
3) Ataxia
4) Peripheral oedema
5) Nausea
6) Weight gain

65
Q

Does the anticonvulsant Gabapentin work in both nociceptive and neuropathic pain?

A

Prevents neuropathic but not nociceptive pain in animal models

66
Q

How is the anticonvulsant Gabapentin excreted?

A

Renally excreted

67
Q

What does operant conditioning have to do with pain?

A

Whilst nociception may be the origin of a pain behaviour, if that pain behaviour is reinforced it is likely to occur even in the absence of nociception

68
Q

What are the non medical approaches to managing chronic pain?

A

1) Cognitive behavioural therapy
2) Stress management
3) Attention/ distraction techniques

Year 2 C&M Clinical Symposia (21 decks)

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