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MD3 Palliative care > Pain > Flashcards

Pain Flashcards

1
Q

What are the 3 dimension of experiencing pain?

A

Sensory: eg location, intensity etc
Affective: unpleasant etc
Cognitive: it might mean something bad is happening

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2
Q

Which spinal tract is pain conveyed in? Where does it cross over?

A

Spinothalamic tract/ anterolateral system

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3
Q

What aspect of pain does the medial spinal system convey? (including in the brain the medulla, medial thalamus, hypothalamus, limbic system and insula)

A

Emotional aspects of pain

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4
Q

What is chronic pain?

A
  • Pain lasting longer than 3 months
  • Pain persisting longer than expected period of healing or tissue damage
  • May be no apparant patholohy
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5
Q

What are the 3 emotional problems associated with chronic pain?

A

Depression, anxiety, malingering/ need for secondary gain

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6
Q

What are the 4 classifications of pain?

A

Nociceptive
Neuropathic
Functional
Psychological

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7
Q

What is the typical quality of neuropathic pain?

A 
Numbness
Burning
Tingling
Pins and Needles
Sharp pain
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8
Q

What are the psychological and physical vicious cycles of pain?

A

Psych:

Pain–> anger, stress, fear–> low mood–> depression–> increased pain perception–> Pain

Physical:

Pain–> activity avoidance–> deconditioning–> pain with activity

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9
Q

Does chronic pain prevalence increase with ageing?

A

Yes

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10
Q

What are the most common types of pain in the elderly?

A
  • articular, leg and foot pain

- Neuropathic lesions: postherpetic neuralgia, central post-stroke pain, painful peripheral neuropathies

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11
Q

What kinds of pain decrease in prevalence with age?

A
  • headaches (peak 45-50 years) • facial / dental pain
  • abdominal / stomach pain
  • chest pain
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12
Q

Is pain in older people generally over or under reported?

A

Under

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13
Q

What are some of the challenged of assessing pain in older people?

A
  • Stoicism
  • Nihilism
  • Cognitive impairment, particularly memory
  • Language: dysphasias
  • Autonomic blunting
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14
Q

Does degenerative spine disease severity correlate with back pain severity/?

A

No

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15
Q

What are some examples of pain rating scales?

A 
Visual analogue
Numerical
Wong-Baker Faces
Verbal rating
Brief pain inventory
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16
Q

What are 5 issues with prescribing pain meds in older people?

A
  • Medication interactions
  • Chronic disease interactions
  • Altered pharacokinetics and pharmacodynamics
  • Cost
  • Reduced physiological reserve
17
Q

What are the 3 broad issues associated with opioid use?

A
  • Tolerance: increased doses required for the same physiological effect
  • Dependence: physiological adaptation to the presence of the drug and withdrawal syndrome if the dose stops
  • Addiction: Preoccupation, drug-seeking behaviours, harm, functional impairment etc
18
Q

What is pseudoaddiction?

A

Poorly controlled pain resulting in behaviour which appears to be drug seeking

19
Q

Long vs short acting medications:

  • Acute pain
  • Chronic pain
A

Short

Long

20
Q

What is breakthrough pain and how do you manage it?

What is incident pain and how do you manage it?

A 
Breakthrough pain (pain flare) is an exacerbation of chronic pain otherwise stabilised on round-the- clock analgesia.
– managed with PRN analgesia when pain occurs – if frequent PRN doses are required, increase
background analgesia

Incident pain occurs with, or is exacerbated by, physical activity or an event such as a wound dressing.
– managed with analgesia PRIOR to the incident

21
Q

Give 3 examples of adjuvant analgesics:

A

Antidepressants
Anticonvulsants
Corticosteroids

22
Q

What kinds of pain are TCAs useful for?

What kinds of pain are SNRIs useful for?

What kinds of pain are anticonvulsants useful for?

A 
Tricyclic antidepressants, eg amitriptyline
– neuropathic pain 
– fibromyalgia
– low-back pain
– headaches
– irritable bowel syndrome

Selective serotonin and noradrenaline reuptake inhibitors
eg duloxetine, venlafaxine
– neuropathic pain esp diabetic peripheral neuropathy
– fibromyalgia

Gabapentin and Pregabalin
α2δ subunit of Ca++ channels: brain and dorsal horn

  • good evidence
  • neuropathic pain
  • fibromyalgia
  • some evidence
  • low back pain with radiculopathy
  • no evidence
  • non-specific low back pain

Carbemazepine
• trigeminal neuralgia

23
Q

If a non-verbal person presents with pain-behaviour during movement, should they have pain meds?

A

yes

24
Q

Chronic pain management: Approach (pall care)

A

Treat any underlying pathology

Treat co-morbid psychiatric conditions

Screen for red flags

Refer to chronic pain service: anaesthatist, OT, physio, phycologist

NON-PHARM:

Physical therapies:

  • Heat or cold
  • Physical therapies – walking, stretching and strengthening or aerobic exercises.

Psychological therapies:
- Cognitive Behavioural Therapy

CAM:

  • Massage
  • Acupuncture
  • Yoga
  • Meditation and mindfulness

PHARM:

Paracetemol

NSAIDs

(codeine and tramadol not used lots)

Morphine

  • renally excreted
  • short acting= morphine (oral, S/C, IV)
  • long acting= MS contin (oral)

Oxycodone

  • Short acting= endone, oxynorm
  • Long acting= oxycontin
  • With naloxone, long acting= targin (need good liver function)
  • renally excreted

Hydromorphone

  • Short and slow release options
  • Partial agonist
  • Can use in renal impairment

Fentanyl

  • IV, S/C, pathc, inhaled
  • Can use in renal impairment
  • Patch takes 12 hrs for effect but then takes 3 days for a steady state
  • Safe in renal failure

Buprenorphine

  • Patch
  • Hepatic clearance, good in renal failure

Other: anticonvulsants, antidepressants, ketamine, nerve blocks, spinal implants

25
Q

What is an example of how CBT can help someone with chronic pain?

A

Cognitive therapy aims to change the way the person thinks about the issue, eg:
• my pain is a reflection of serious disease
• this is the worst thing that could ever happen to me
• activity will cause more tissue damage

Behavioural therapy aims to teach the person techniques or skills to alter their behaviour, eg:
• goal setting
• paced physical activity
• pain behaviours - moaning, limping, rubbing

26
Q

Can treating pain help BPSD?

A

Yes

27
Q

What are the pain SE of gabbapentin and pregabalin and what time of day should patients take them?

A

Drowsiness, confusion, postural hypotension, peripheral oedema–> start at night

28
Q

Opioid prescribing:

How do you start an opioid?

What dose to give in a breakthrough?

How many breakthroughs cause you to titrate basal dose?

How much do you increase the doses by?

A
  • Start at a low dose (bd) and prescribe a short acting dose as a PRN for breakthroughs
  • Breakthough give 1/10-1/6 daily dose (ie take BD dose and double and divide by 6 or 10)
  • 3 breakthroughs–> increase daily dose by 10-25% (or by 2/3 of the converted PRN dose) AND also increase PRNs proportional to new daily dose
29
Q

5 critical opioid SEs:

A
  • NV
  • Drowsiness
  • Resp depression
  • Confusion/ delirium
  • Urinary retension
30
Q

What is useful for bone pain, radiotherapy pain and liver capsule stretching pain?

A

Dexamethasone

31
Q

What are the relative potencies of opioids?

(ie in mg/day)- oral morphine=1

A

Oral:

Codeine: 0.13
Tramadol: 0.2
Oxycodone: 1.5
Hydromorphone: 5

Sublingual:

Buprenorphine: 0.04 (mcg/day)

Transdermal:

Buprenorphine: 2 (mcg/hr)
Fentanyl: 3 (mcg/hr)

Parenteral:

Pethidine: 0.4
Oxycodone: 3
Morphine: 3
Hydromorphone: 15
Fentanyl: 0.2 (mcg/day)
32
Q

Rotating opioids- when is this appropriate in chronic pain?

A

Rotating is useful for SEs. If non responsive to one opioid, unlikely to be responsive to another kind.

33
Q

What are the principles of treating cancer pain?

A
  • Palliative treatment of the cancer for symptomatic relief even if it won’t be curative: chemo, radio, surgery
  • Anaesthetic interventions such as nerve blocks can be used
  • Spinal stimulators can be implanted by neurosurg
  • Consider multidisciplinary approach: nursing and physio interventions

Meds:
Use the WHO analgesic stepladder

Non-opioid+/- adjuvant–>opioid for mild to mod pain +/- non opioid +/- adjuvant–> opioid for mod to severe pain +/- non-opioid +/- adjuvant

34
Q

What are the indications for use of a syringe pump?

A
  • Patient can no longer swallow
  • Persistent NV
  • Dysphagia
  • Persistent seizures
  • Profound weakness
  • Poor absorption

MD3 Palliative care (3 decks)

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