Pain Flashcards by Erin Sanderson

What is pain

Patients perspective

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Physical benefits of treating pain

Improved sleep
Better appetite
Fewer medical complications

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Psychological benefits of treating pain

Decreased suffering

Less depression, anxiety

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Family benefits of treating pain

Improved functioning as a family member

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Duration classification of pain

Acute
Chronic
Acute on Chronic

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Cause classification of pain

Cancer

Non-cancer

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Mechanism classification of pain

Nociceptive

Neuropathic

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Describe acute pain

Pain of recent onset and probable limited duration

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Describe chronic pain

Pain lasting >3 months

Pain lasting after normal healing

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What is nociceptive pain

Obvious tissue injury or illness
Damage to nociceptive afferents
Also called:
Physiological or Inflammatory pain

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Description of nociceptive pain

Sharp+/- dull
Well localised
Visceral pain slightly less localised

Protective function

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What is neuropathic pain

Nervous system damage of abnormality

Tissue injury may not be obvious

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Description of neuropathic pain

Burning, shooting +/- numbness, tingling, pins and needles
Not well localised

Does not have a protective function

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4 steps of pain

Periphery (spinothalamic tract)
Spina Cord
Brain
Modulation

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Which chemicals are release at the site of tissue damage

Prostaglandins

Substance P

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What are nociceptors

Pain receptors

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Through which fibres does pain travel

Alpha
Delta
or C

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What is the first relay station in pain sensation

Dorsal horn

alpha, delta or c nerves synapse with 2nd neruon

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Where is the 2nd relay station in pain sensation

Thalamus

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Where does pain perception occur

Cortex

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Examples of neuropathic pain

Nerve trauma, Diabetic pain

Fibromyalgia, Chronic TTH

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Pathological mechanisms in neuropathic pain

Increased number of receptors
Abnormal sensation of nerves
Chemical changes in dorsal horn
Loss of normal inhibitory modulation

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Name some simple analgesics

Paracetamol

NSAIDs

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Pros of paracetamol

V. useful
V. cheap
Better when used in combination

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Examples of NSAIDs

Ibuprofen | Diclofenac

Examples of opioids

``` Codeine Morphine Fentanyl Oxycodone Dyhydrocodeine ```

Which anti-depressants can be used to treat pain

SNRI: Duloxetine TCA: Amitryptiine

Other analgesic types

``` Tramadol Antidepressants Anti-convulsants (e.g gabapentin) Ketamine (NDMA receptor) Local anaesthetics Topical agents (Capsaicin) ```

Non-drug treatments of pain at the periphery

Rest Ice Compression Elevation

Drug treatments of pain at the periphery

NSAIDs | Local anaesthetics

Non-drug treatments of pain at the spinal cord

Acupuncture Massage TENS

Drug treatments of pain at the spinal cord

Local anaesthetic Opioids Ketamine

Non-drug treatments of pain at the brain

Psychological

Drug treatments of pain at the brain

Paracetamol Opioids Amitryptiline Clonidine

Pros Paracetamol

Cheap Safe Can be given orally, IV or rectally

Cons of paracetamol

Liver damage in overdose

Pros of NSAIDS

Cheap Generally, safe Best for nociceptive pain Best given regularly with paracetamol (Synergism)

What type of relationship do paracetamol and NSAIDs have

Synergistic

Cons of NSAIDs

GI side effects Renal SE Plus sensitive asthmatics

Pros of codeine

Cheap Safe Good for mild-moderate acute nociceptive pain

Cons of codeine

Constipation Nausea Not good for chronic pain

Pros of Tramadol

Weak opioid effect plus inhibitor of serotonin and noradrenaline reuptake (modulation) Advantage Less respiratory depression Can be used with opioids and simple analgesics Not a controlled drug

Cons of tramadol

Nausea | Vomiting

Pros of morphine

Cheap Generally safe Can be given orally, IV< IM , SC Effective if given regularly

What is morphine good for

Mod-severe acute nociceptive pain | Chronic cancer pain

Cons of morphine

``` Constipation Respiratory distress in high dose Misunderstandings about addiction: As long as you stop taking it when pain resolves this shouldn’t be an issue Controlled drug ```

Pros of Amitryptiline

Cheap | Safe in low dose

What is amitryptiline good for treating

Neuropathic pain | Also treats depression and poor sleep

Cons of amitryptiline

Anti-cholinergic SE

Pros of anti-convulsants

Good for neuropathic pain

Examples of anti-convulsants used to treat pain

Carbamezepine Sodium Valproate Gabapentin

What is the preferred route of delivery

Oral

Other routes of delivery for pain medication

``` Rectal Sublingual Subcutaneous Transdermal Intramuscular Intravenous (boluses, possible patient controlled systems) ```

Delivery routes for local anaesthetics

``` Epidural Intrathecal Wound catheters Nerve plexus catheters Local infiltration of wound ```

How do we assess severity of pain

Ask the patient Verbal rating score (none, mild, severe ect) Numerical rating score (0-10) Visual analogue scale (theoretical 10cm line) Smiling faces (children) Abbey Pain Scale (for confused patient)

Which ladder should be used for acute pain

WHO pain ladder

Should the WHO pain be used for neuropathic pain?

No | Not responsive

Step 1 WHO pain ladder

Mild to Moderate Pain: Non-opioids – aspirin, NSAIDs or paracetamol

Step 2 WHO pain ladder

Moderate to severe pain : Opioids: Codeine with or without non-opioids

Step 3 WHO pain ladder

Severe pain: Strong opioids Morphine with or without non- opioids

What should you give according to WHO pain ladder for mild pain

Start at the bottom of the ladder | Step 1

What should you give according to the WHO pain ladder for Moderate pain

Step 1 and Step 2

What should be given according to the WHO pain adder for Severe pain

Step 1 and Step 3 | Miss out middle (step 2)

Is it okay to start at the to of the WHO pain ladder

Yes | For severe/unbearable pain

As pain resolves how should you move down the WHO pain ladder

``` Move down the ladder Do not kip Continue step 1 drugs at all times Lastly stop NSAIDs Then paracetamol as adverse SE with NSAIDs ```

What does RAT approach stand for

Recognise Assess Treat

RAT assessing pain

Severity?: Pain score At rest and on movement Types? Acute or chronic Cancer or non-cancer Nociceptive or neuropathic Other factors? Physical factors Psychological factors (anger, anxiety, depression)

RICE non-drug treatments

Rest Ice Compression Elevation

Recognising pain RAT approach

Ask do you have pain Look (at facial expressions, sweating ect..) Do other people know the patient has pain

What should you do after RAT

Reassess the patient Is Rx working? Is other RX required?