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Pharmacotherapeutics Theory 2 > Pain > Flashcards

Pain Flashcards

1
Q

What are the Different Types of Pain?

A
  • Nociceptive (damage to the tissues)
    • Non-cancer acute
    • Chronic
  • Neuropathic pain (damage to the nerves)
  • Cancer related pain
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2
Q

What is Pain?

A

Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

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3
Q

What is nociception?

A

Nociception is the neural process by which body detects noxious stimuli

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4
Q

What is the process of Pain?

A
  1. Detection – nociceptors detect noxious stimulus
  2. Transmission – after detection done by calcium channels, there’s an influx of calcium ions through calcium channels which release vesicles containing new stimulatory receptors
  3. Central perception – emotionally will respond differently
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5
Q

What is the Assessment of Pain?

A
  • Vocalisation: whimpering, crying
  • Facial expression: looking tense, frowning, look frightened
  • Behavioural change: increased confusion, refusing to eat, rocking, look withdrawn
  • Physiological change: Temperature, pulse or BP, flushing or pallor
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6
Q

What is Acute Pain?

A
  • Positive biological function – protective role
  • Short duration (<12 weeks)
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7
Q

What are the Goals of Treatment of Acute Pain?

A
  • Relieve pain with minimal side effects
  • Optimise function
  • Prevent progression to chronic pain
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8
Q

Is there specific treatment for acute pain?

A
  • Specific treatment for the underlying condition and symptomatic management of pain which usually resolves with healing of the underlying illness or injury
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9
Q

What is the Approach to Acute Pain Management?

If analgesics are required?

A
  • Non-pharmacological approaches may be adequate in patients with mild pain
  • If analgesics are required
    • Use a stepwise approach starting at a step that corresponds to the severity of the patient’s pain
    • Pick the analgesic based on the pain that is being reported
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10
Q

What are the 5 Guiding Principles Pain Management of Analgesics?

A
  • ‘By Mouth’: Oral forms preferred where possible
  • ‘By the Clock’: Given at regular intervals rather than on demand
  • ‘By the Ladder’: Adhere to principles of ladder
  • ‘For the Individual’: Individualise therapy based on the level of the patient’s reported pain
  • ‘Attention to Detail’: Monitor patient’s pain closely
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11
Q

What is Chronic Pain?

A
  • Pain which has been present daily for 3 months
  • Persists after healing is complete or due to chronic disease
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12
Q

Chronic pain may be precipitated by:

A
  • Acute pain following surgery or injury
  • Acute pain associated with illnesses such as HIV, herpes zoster
  • Stroke resulting in central post-stroke pain syndromes
  • Spinal cord injury resulting in radicular ‘at level’ pain, distal neuropathic pain and various musculoskeletal pain syndromes
  • Therapy with antineoplastic drugs
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13
Q

What are the Risk Factors for Transition from Acute to Chronic Pain?

A
  • Disease that doesn’t abate
  • Significance of the pain
  • Inadequate pain relief
  • Neuropathic nature of pain
  • Patient factors (poor understanding of cause of pain and uncertainty about its significant)
  • Inappropriate non-drug treatment (e.g. prolonged immobility)
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14
Q

What are the General Principles for Managing Chronic Pain?

A
  • Perform a comprehensive clinical assessment
  • Focus on appropriate combinations of physical, psychological and pharmacological therapies
  • Consider non-pharmacological therapies first if no need for immediate drug therapy
  • Consider drug therapy if non-pharmacological therapies are unsuccessful or inappropriate
  • If drug therapy is used, give each drug in an appropriate dose for required effects before adding other drugs
  • Regularly review patients to check their pain control, function and quality of life and their need for ongoing or change of therapy
  • Provide long-term support
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15
Q

What are Pharmacological Management Strategies for Chronic Pain?

A
  • If drug therapy is used, give each drug in an appropriate dose for required effects before adding other drugs
  • Use regular medications and minimise PRNs (unlike cancer pain where we ‘maximise prns’)
  • Avoid parenteral routes
  • Avoid pethidine, benzodiazepines and long-term NSAIDs
  • Optimise adjuvant/non-opioid analgesics
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16
Q

What are Non-Pharmacological Modalities?

A
  • Physical techniques
  • Mind-body techniques
  • Mind-based techniques
  • Use of aids/orthotics and OT
  • Social/environmental interventions
  • Combination of any or all of the above
17
Q

In chronic pain, what should be taken into consideration before starting opioids?

A
  • Explore all other treatment options, both physical and psychological
  • Discuss the adverse effects and possible harms and benefits of long-term opioid therapy
  • Obtain acceptance from patient about the expected outcome of therapy
  • Explain that the opioid is being used as a trial and treatment will cease if there hasn’t been significant progress towards achieving treatment goals over 4 weeks
  • Assess the potential for opioid abuse or misuse
  • Obtain agreement about monitoring, treatment adherence and the consequences of non-adherence
18
Q

When changing from one opioid to another opioid, what should be taken into consideration?

A
  • Always consider the dose potency (in relation to oral morphine) before swapping opioids
  • When changing from one opioid to another, commence with 50%-75% of the calculated ‘equianalgesic’ dose and then titrate to response
19
Q

What is Neuropathic Pain?

A
  • Dysfunction or damage to the nerves, spinal cord or brain
  • Constant burning, episodic shooting or electric pain in a region where there’s a disturbance of sensory and/or motor function, particularly to pinprick and thermal (warm and cold) sensibility
20
Q

What are the 3 types of Neuropathic Pain?

A
  • Hyperalgesia: increased responsiveness to normally painful stimuli
  • Allodynia: painful response to normally non-painful stimuli
  • Hyperpathia: abnormally painful reaction to a repetitive stimulus
21
Q

What is considered an appropriate positive clinically relevant end point in neuropathic pain?

A
  • 50% reduction in the level of pain is considered an appropriate positive clinically relevant end point, although 30% is sometimes accepted
22
Q

If patient isn’t making progress in neuropathic pain, what referral should be made?

A
  • If patient isn’t making progress, referral to a multidisciplinary pain management clinic may become necessary
23
Q

Neuropathic Pain is usually refractory to what?

A
  • Usually refractory to simple analgesics including paracetamol, NSAIDs and opioids
24
Q

What is Trigeminal Neuralgia?

What is it treated with?

A
  • Painful condition affecting nerves on the face
    • Pain one side of the face, can be like an electric shock
  • Treated with carbamazepine
25
Q

What is Acute Herpes Zoster Pain?

How is it treated?

A
  • Reactivation of varicella zoster virus
  • Virus lies dormant in the DRG but causes an inflammatory response when reactivated
  • Treatment
    • If the rash has been present < 72 hrs, antiviral treatment reduces acute pain, duration of the rash, viral shedding and ophthalmic complications
      • Valaciclovir, Famciclovir, Aciclovir
      • Pain may occur before, with or following rash
        • Pain persisting > 4 weeks after crusting of vesicles is considered Post Herpetic Neuralgia (PHN)
    • Mild Pain – Paracetamol
    • Severe Pain – Add Prednisolone to antiviral
    • Alternatives for severe pain: TCA or opioid
    • Topical: lignocaine ointment or lignocaine + prilocaine cream
      • Advise patients not to apply on broken skin
26
Q

What is the Treatment of Post Herpetic Neuralgia?

A
  • Start with simple analgesics: paracetamol (or ice massage)
  • If simple analgesia inadequate: consider adjuvant analgesics: TCA, gabapentin or pregabalin
27
Q

What are the General management principles of cancer pain?

A
  • Follow WHO step-ladder approach

AND/OR

  • Pick the analgesic based on the pain that’s being reported e.g. nociceptive or neuropathic or other
28
Q

What is the Therapeutic Strategy in Cancer Pain?

A
  • Analgesia should include:
    • Background/preventative component
      • Take regularly, irrespective of pain status
    • Breakthrough/as needed component
      • To be taken when pain ‘breaks through’ background analgesia
29
Q

How is Neuropathic Pain in cancer treated?

A
  • Gabapentin has the best evidence
  • Other AEDs, tramadol and TCAs also used
  • Opioids usually use in combination with the medications used above
30
Q

How is Breakthrough Pain Treated?

A
  • Initially 1/6 to 1/10 of the background analgesia
  • Ideally analgesics will have fast onset and short duration
  • Give as needed with no strict minimum between doses
31
Q

Breakthrough Pain Treatment: What are the Options?

A
  • Morphine elixir/IR tablets, oxycodone IR tablets/elixir
  • Onset in 30 mins and duration 4-6 hrs
  • Transmucosal fentanyl, intranasal opioids and sub-cutaneous injections
32
Q

Discuss Constipation due to Opioid use

A
  • Dose related, tolerance doesn’t develop
  • Prophylactic use in all patients
  • 1st line treatment: docusate and senna
    • Additional options include:
      • Additional docusate
      • Lactulose/Sorbitol
      • Movicol
      • Benefibre
      • Suppositories/enemas
33
Q

When should IR preparations be used?

A
  • IR preparations: Breakthrough pain, works within 30 mins, take when pain starts
    • Take prn medications as soon as they are required – pain better controlled
34
Q

When should SR preparations be used?

A

Background pain, take on regular basis

35
Q

What should you make patients aware of when starting opioids?

A
  • May notice sedation, ‘fuzzy’/difficulty thinking or nausea
    • Tends to be transient (7-10days)
    • Caution with machinery driving
36
Q

Discuss Changing between opioids/routes in Cancer Pain and Chronic Pain

A
  • Cancer pain: change to 50-100% of equianalgesic dose
  • Chronic pain: change to 50-75% of equianalgesic dose

Pharmacotherapeutics Theory 2 (17 decks)

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