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DPD Stuff > Pain > Flashcards

Pain Flashcards

1
Q

What is pain?

A

An unpleasant sensory and emotional experience associated with actual or potential issue damage, or described in terms of such damage Treating pain is humane and has many benefits

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2
Q

What are the benefits of treating pain for the patient?

A

– Physical • Improved sleep, better appetite • Fewer medical complications (e.g. heart attack, pneumonia) – Psychological • Reduced suffering • Less depression, anxiety

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3
Q

What are the benefits of treating pain for the family?

A
  • Improved functioning as family member - Able to keep working
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4
Q

What are the benefits of treating pain for society?

A

– Lower health costs (e.g. shorter hospital stay) – Able to contribute to the community

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5
Q

What are the 3 main questions for pain?

A
  1. How long has the patient had pain 2. What is the cause 3. What is the mechanism
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6
Q

How can you class pain?

A

Duration Cause Mechanism

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7
Q

What are the duration classes of pain?

A
  • Acute - Chronic - Acute on chronic
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8
Q

What are the cause classes of pain?

A

Cancer Non cancer

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9
Q

What are the mechanism classes of pain?

A

Nociceptive Neuropathic

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10
Q

How are acute and chronic pain different?

A

• Acute – Pain of recent onset and probable limited duration • Chronic – Pain lasting for more than 3 months – Pain lasting afternormal healing – Often no identifiable cause

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11
Q

How are cancer and non cancer pain different?

A

• Cancer pain – Progressive – May be mixture of acute and chronic • Non-cancer pain – Many different causes – Acute or chronic

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12
Q

What is nociceptive pain?

A

• Obvious tissue injury or illness • Also called physiological or inflammatory pain • Protective function • Description – Sharp ± dull – Well localised

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13
Q

What is neuropathic pain?

A

• Nervous system damage or abnormality • Tissue injury may not be obvious • Does not have a protecve function • Description – Burning, shooting ± numbness, pins and needles – Not well localised

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14
Q

What is acute non cancer pain?

A

• Examples – Fracture, appendici9s • Symptom of tissue injury or illness • Usually nociceptive • Occasionally neuropathic (e.g. sciatica)

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15
Q

What is chronic non cancer pain?

A

• Examples – Chronic back pain, arthritis • Injury may not be obvious • Complex, may be mixed nociceptive and neuropathic • Does not respond to usual drug treatment

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16
Q

What is cancer pain?

A

• Examples – Uterine cervical cancer, breast cancer • Features of acute and chronic pain – May be acute on chronic • Often mixed nociceptive and neuropathic pain • Usually gets worse over time if untreated

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17
Q

What is the difference between nociception and pain?

A

• Nociception – How signals get from the site of injury to the brain • Pain perception – How we “feel” pain

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18
Q

What is nociception in reference to pain?

A
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19
Q

What is the gross physioogy of pain?

A

4 steps:

  • Periphery
  • Spinal cord
  • Brain
  • Modulation
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20
Q

What happens in the periphery in pain sensation?

A
  • Tissue injury
  • Release of chemicals
  • Stimulation of pain receptors (nociceptors)
  • Signal travels in Aδ or C nerve to spinal cord
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21
Q

What happens in the spinal cord in a pain response?

A
  • Dorsal horn is the first relay station
  • Aδ or C nerve synapses (connects) with second nerve
  • Second nerve travels up opposite side of spinal cord
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22
Q

What happens in the brain when feeling pain?

A
  • Thalamus is the second relay station
  • Connections to many parts of the brain

– Cortex

– Limbic system

– Brainstem

• Pain perception occurs in the cortex

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23
Q

What does modulation do in the pain pathway?

A
  • Descending pathway from brain to dorsal horn
  • Usually decreases pain signal
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24
Q

Why might placebo treatment be helpful?

A
  • Psychological factors are important.
  • If a placebo treatment works, this does not mean the patient did not have pain or was telling lies!
  • Many factors affect how we “feel” pain.

– Psychological factors are very important.

• Different treatments work on different parts of the pathway.

– More than one treatment may be needed.

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25
Q

Why might there be pain pathology?

A
  • Abnormal processing of pain signal
  • Nervous system damage or dysfunction
  • Needs to be treated differently
  • Examples

– Nerve trauma, diabetic pain (damage)

– Fibromyalgia, chronic tension headache (dysfunction)

26
Q

What are the pathological mechanisms in pain pathologies?

A
  • Increased receptor numbers
  • Abnormal sensitisation of nerves

– Peripheral

– Central

  • Chemical changes in the dorsal horn
  • Loss of normal inhibitory modulation
27
Q

What are the non drug treatments of pain?

A

Physical

  • Rest, Ice, compression, elevation
  • surgery
  • Acupuncture, massage, physiotherapy

Psychological

  • Explanation
  • Reassurance
  • Counselling
28
Q

What are the drug classifications in pain?

A
  • Simple analgesics (e.g. paractemol, anti infl: Ibuprofen, diclofenac)
  • Opioids (Mild: codeine, Strong: morphine, pethidine, oxycodone)
  • Other (tramadol, TCAs, anticonvulsants, ketamine, local anaesthetics, clonidine)
29
Q

How do we treat pain in the peripheral part of the pain pathway?

A

• Non-drug treatments

– Rest, ice, compression, elevation

  • Anti-inflammatory medicines
  • Local anaesthetics
30
Q

How do we treat pain at the spinal cord level?

A

• Non-drug treatments

– Acupuncture, massage

  • Local anaesthetics
  • Opioids
  • Ketamine
31
Q

How do we treat pain at the level of the brain?

A

• Non-drug treatments

– Psychological

• Drug treatments

– Paracetamol

– Opioids

– Amitriptyline

– Clonidine

32
Q

What are the advantages of paracetamol in pain relief?

A

• Cheap, safe

– Can be given orally, rectally or intravenously

– Good for:

  • Mild pain (by itself)
  • Mod-severe pain (with other drugs)
33
Q

What is the major disadvantage of paracetamol?

A
  • Liver damage in OD
34
Q

What are the pros and cons of anti inflammatory medicine?

A
  • Aspirin, ibuprofen, diclofenac
  • Advantages

– Cheap, generally safe

– Good for nociceptive pain

  • Best given regularly with paracetamol
  • Disadvantages

– Gastrointestinal and renal side effects

35
Q

What are the pros and cons of codeine?

A

• Advantages

– Cheap, safe

– Good for mild-moderate acute nociceptive pain

  • Best given regularly with paracetamol
  • Disadvantages

– Constipation

– Not good for chronic pain

– Misunderstandings about addiction

36
Q

What is the risk for opioids and addiciton?

A
  • Pain is sometimes poorly treated because of concerns about addiction.
  • Addiction is very rare in:

– Acute pain

– Cancer pain

• Addiction is more likely in chronic non-cancer pain.

37
Q
A
38
Q

What are the advantages of morphine?

A

– Cheap, generally safe

– Can be given orally, IV, IM, SC

– Effective if given regularly

– Good for:

  • Mod-severe acute nociceptive pain (e.g. post-op pain)
  • Chronic cancer pain
39
Q

What are the disadvantages of morphine?

A

– Constipation

– Respiratory depression in high dose

– Misunderstandings about addic9on

– Controlled drug

40
Q

How much morphine is given?

A

Oral, 2-3 times

IV/IM/SC

41
Q

What are the pros and cons of pethidine?

A
  • Can be good for severe acute nociceptive pain but has more disadvantages than morphine
  • Disadvantages

– Also a controlled drug

– Must be given more frequently than morphine

– Breakdown product (norpethidine) can cause convulsions

– Not good for chronic pain

42
Q

What are the pros and cons of tramadol?

A
  • Weak opioid effect plus inhibitor of serotonin and noradrenaline reuptake (modulation)
  • Advantages

– Less respiratory depression

– Can be used with opioids and simple analgesics

– Not a controlled drug

• Disadvantages

– Nausea and vomiting

43
Q

What are the pros and cons of amitriptylline?

A
  • Tricyclic antidepressant (TCA)
  • Increases descending inhibitory signals
  • Advantages

– Cheap, safe in low dose

– Good for neuropathic pain

– Also treats depression, poor sleep

• Disadvantages

– Anti-cholinergic side effects (e.g. glaucoma, urinary reten9on)

44
Q

Why are anticonvulsants used in pain treatment?

A

• Examples

– Carbamazepine (Tegretol) [Trigeminal neuralgia]

– Sodium valproate (Epilim)

– Gabapentin (Neurontin) [Nerve pain]

• Also called membrane stabilisers

– Reduce abnormal firing of nerves

• Good for neuropathic pain

45
Q

How do the drugs compare to each other in different types of pain?

A
46
Q

What is the RAT approach to pain management?

A
  • Recognize
  • Assess

– Severity?

– Type?

– Other factors?

• Treat

– Non-drug treatments

– Drug treatments

47
Q

How do you recognise if the patient has pain?

A

• Does the patient have pain?

– Ask

– Look (frowning, moving easily, sweating?)

• Do other people know the patient has pain?

– Other health workers

– Patient’s family

48
Q

How do you assess severity?

A

• What is the pain score?

– At rest

– With movement

• How is the pain affecting the patient?

– Can the patient move, cough?

– Can the patient work?

  • Helps guide treatment
  • Methods

– Verbal (e.g. mild, moderate, severe)

– Numerical

• 0 (no pain) to 10 (worst pain imaginable)

– Visual

  • Visual Analogue Scale (VAS)
  • “Faces” pain scale
49
Q

How do you assess the pain type?

A
  • Acute or chronic?
  • Cancer or non-cancer?
  • Nociceptive or neuropathic?

– Look for neuropathic features:

  • Burning or shooting pain
  • Phantom limb pain
  • Other features (pins and needles, numbness)
50
Q

What must you also think of when assessing pain?

A
  • Physical factors (other illnesses)
  • Psychological and social factors

– Anger, anxiety, depression

– Lack of social supports

51
Q

Summarise the treatments of pain

A
  • Non drug
  • Drug for nociceptive pain
  • Drugs for neuropathic pain
52
Q

What is complex regional pain syndrome

A
  • Can occur following minimal tissue damage
  • Neuropathic pain
53
Q

Summarise the non drug treatments of pain

A
  • RICE
  • Nursing care
  • Surgery, acupuncture, massage
  • Psychological (explanation and reassurance, input from social worker/ pastor)
54
Q

What are the steps in treating nociceptive pain?

A

– Mild

• Paracetamol (± NSAID)

– Moderate

• Paracetamol (± NSAID) + codeine

– Severe

• Paracetamol (± NSAID) + morphine

55
Q

What are the treatments of neuropathic pain?

A

– Traditional drugs may not be as useful

– Use other drugs early

  • Amitriptyline
  • Gabapentin / carbamazepine

– Don’t forget non-drug treatments

56
Q

What do you do after RAT?

A

• Reassess the patient

– Is your treatment working?

– Are other treatments needed?

57
Q

A 32-year-old man caught his right hand in machinery at work. He presents with a compound fracture of his hand.

How would you manage his pain using the RAT approach?

A

R- ask if he has pain, watch facial expression, ask others

A- Pain score, affect on patient, acute non cancer, nociceptive pain, ask about other factors

T- WHO pain ladder for acute pain

58
Q

A 55-year-old woman presents with a large breast tumour with spread to her spine. She has severe pain.

How would you manage her pain using the RAT approach?

A

R- ask if he has pain, watch facial expression, ask others

A- Pain score, affect on patient, chronic cancer, neuropathic pain, ask about other factors

T- Other drugs (gabapentin, amitriptylline), WHO pain ladder

59
Q

What is allodynia?

A

Pain provoked in response to a stimulus that does not normally cause pain

60
Q

What is hyperalgesia?

A

Increased pain in response to something that causes pain

61
Q

What types of pain response are linked to neuropathic pain?

A

Allodynia

Hyperalgesia

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