Pain Flashcards
what is pain?
– Unpleasant sensory and emotional experience
– Often associated with long term conditions (chronic)
– Can be experienced in a multiple of ways or due to multiple causes within the patient
what is the duration of acute pain vs chronic pain?
acute = short chronic = persistent after healing > 3 months
what is the treatment for acute v chronic pain?
acute = treat the underlying cause chronic = pain control but not cure
what is the physical response to acute v chronic pain?
acute = increase HR, BP, RR, dilated pupils, pallor and dry mouth
chronic = no automatic nervous symptoms
what does total pain include?
- Physical
- Social
- Spiritual
- Psychological
how do we assess pain/
Site – where is it
Onset – what causes
Character – what does it feel like, dull pain or ache?
Radiation – does it radiate to other parts of the body
Associations – does it come with nausea?
Timing - Is it constant or intermittent
Exacerbation – does anything make it worse? Or does anything manage the pain?
Severity – various pain score to assess this
what is visceral pain?
pain that results from activation of nociceptors in the thoracic, pelvic or abdominal region usually associated with organs. This type of pain is usually responsive to opioids.
what is somatic pain?
skin or tissue pain or muscle pain. Nerves that detect this are deep within the skin and other tissues
what is neuropathic pain?
this comes as a result of damage or disruption to the CNS. Tingling/shooting or stabbing paints. It can also present as numbness
what is titration pain?
o Inadequately relieved background pain. Might happen as drug wears off before you next dose
what is incident pain?
o Predictable, relate to movement or activity. Usually due to known triggers, predictable and nothing to worry about. Dressing change or passing urine
what is episodic pain/
o Unpredictable, unrelated to movement or activity. Not always a known trigger which causes this pain
what are the WHO guidelines for pain?
step 1 –> non opioid
step 2 –> weak opioid as an add on
step 3 –> strong opioid + opioid+ adjuvant
what is the pain ladder exampls?
- paracetamol / ibuprofen
- codeine
- use a stronger opioid i.e. morphine
what are examples of adjuvants?
- Tricyclic antidepressants
- Antiepileptics
- Ketamine
- Corticosteroids
- Topical agents
- Anxiolytics
what are strong opioids?
- Widely used to treat cancer pain. 1/3 of cancer patients report pain but this increase to ¾ when you look into those with advance disease
- Very little evidence to support their use
- Problems due to side effects which might affect your quality of life, dependence and overdose. They can also cause hyperalgesia this can make a patient feel increased pain for something that never used to be a trigger
how do you iniate strong opioids?
o Is the patient already using a weak opioid? If so, can the equivalent dose of strong opioids be used?
o Is the patient opioids naïve? What is the lowest dose at which treatment can be started?
o Also, discuss addiction, tolerance, side effects and fears as a lot of patient feel a stigma against some of these drugs.
• Start low and go slow
what are the diff routes of admin of pain relief?
o Liquid/sachets/opening capsules must never be crushed for modified release. If you are putting them into a PEG you need to be careful that the size of the tube is large enough for this granules without crushing as modified release cannot be crushed.
o Transdermal fentanyl and buprenorphine. Can take 12-24 hours till you reach steady state. Certain environments might change how the drug is released from the patch (high temp)
o Sublingual/buccal instant relief pain
o Intranasal
o Epidural post surgery
o SC
o IV
what happens with opioids in those with renal impairment?
• Opioids should generally be used with caution in renal impairment due to accumulation of active drug and metabolites in things that are renally excreted.
• Some opioids are considered better than others
o Fentanyl
o Alfentanil
o Buprenorphine
• Monitor the patient for any side effects as they are at high risk and also maybe opt to use lower dose of these drug if needed
what happens in pateitns with hepatic impairment?
• Clearance can be reduced and side effects increased
o Acute reduce doses and monitor closely
o Chronic start low and titrate very slowly
when are different adjuvants used?
o Neuropathic pain -tricyclic antidepressants, antiepileptics, anxiolytics
o Visceral e.g. liver capsule pain – corticosteroids
o Somatic – anti-inflammatory drugs
what are ADRs of opioids?
o Constipation
o Nausea
o Drowsiness – this is an issue with driving regulations
o Additive effects e.g. serotonin syndrome, QT prolongation this is due to similar mode of action
what is palliative care>
• End of life
o Symptoms control in the last days of life
o Pain is common
o Oral route often compromised or not appropriate
o Transdermal or sc
o Other symptoms to consider include restlessness, nausea and excess respiratory secretion
