Pain

Question 1

what is pain?

Answer 1

– 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

Question 2

what is the duration of acute pain vs chronic pain?

Answer 2

acute = short
chronic = persistent after healing > 3 months

Question 3

what is the treatment for acute v chronic pain?

Answer 3

acute = treat the underlying cause
chronic = pain control but not cure

Question 4

what is the physical response to acute v chronic pain?

Answer 4

acute = increase HR, BP, RR, dilated pupils, pallor and dry mouth

chronic = no automatic nervous symptoms

Question 5

what does total pain include?

Answer 5

• Physical
• Social
• Spiritual
• Psychological

Question 6

how do we assess pain/

Answer 6

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

Question 7

what is visceral pain?

Answer 7

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.

Question 8

what is somatic pain?

Answer 8

skin or tissue pain or muscle pain. Nerves that detect this are deep within the skin and other tissues

Question 9

what is neuropathic pain?

Answer 9

this comes as a result of damage or disruption to the CNS. Tingling/shooting or stabbing paints. It can also present as numbness

Question 10

what is titration pain?

Answer 10

o Inadequately relieved background pain. Might happen as drug wears off before you next dose

Question 11

what is incident pain?

Answer 11

o Predictable, relate to movement or activity. Usually due to known triggers, predictable and nothing to worry about. Dressing change or passing urine

Question 12

what is episodic pain/

Answer 12

o Unpredictable, unrelated to movement or activity. Not always a known trigger which causes this pain

Question 13

what are the WHO guidelines for pain?

Answer 13

step 1 –> non opioid
step 2 –> weak opioid as an add on
step 3 –> strong opioid + opioid+ adjuvant

Question 14

what is the pain ladder exampls?

Answer 14

1. paracetamol / ibuprofen
2. codeine
3. use a stronger opioid i.e. morphine

Question 15

what are examples of adjuvants?

Answer 15

• Tricyclic antidepressants
• Antiepileptics
• Ketamine
• Corticosteroids
• Topical agents
• Anxiolytics

Question 16

what are strong opioids?

Answer 16

• 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

Question 17

how do you iniate strong opioids?

Answer 17

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

Question 18

what are the diff routes of admin of pain relief?

Answer 18

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

Question 19

what happens with opioids in those with renal impairment?

Answer 19

• 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

Question 20

what happens in pateitns with hepatic impairment?

Answer 20

• Clearance can be reduced and side effects increased
o Acute  reduce doses and monitor closely
o Chronic  start low and titrate very slowly

Question 21

when are different adjuvants used?

Answer 21

o Neuropathic pain -tricyclic antidepressants, antiepileptics, anxiolytics
o Visceral e.g. liver capsule pain – corticosteroids
o Somatic – anti-inflammatory drugs

Question 22

what are ADRs of opioids?

Answer 22

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

Question 23

what is palliative care>

Answer 23

• 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