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Pain and analgesia Flashcards

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1
Q

What is the definition of 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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2
Q

What is chronic pain?

A

pain that persists beyond the normal healing time or pain that persists in conditions where healing has not or will not occur

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3
Q

What is the difference between acute and chronic pain?

A

acute: obvious cause, relatively short duration, protective mechanism, easier to tx
chronic: multiple causes, persists after healing, non adaptive mechanism, often refractory to tx

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4
Q

What are the 3 types of pain?

A

nociceptive
inflammatory
maladaptive-pathological

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5
Q

What is nociceptive pain?

A

noxious stimuli activate neural receptors

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6
Q

What is inflammatory pain?

A

response of immune system to injury or infection

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7
Q

What is maladaptive-pathological pain?

A

amplification of pain, peripheral and central hypersensitization

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8
Q

What is the transduction pain pathway?

A

noxious stimulus is converted to electrical signal at a nociceptor

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9
Q

What is the transmission pain pathway?

A

transmission of nerve impulse along the nerve fiber to dorsal horn of spinal cord

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10
Q

What is the modulation pain pathway?

A

modulation of incoming pain at various CNS sites

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11
Q

What are the fiber systems that transmit pain impulses?

A

myelinated ao fibers: fast sharp well localised pain,fast conduction velocity
unmyelinated c fibers: slow dull poorly localised/visceral pain, slow conduction velocity

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12
Q

What is the gate control theory?

A

there are thought to be gates at the spinal cord, if these can be closed the pain cant be transmitted to the brain

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13
Q

What is hyperalgesia?

A

when peripheral sensory nerves impulses are amplified by the spinal cord
get confused and touch can feel like pain

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14
Q

What is part of the pain matrix?

A

primary and secondary somatosensory cortex, insular, anterior cingulate cortex and prefrontal cortex, thalamus

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15
Q

What is the role of the descending pathways in pain?

A

inhibitory and facilatory pathways
project to dorsal horn and inhibit pain transmission

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16
Q

What are the 4 tiers of descending inhibition (blocking pain)?

A

cortex and thalamus
prei-aquductal grey matter in midbrain
nucleus raphe magnus in pons, rostral medulla
medulla oblongata, spinal cord

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17
Q

What are the neurotransmitters involved in the descending pathways for inhibition of pain?

A

mainly: noradrenaline and serotonin
alose: dopamine, endocannabinouds, GABA, glycine, tonic control

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18
Q

What is central sensitisation?

A

sensitisation of nerves in the spinal cord and brain
amplification, facilitation of synaptic transfer from the periphery

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19
Q

What is the trigger and key role of central sensitisation?

A

trigger: intense nociceptor input
key role: nmethyldaspartate NMDA receptors

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20
Q

What is peripheral sensitisation?

A

injury/inflammation of tissue causing alterations of the chemical environment of the peripheral nerve terminal = activation/sensitisation

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21
Q

What is hyperalgesia?

A

increased sensitivity to a normally painful stimulus

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22
Q

How does hyperalgesia come about?

A

occurs at site of injury due to the inflammatory mediators
activation/sensitisation of nociceptors
spreads to surrounding non-injured tissues due to spinal cord events (central sensitisation)

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23
Q

What is allodynia?

A

painful response to a normally innocuous stimulus
mechanical receptors recruited to relay pain info

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24
Q

What are the ideal characteristics of a pain assessment tool?

A

discriminate presence or absence of pain
evaluate both the sensory and emotional aspects of the conditiion
evaluate pain in different contexts or at least clearly state the possible limitations
be as simple as possible, requiring minimal training and instrumentation

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25
What are the 3 domains of the psychological state of pain?
sensory-discriminatory: intensity, location, duration of pain affective motivational: emotional, unpleasantness and aversive aspects cognitive-evaluative: evaluation upon quality of life
26
What are physiological and neuroendocrine markers for pain?
HR RR BP circulating stress hormones
27
What is an algometer?
pressure testing device to determine pain in a quantitative way
28
What are the subjectives measure of pain?
behavioural assessment! body posture and activity locomotor activity vocalisation altered facial expression appetite response to manipulation urinary and bowel habits physiological signs anxiety
29
What are the unidimensional pain scales?
simple descriptive scales numerical rating scale visual analog scale
30
Why do we use pre-emptive analgesia?
prevention or minimization of pain by the dministration of analgesics before the production of pain or the induction of noxious stimulus (surgery) if pain already exists decreased need for follow up meds
31
What is multimodal analgesia?
administration of multiple drugs that act by different mechanisms of action to produce the desired analgesic effect
32
What are pharmacological interventions that provide analgesia?
opioids nsaids local anaesthesia alpha 2 adrenergic agonist ketamine tramadol gabapentin amantadine tricyclic antidepressants maropitant biphosphates
33
What are non pharmacological modalities that can provide an analgesic effect?
weight optimization acupuncture physical rehabilitation nutrition amanagement thermal modification environement modification chiropractic care homeopathy surgical intervention
34
What are opioids?
general term that refers to any naturally occuring, semi-synthetic and synthetic substance with morphine like activity
35
What is morphine?
a natural alkaloid from the seeds of the opium poppy binds to opioid receptors in CNS and periphery receptor distribution varies among species
36
What are the classes of opioids?
delta kappa mu epsilon (theoretical receptor for endogenous endorphin) nociceptin/orphanin fq peptide (NOP) receptor
37
What are the 4 pure mu agonist opioids?
morphine pethidine methadone fentanyl/alfentanyl/remifentanyl
38
Wha is the agonist antagonist opioid?
butorphanol
39
What is the mu anatgonist opioid?
naloxone
40
What are the characteristics of morphine?
IM SC IV extradurally intraarcticular cats have poor gluuronyl transferase activity = spread out dose
41
What are the characteristics of pethidine?
SC IM no IV due to histamine release anticholinergic spasmolytic action can cause seizures in high doses NMDA antagonist
42
What are the characteristics of methadone?
IV IM SC similar to morphine doesnt initiate vomiting because crosses BBB great lipid solubility NMDA antagonist
43
What are the characteristics of fentanyl?
very potent analgesic fast onset and short half life time potent resp depressant high fat solubility
44
What are the characteristics of buprenorphine?
high affinity for mu receptors doesnt produce max effect, differs in species analgesia, not as profound as full agonists appropriate only for mild to moderate pain
45
What is the partial mu agonist opioid?
buprenorphine
46
What are the characteristics of butorphanol?
anatgonist at mu: poor analgesic agonist at kappa: sedation, mild anagesia, antitussive
47
What are the characteristics of naloxone?
pure antagonist in all opioid receptors used to anatgonis effect of full and partial agonists short duration of action, repeated doses needed
48
Why is tramadol an atypical opioid?
synthetic analogue of codeine weak mu opioid receptor agonist NMDA receptor antagonist serotonin reuptake inhibitor norepinephrine reuptake inhibitor
49
How do opioids allow an analgesic effect?
determined by receptor location spinal cord: inhibit release of pain neurotransmitters grey matter: stimulate descending pain control system limbic system: emotional aspect of pain
50
What type of pain transmission are opioids analgesic effect most effective against?
dull pain C fibers not as effective for sharp pain
51
How do opioids affect arousal in dogs, monkey and people?
CNS depression translated in a sedative effect = sedative
52
How do opioids affect arousal in cats, horses and ruminants?
CNS stimulation (excitement, locomotor activity) euphoria and dysphoria
53
Why do opioids affect arousal differently in different species?
differences in type and districution of receptors in various regions of the brain presence or abence of pain dose and route of administration specific opioid administeres
54
What are the unwanted effects of opioids?
nausea and vomitinh variation in pupil size catecholamine release in cats
55
How do opioids cause nausea and vomiting?
direct stimulation of CRTZ antiemetic effects on vomit center mostly in dogs morphine ++++, methadone + rarely occur if pain is already present
56
How do opioids affect pupil size?
increase firing in oculomotor nucleus neurons miosis in dogs and humans
57
How do opioids affect thermoregulation?
dogs: decrease in thermoregulatory point and panting cats, horses, swine, ruminants: hyperthermia due to increase in muscular activity
58
How do opioids affect respiratory depression?
mu mediated effect in resp center due to decrease responsiveness to CO2 especially if coadministeres with sedative
59
How do opioids affects bradycardia?
vagal stimualtion responsice yo anicholinergics
60
What is the schedule 2 legislation of controlled drugs?
pure agonists must be kept in locked cupboard records kept of purchase and use special RX requirements must be disposed of according to legislation
61
What is the schedule 3 legislation for controlled drugs?
partial agonists: buprenorphine should be kept in locked cupboard with schedule 2 drugs no record of use necessary
62
Which opioid is currently exempt from controled drug legislation restrictions?
butorphanol
63
What are the common adverse effects of nsaids?
GI toxicity, ulcers, erosions nephrotoxicity idiosyncratic hepatocellular necrosis platelet effects
64
What are the pharmacokinetic properties of nsaids?
oral/parenteral administration highly protein bound (except aspirin) hepatic metabolism renal excretion dtermined by plasma protein binding and urine pH
65
What can decrease effectiveness of NSAIDs in the body?
leakage of plasma protein at the site of inflammation promotes entrapment of nsaids
66
What is important to know when administering NSAIDs?
animal needs to be eating and drinking
67
Which NSAID is cox1 selective?
aspirin
68
What are the different effects of NSAIDs?
antiinflammatory antipyretic analgesic antihyperalgesic antiendotoxic antithrombotic weak antispasmodic effects some are chondroprotective (meloxicam, carprofen)
69
What is Grapriprant?
new type of NSAID analgesic/antiinflammatory drug in priprant class functions as a selective EP4 PRA
70
How does grapiprant work?
it functions as a selective EP4 PRA PGE2 (prostaglandin) is a key inflammatory mediator it exerts its effects via 4 receptors: EP4 receptor is the primary mediator drug blocks this receptor and doesn't interfere with the other prostglandin receptor pathways/functions
71
How do most NSAIDs work?
inhibiting COX (selective or not vs 1 or 2) COX is responsible for producing prostagalndins prostaglandins are and inflammatory mediator among other things
72
How does ketamine work?
NMDA receptor antagonist antihyperalgesic and antiallodynic effect with sub anaesthetic constant rate infusion sympathomimetic effect increases vasc tone, HR and myocardial oxygen demand direct myocardial depressant effect
73
What is paracetamol?
NSAID not classic cox-1 inhibitor, may act on central cox3 acts as a prodrug active substance is an endogenous cannabinoid
74
How is paracetamol metabolised?
hepatic metabolism by conjugation once overwhelmed: oxidative metabolism causing protein damage, red cell lysis, hepatic necrosis
75
When is paracetamol contraindicated?
in cats! causes anorexia, vomiting, facil swelling, heinz body anaemia, metheglobinaemia with hepatic dz?
76
What is the antidote to paracetamol?
n-acetylcysteine
77
What are Monocolonal antibodies?
produced from single b lymphocyte clones in mice through recombinant engineering target specific molecules
78
What is NGF?
cytokine key regulator involved in both inflammatory and neuropathic pain major determinant of plasticity in PNS and CNS
79
What are the types of anti NFG monoclonal antibodies in vet med?
Ranevetmad/bedinvetmab (librela) in clinical trials in dogs injection improved pain scores frunevetmab in cats (solencia?) improvement of lameness, increased activity
80
What are the characteristics of systemic lidocaine?
anaesthetic sparing effect beneficial effect in visceral pain and bowel function (prokinetic)
81
What are the things to be careful with when using lidocaine?
rapid IV administration can cause muscle tremors and collapse in horses profound negative cardiovascular effect on cats
82
What is gabapentin?
anticonvulsant with analgesic properties modulate and inhibit the action of voltage gates calcium channels
83
84
What is maropitant?
central antiemetic inhibits binding of substance P to the neurokinin 1 anaesthetic sparing effect after IV administration
85
What are SSRIs?
selective serotonin (norepinephrine) reuptake inhibitors increase serotonin with or without norepinephrine in the synaptic cleft
86
What is amantadine
pain modifying effect NMDA antagonist similar to ketamine
87
What are biphosphates?
used for hypercalcemia treatment analgesia for bone cancer, inflammatory bone disorders

POS 2 (10 decks)

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