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SPM- Oncology and Palliative Care > Pain and Pain Management > Flashcards

Pain and Pain Management Flashcards

1
Q

What are some of the core features of palliative care?

A

Affirms life with emphasis on quality of life
Prevention and relief of suffering
Dying is a normal part of life
Support for patients- physical, psychological and spiritual
Support for families and carers

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2
Q

What are the four factors that influence total pain?

A

Physical
Social
Spiritual
Phychological

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3
Q

What physical factors can cause pain?

A

Pain due to disease process
Symptoms such as nausea and vomiting
Physical decline and fatigue

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4
Q

What psychological factors can influence pain?

A 
Grief
Depression
Anxiety
Frustration
Anger
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5
Q

What social factors might influence pain?

A

Relationships with family or cares
Changing roles in family
Work life
Financial problems

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6
Q

What spiritual factors might influence pain?

A 
Existential issues
Conflicting thoughts
Religious issues
Questions about the meaning of life
Difficulty rationalising the disease process
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7
Q

How does palliative care continue after the patient’s death?

A

Support for family members and carers

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8
Q

How can pain be described?

A

An unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage

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9
Q

What are the two types of pain fibres?

A

C Fibres

Delta fibres

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10
Q

What kind of pain do C fibres transmit

A

Dull, poorly localised, ill defined pain

They’re unmyelinated

C= Crap pain fibres

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11
Q

What kind of pain do delta fibres transmit?

A

Myelinated fibres which transmit fast, sharp, well localised pain.

D= Direct pain location

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12
Q

What are some features seen in patients with acute pain?

A

Acute pain causes a flight or flight response. It is therefore associated with sweating, tachypnoea, tachycardia, cold extremities and pupil dilation

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13
Q

What are some features seen with chronic pain?

A

Chronic pain serves no useful purpose. It causes sleep disturbance, depression, personality change, decreased libido, lethargy, anorexia

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14
Q

What is important to ask about in a pain history?

A

SOCRATES
Drug History- ask about what has been tried in the past, why it didn’t work, side effects in order to evaluate previous treatments
Psychological history- assess mental state

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15
Q

What would you want to know about previously tried analgesic agents?

A 
Drug
Dose
Route of administration
Side effects
Duration of treatment
Why was it stopped
Compliance
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16
Q

What are the steps in the WHO pain letter?

A

Step 1- Non-Opioid- Paracetamol/NSAID (with or without adjuvant agents e.g. Gabapentin)

Step 2- Weak Opioid +/- Paracetamol/ NSAID (with or without adjuvant agents)

Step 3- Strong Opioids +/- Non-opioid analgesic agents (with or without adjuvant agents)

Step up and down as appropriate

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17
Q

What opioid agents might be used at Step 2 of the WHO pain ladder?

A

Step 2 is Weak Opioids +/- Step 1

Weak opioids include codeine and dihydrocodeine and tramadol

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18
Q

What opioid agents might be used in Step 3 of the WHO pain ladder?

A

Step 3 is Strong Opioids +/- Step 1

Strong opioids include morphine, fentanyl, oxycodone, diamorphine, hydromorphine

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19
Q

What are some adjuvant agents used in the treatment of pain?

A 
Antidepressants- indicated for neuropathic pain
Anticonvulsants- e.g. Gabapentin
Smooth muscle relaxants
Steroids- reduce swelling around tumours
Bisphosphonates- reduce osteoclast activity to reduce bone pain
Radiotherapy
Chemotherapy
Surgery
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20
Q

What are the types of pain seen in cancer?

A 
Somatic
Visceral
Neuropathic
Background
Breakthrough
Incident pain
21
Q

What is somatic pain?

A

Somatic pain is well localized pain
Aching and often constant pain
May be dull or sharp
Often worse with movement

22
Q

What are some examples of somatic pain?

A

Often MSK issues

Bone mets, arthritis, muscle sprain, fracture

23
Q

How is somatic pain often treated?

A

NSAIDs, Opioids

For bone mets- High dose dexamethasone, radiotherapy, surgery, bisphosphonates (inhibit osteoclasts so prevent further breakdown)

24
Q

What is visceral pain?

A

Visceral pain is poorly localised pain, it comes from the viscera
Features include aching, cramping, dull, continuous pain
Can also experience referred pain

25
Q

Give some examples of things that might cause visceral pain in cancer patients?

A

Liver capsular pain due to metastatic disease

Bowel obstruction due to cancer

26
Q

How is visceral pain often managed?

A

Visceral pain responds well to opiods

Colicy pain as with bowel osbtruction responds well to smooth muscle relaxants

High dose steroids reduce oedema around tumours and can help to reduce the symptoms- e.g. Dexamethasone 4-8mg

27
Q

What is neuropathic pain?

A 
This is pain that arises due to nerve pathology, features include:
Shooting pains
Paresthesia
Hyperalgesia
Burning/tingling sensation
Allodynia
28
Q

What is allodynia?

A

Pain that arises from normally non-painful stimuli

29
Q

What are the management options for neuropathic pain?

A

Antidepressant agents- TCAs such as amitriptyline
Anticonvulsant agents- Gabapentin
Irritation at nerve root could be due tumou- dexamethasone, radiotherapy, surgery
Nerve blocks can be carried out

30
Q

What is background pain?

A

This is pain that is consistent in nature occurring with cancer and it will require regular analgesia

Background pain should be managed with long acting morphine (e.g. morphine sulphate), fentanyl patches or infusions

31
Q

What is breakthrough pain?

A

This is pain that is occurring despite management for background pain, this will require further analgesic agents

Patients should have plans to manage breakthrough pain

32
Q

How is breakthrough or incident pain usually managed?

A

Usually difficult to treat as it is severe but short lived.

Strong opioids- Oramorph or Fentanyl lozenge

33
Q

What is 10g of oral morphine equivalent to?

A

100mg of codeine
100mg of dihydrocodeine
100mg of tramadol

Therefore if moving to step 3 on the pain ladder you must at least make sure you have made the dose greater than or equal to the equivalent values for step 2 drugs.

34
Q

Is there a ceiling dose for morphine?

A

No, the dose is limited by the development of side effects.

35
Q

What morphine type is immediate release?

A

Oramorph liquid

Rapid onset: 20-30 minutes and last for around

Immediate release morphine can therefore be used for the management of breakthrough pain

36
Q

What morphine type is slow release?

A

Morphine sulphate
Zomorph

(Given every 12 hours)

Slow release morphine is therefore used for the management of background cancer pain

37
Q

What is usually given for breakthrough pain?

A

Immediate release morphine e.g. oramorph

This is usually 1/6th of the total (24 hour) morphine requirements

38
Q

What are some side effects of morphine?

A 
Constipation
Nausea
Sedation
Respiratory depression
Myoclonic jerks
Itching
Euphoria
Visual hallucinations
Dry mouth
39
Q

What is given to manage constipation due to opiods?

A

Laxative- Senna

40
Q

What is given to manage nausea due to opiods?

A

PRN antiemetic

41
Q

What is might done to manage hallucinations with opioids?

A

Switch to a different agent

Haloperidol at a low dose

42
Q

What is tolerance?

A

A normal physiological phenomenon where the body adapts the the presence of an agent so that more is required for the sam effect

43
Q

What is physical dependence?

A

A normal physiological phenomenon where a withdrawal syndrome occurs when an opioid is abruptly stopped

44
Q

What is psychological dependence?

A

Pattern of drug use characterised by continuous craving for an opiod which manifests as compulsive drug seeking behaviour

45
Q

What neurological features suggests opioid toxicity?

A

Myoclonic jerks

46
Q

What features suggest opioid toxicity?

A

Pinpoint pupils
Respiratory depression
Myoclonic jerks

47
Q

What agents might be used in the management of bone pain?

A 
NSAIDs
Radiotherapy
Surgery
High dose steroids- dexamethasone
Bisphosphonates - e.g. Zoledronic acid
48
Q

What methods should be used to deliver morphine if oral no longer suitable?

A

Syringe drivers
Patient controlled analgesia
Fentanyl patches

SPM- Oncology and Palliative Care (10 decks)

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