Pain Management

Question 1

Define chronic pain

Answer 1

pain that persists beyond normal/expected healing time

affects 1 in 5 adults

Question 2

What is the current gold standard psychological treatment for chronic pain?

Answer 2

Cognitive behavioural therapy

some others include:

• hypnosis
• mindfulness-based therapies
• acceptance-based therapies
• condition specific therapies (i.e. mirror therapy for phantom limb pain)

Question 3

How does cognitive behavioural therapy work?

Answer 3

promotes realistic/positive reappraisal of situations initially judged as stressful (cognitive restructuring)

promotes engagement in meaningful activities

promote behavioural activation

key variables:

• catastrophizing
• self-efficacy
• increased engagement time

Question 4

What is the difference between incident pain and breakthrough pain?

Answer 4

incident pain is predictable and linked with a specific event, breakthrough pain is unpredictable and linked with a sudden event i.e. bleed into a tumour

Question 5

What is the WHO analgesic step ladder?

Answer 5

Pain management using opioids

Step 1: non-opioid +/- adjuvant
Step 2: mild/moderate opioid +/- non-opioid +/- adjuvant
Step 3: opioid for moderate to severe pain +/- non-opioid +/- adjuvant

Question 6

What are simple analgesics?

Answer 6

simple painkillers

paracetamol, aspirin

Question 7

How can opioids be administered?

Answer 7

oral (either immediate release or slow release)

parenteral (IV)

transdermal (patches)

intrathecal, epidural

Question 8

Name some alternative opioids

Answer 8

Fentanyl –patches, less sedation, constipation, very strong

Hydromorphone- less constipation, hepatic metabolism

Oxycontin-less sedation, confusion

Buprenorphine –patches, weaker –ideal for older people

Question 9

Name some adjuvants for nociceptive pain that target inflammatory soup.

Answer 9

NSAIDS

steroids

Question 10

Name some adjuvants for nociceptive pain that target skeletal muscle spasm.

Answer 10

Benzodiazepines

baclofen

Question 11

Name some adjuvants for nociceptive pain that target smooth muscle spasm.

Answer 11

hyoscine butylbromide

Question 12

Name some adjuvants for neuropathic pain.

Answer 12

antidepressants: amitryptaline

anti-epileptics: pregabalin, gabapentin, valproate, carbamezepine

anti-arrhythmics: mexilitine, flecainide

Question 13

How are NSAIDs classified?

Answer 13

by their effect on cyclo-oxygenase (COX) enzyme

COX-1 & COX-2

‘non-selective’ NSAIDs work on both enzymes (i.e. aspirin, ibuprofen)

‘selective’ NSAIDs work on just COX-2 enzymes (i.e. celecoxib, meloxicam)

Question 14

What are some consequences of side-effects caused by NSAIDs?

Answer 14

gastrointestinal damage i.e. peptic ulcear disease (COX-2 selective cause less damage)

renal impairment & worsening of heart failure

myocardial infarction & stroke (COX-2 selective especially)

may worsen asthma

Question 15

What are some side-effects of opioids?

Answer 15

constipation, sedation, respiratory depression (in overdose), physical dependence, europhia

Question 16

What opioids are preffered for patients with renal impairment?

Answer 16

oxycodone & fentanyl

Question 17

What are some red flags?

Answer 17

General malaise, unexplained fever

History of cancer, unexplained weight loss, severe night pain and/or sweats; constant, progressive, non-mechanical pain (doesn’t worsen or improve with change in posture or movement)

Widespread, severe or progressive neurological changes (e.g. sensation in arms/legs, dizziness, problems with balance or vision)

Prolonged use of corticosteroids

History of violent trauma (e.g. MVA, fall from a height); presence of structural deformity

Question 18

What are some yellow flags?

Answer 18

Awaiting outcome of compensation claim

Social situation overly or under supportive

Fear-avoidance behaviour with severely reduced activity levels

Belief that pain is always and indication of harm

Tendency to low mood and withdrawal from social interaction

Seeking passive treatments rather than active participation

Question 19

Name some questionaires typically used for assessing psychosocial factors (yellow flags)?

Answer 19

Tampa Scale for Kinesiophobia

Fear Avoidance Beliefs Questionnaire (for back pain)

Pain Catastrophising Scale

Pain Self Efficacy Questionnaire

Hospital Anxiety and Depression Scale

Question 20

When would you consider using imaging?

Answer 20

Serious pathology suspected

Unsatisfactory response to conservative care, or unexplained progression of signs and symptoms

Imaging is likely to change management