Pain Management Flashcards
Define chronic pain
pain that persists beyond normal/expected healing time
affects 1 in 5 adults
What is the current gold standard psychological treatment for chronic pain?
Cognitive behavioural therapy
some others include:
- hypnosis
- mindfulness-based therapies
- acceptance-based therapies
- condition specific therapies (i.e. mirror therapy for phantom limb pain)
How does cognitive behavioural therapy work?
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
What is the difference between incident pain and breakthrough pain?
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
What is the WHO analgesic step ladder?
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
What are simple analgesics?
simple painkillers
paracetamol, aspirin
How can opioids be administered?
oral (either immediate release or slow release)
parenteral (IV)
transdermal (patches)
intrathecal, epidural
Name some alternative opioids
Fentanyl –patches, less sedation, constipation, very strong
Hydromorphone- less constipation, hepatic metabolism
Oxycontin-less sedation, confusion
Buprenorphine –patches, weaker –ideal for older people
Name some adjuvants for nociceptive pain that target inflammatory soup.
NSAIDS
steroids
Name some adjuvants for nociceptive pain that target skeletal muscle spasm.
Benzodiazepines
baclofen
Name some adjuvants for nociceptive pain that target smooth muscle spasm.
hyoscine butylbromide
Name some adjuvants for neuropathic pain.
antidepressants: amitryptaline
anti-epileptics: pregabalin, gabapentin, valproate, carbamezepine
anti-arrhythmics: mexilitine, flecainide
How are NSAIDs classified?
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)
What are some consequences of side-effects caused by NSAIDs?
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
What are some side-effects of opioids?
constipation, sedation, respiratory depression (in overdose), physical dependence, europhia
What opioids are preffered for patients with renal impairment?
oxycodone & fentanyl
What are some red flags?
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
What are some yellow flags?
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
Name some questionaires typically used for assessing psychosocial factors (yellow flags)?
Tampa Scale for Kinesiophobia
Fear Avoidance Beliefs Questionnaire (for back pain)
Pain Catastrophising Scale
Pain Self Efficacy Questionnaire
Hospital Anxiety and Depression Scale
When would you consider using imaging?
Serious pathology suspected
Unsatisfactory response to conservative care, or unexplained progression of signs and symptoms
Imaging is likely to change management
