Pain Management

Question 1

What is the ‘Nociception’ process?

Answer 1

The transmission of electrical nerve impulses to the brain and spinal cord creating conscious awareness of pain and alterations of pain signals

Question 2

What are the stages of nociception?

Answer 2

Transduction: stimulus (e.g temp) is converted into electrical signals in the nerve cells.

Transmission: information from the signal is relayed along two peripheral nerve fibre - A-delta and C.

Perception: conscious awareness of pain. The person is aware of pain and responds emotionally and is motivated to take action

Modulation: the body modulates pain by mechanisms decreasing or increasing pain impulses.

Question 3

What is Neuropathic pain

Answer 3

Pain arising as a result of nerve lesions, damage or dysfunction of the nervous system, it has no protective functions.

Example: post amputation

Question 4

Characteristics of nociceptive pain?
Subtypes
Duration
Causes
Management

Answer 4

Subtypes:
Somatic - sharp, stabbing localised pain.
Visceral - dull, heavy, aching may occur over a wide area

Duration: less than 3months

Causes: stimulation of nociceptors in response to inflammation or damage.

Management: multimedia analgesia
Opioid therapy

Question 5

Characteristics of neuropathic pain?
Subtypes
Duration
Causes
Management

Answer 5

Subtypes: usually experienced with sensory loss. Can be associated with increased sympathetic response (rise in tempt)
Described as burning, stinging, pricking

Durayion: more than 3 months

Causes: associated with injury or disease of peripheral or central nervous system.

Mamagement: Poor response to opioid consider adjuvant (antidepressant or anticonvulsant therapy)

Question 6

What questions would you ask in a pain assessment?

Answer 6

Where is the pain
How strong is it
Is it there all the time or does it come and go
What does it feel like
What makes it worse
What makes it better

Question 7

What is meant by the
Ascending pathway and descending pathway of pain

Answer 7

Acending: Responsible for transmitting the pain signal to the brain
Decending: controlling and inhibiting the Ascending pathway

Question 8

Name 3 types of pain

Answer 8

Acute

Chronic

Breakthrough

Question 9

According to the WHO pain ladder there are 3 steps to pain management. In each step what pain management is recommended?

Answer 9

Step 1: mild pain - non-opioid analgesic (NSAID, paracetamol)

Step 2: moderate pain - week options (codeine, dihydrocodeine), with or without non-opioids

Step 3: severe pain- potent opioids (morphine, fentanyl, buprenorphine), with or without non-opioids

Question 10

What is the physiology for opioid function?

Answer 10

Opioid bind to opioid receptors located throughout the body. They cause depending inhibitory impulses which lead to a decrease in nociception transmission.

Question 11

Which theory explains how the brain modulates it’s own pain after perception?

Answer 11

Modulation Gate Theory

Endorphins and the bodies own opioids are released between the 1st and 2nd order nerves to block additional pain signals being transmitted.

Question 12

What four elements should be included in an assessment of Total Pain?

Answer 12

Physical, Psychological, Social and Spiritual

Question 13

Applying the Theory of Total Pain, what is a limitation of analgesic medication.

Answer 13

Medication only addresses the physical symptoms of pain, ignoring the psychological, social and spiritual aspects of Total Pain.

Question 14

Frank is reporting a pain score of 5/10 after tripping at home.
Using the WHO pain ladder, what analgesia would you recommend he be given?

Answer 14

Moderate Pain:

Non-Opioids (NSAIDs, paracetamol)
Weak Opioids (codeine, tramadol)
+/- adjuvants (heat/cold packs, TENS, Acupuncture, CBT)

Question 15

Tina reports a pain score of 2/10, using the WHO pain ladder, what analgesia would you reccomend?

Answer 15

Mild Pain:

Non-Opioids (NSAIDs, Paracetamol)
+/- Adjuvants (heat/cold packs, TENS)

Question 16

Following a fall with a #NOF (neck of femur), Betty has a pain score of 9/10. Using the WHO pain ladder, what analgesia would be appropriate?

Answer 16

Non-Opioids (NSAIDs, paracetamol)
Potent Opioids (Morphine, Fentanyl, Ketamine)
+/- adjuvants (heat/cold packs, TENS, Acupuncture, CBT)

Question 17

What considerations should be made before giving opiod medications?

Answer 17

The are MU Opioid receptors all over the body, including:

Bowel - increased fluid absorption leads to constipation.
Respiratory - respiratory chemoreceptor centre also has opiod receptors which can lead to respiratory depression when blocked.
CNS - Can lead to euphoria, drowsiness and confusion.

Tolerance, Dependance, Addiction.

Question 18

In terms of drug use, misuse and abuse, what is meant by the term Tolerance?

Answer 18

Tolerance to opioid medication builds with each use, meaning that regular use makes it less effective for that individual.

Question 19

In terms of drug use, misuse and abuse, what is meant by the term Dependence?

Answer 19

This refers to the phsyical and psychological reliance on long-term medications to perform daily tasks. Without the medication the patient can decline rapidly and suffer withdrawl symptoms.

Question 20

In terms of drug use, misuse and abuse, what is meant by the term Addiction?

Answer 20

Addiction is a multi-factorial condition that goes beyond management of symptoms.
If given as prescribed, opioid medications should have very low rates of addiction.

Question 21

Pharmacodynamics NSAIDS:
What are the three types of NSAIDs and how do they differ?

Answer 21

COX 1 inhibitors, COX 2 inhibitors and non-selective COX inhibitors.

COX 1 regulates many cellular processes including platelet aggregation, kidney afferent arteriole vasodilation and gastric mucousa acid protection.

COX 2 is part of the inflammatory process, inhibiting this reduces inflammation.

Non-selective - Bit of both.

Question 22

Give an example of each of the three types of NSAID medication.

COX 1 -
COX 2 -
Non-selective -

Answer 22

COX 1 - Aspirin, Ketoralac

COX 2 - Naproxen, Diclofenac

Non-selective - Ibuprofen

Question 23

What are some considerations that must be made before giving NSAIDs?

Answer 23

Renal Failure
Hepatic Failure
GI Bleeds.
Dyspepsia (indigestion)

Question 24

Pharmacodynamics Paracetamol

How does paracetamol work and what are it’s therapeutic effects?

Answer 24

No-one quite understands how it works, though it thought to have some effect on prostaglandins.

Therapeutic effects include analgesia and antipyretic actions.

Question 25

What is meant by the term co-analgesics?

Answer 25

Co-analgesics are a group of medications that were developed for a reason other than analgesia, but have analgesic effects.

Question 26

Give 2 examples of a common co-analgesic medication.

Answer 26

Antidepressants - Amitriptiline, duloxetine.
Anti-convulsants - Pregablin, gabapentin.
NMDA Antagonists - ketamine, methadone.
Corticosteroids - Prednisolone, dexamethasone.

Question 27

Jamie refuses to take any pain medications because his body is a temple and “you don’t know what big-pharma put in them pills.”

Identify 3 alternatives to pharmaceutical pain management for Jamie.

Answer 27

Hot/Cold packs
Massage
Physio

TENS
Acupuncture

CBT
Acceptance therapy

Question 28

What is meant by hyper-algesia?

Answer 28

Hyper-algesia describes a patient who has become very sensitive to pain.
This could possibly have been caused by opioid use.