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MD2 Musculoskeletal > Pain Management > Flashcards

Pain Management Flashcards

1
Q

What are the 3 main questions to ask when classifying pain?

A

How long has the patient had pain? Acute, chronic or acute on chronic

What is the cause? Cancer or non-cancer

What is the pain mechanism? Nociceptive (physiological) or neuropathic (pathological)

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2
Q

Distinguish between acute and chronic pain

A

Acute: pain of recent onset and probable limited duration

Chronic: pain persisting beyond healing of injury, often no identifiable cause, lasting >3/12

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3
Q

Distinguish between cancer and non-cancer pain

A

Cancer pain: progressive, may be mixture of acute and chronic

Non-cancer pain: many different causes, can be acute or chronic

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4
Q

What is the mechanism of nociceptive pain and how can it be further classified?

A

Obvious tissue injury or illness (“physiological pain”)

Can be further classified into superficial somatic, deep somatic or visceral

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5
Q

Give a clinical description of nociceptive pain

A

Can be sharp, aching, dull, throbbing, cramping, pressure, etc

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6
Q

What is the mechanism of neuropathic pain?

A

Nervous system damage or abnormality (“pathological pain”); tissue injury may not be obvious

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7
Q

Give a clinical description of neuropathic pain

A

Burning, shooting +/- numbness, parasthesia

Not well localised

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8
Q
A
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9
Q

What are the 4 steps in the physiology of pain?

A

Periphery: tissue injury results in release of chemicals which stimulate nociceptors and result in propagation of signal in A-delta or C nerve to spinal cord

Spinal cord: dorsal horn is the “first relay station” where the A-delta or C nerve synapses (connects) with the second nerve, and the second nerve travels up the opposite side of the spinal cord

Brain: thalamus is the “second relay station” with connections to many parts of the brain including the cortex, limbic system and brainstem (pain perception occurs in the cortex)

Modulation: descending pathway from brain to dorsal horn, typically decreases the pain signal

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10
Q

Where is the abnormality in neuropathic pain?

A

Peripheral nerves

Spinal cord or brain

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11
Q

What peripheral or central changes can result in neuropathic pain?

A

Peripheral: damaged nerves (e.g. trauma, DM), abnormal firing of nerves

Central: changes in “wiring”, abnormal firing, loss of modulation

Sensitisation can occur in peripheral and central nervous system; persistent central sensitisation is a possibe mechanism for some chronic pain conditions

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12
Q

What is the mechanism of action of paracetamol (acetaminophen)?

A

Unclear but acts in CNS

Inhibits peripheral prostaglandin synthesis

Analgesic and antipyretic

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13
Q

What are the indications for paracetamol?

A

Analgesia either alone or in combination

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14
Q

What is the main AE of paracetamol?

A

Hepatic necrosis

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15
Q
A
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16
Q

Describe important drug interactions of paracetamol with other pain medications

A

Effects are additive with NSAIDs

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17
Q

What monitoring is indicated for paracetamol?

A
18
Q
A
19
Q

What is the mechanism of action of NSAIDs?

A

Non-specific inhibition of COX1 and COX2 to inhibit PG synthesis

Analgesic, antipyretic, anti-inflammatory

20
Q

What is the indication for NSAIDs?

A

Analgesia alone or in combination

21
Q

List 5 adverse effects of NSAIDs

A

Peptic ulceration

Renal impairment

Anti-platelet action

Bronchospasm in asthmatics

Exacerbation of CCF

22
Q

Name one drug interaction of NSAIDs with other analgesics

A

Reduce opioid requirements by 20-40%

23
Q

What monitoring considerations are important with NSAIDs?

A

Care with renal impairment or hypovolaemia

24
Q

What is the mechanism of action of opioids?

A
25
Q

What are the indications for opioids?

A

Severe pain

26
Q

List 8 AEs of opioids

A

Sedation

Respiratory depression

Nausea

Euphoria

Miosis

Bradycardia

Postural hypotension

Urinary retention

27
Q

What drug interactions occur with the use of opioids for analgesia?

A

Interacts with other sedative agents

28
Q

What kind of monitoring is important with use of opioid analgesics?

A

Sedation, CV and respiratory

29
Q

What is the mechanism of action of tramadol?

A

Weak opioid effect plus inhibitor of serotonin and noradrenaline reuptake (modulation)

30
Q

List 3 advantages and one disadvantage of tramadol

A

Advantages: less respiratory depression, can be used with opioids and simple analgesics, not a controlled drug

Disadvantages: N+V

31
Q

What is the mechanism of action of amitriptyline as an analgesic?

A

Increases descending inhibitory signals (tricyclic antidepressant)

32
Q

Outline 3 advantages and one disadvantage of amitriptyline for analgesia

A

Advantages: cheap, safe in low dose, good for neuropathic pain, also treats depression and poor sleep

Disadvantages: anti-cholinergic side effects (glaucoma, urinary retention)

33
Q

What drugs can be used for neuropathic pain Mx?

A

Amitriptyline

Anti-epileptics: carbamazepine, sodium valproate, gabapentin/pregabalin

34
Q

Tegretol

A

Carbamazepine

35
Q

Epilim

A

Sodium valproate

36
Q

What is the mechanism of anti-epileptics as analgesics?

A

“Membrane stabilisers”; reduce abnormal firing of nerves

37
Q

Summarise commonly used analgesics and the types of pain they are best for

A
38
Q

What is the RAT approach to pain?

A

Recognise

Assess

Treat

39
Q

What methods are commonly used for pain measurement?

A

Verbal (e.g. mild, moderate, severe)

Numerical (0 to 10)

Visual (VAS, “faces” pain scale)

40
Q

What non-drug treatments can be used to manage pain?

A

RICE

Nursing care, physiotherapy

Surgery, acupuncture, massage, TENS

Psychological (explanation and reassurance, input from SW/pastor, relaxation, imagery, distraction, coping strategies)

41
Q

Describe the types of drug treatments commonly used for mild, moderate and severe nociceptive pain

A

Mild: paracetamol (+/- NSAID)

Moderate: paracetamol (+/- NSAID) + codeine/oxycodone/tramadol

Severe: paracetamol (+/- NSAID) + morphine/oxycodone, regional anaesthesia, adjuvants (alpha 2 agonists, NMDA agonists)

42
Q

How should neuropathic pain be treated?

A

Traditional drugs may not be as useful

Use other drugs early: amitriptyline, carbamazepine, gabapentinoids

Don’t forget non-drug treatments!

MD2 Musculoskeletal (12 decks)

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