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TAS Palliative Medicine > Pain Management ✅ > Flashcards

Pain Management ✅ Flashcards

1
Q

What does good pain management require?

A

Assessment, communication, planning, and a good knowledge of pharmacology and physiology

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2
Q

Who is pain often under-recognised in?

A

Children with disability

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3
Q

What is pain defined as?

A

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

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4
Q

What is pain influenced by?

A
  • Past pain experiences
  • Concerns about personal wellbeing or that of others
  • Context
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5
Q

What is total pain?

A

The concept that pain always occurs in the context of emotional need, fears, past experiences, and understanding of the pain as well as biological experience

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6
Q

Are all children able to feel pain?

A

Yes

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7
Q

What does assessment of pain in children require?

A
  • Detailed history
  • Observation of the child, ideally in a variety of settings
  • Examination
  • Consideration of all possible contributing factors
  • Discussion with parents
  • Use of pain assessment tools
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8
Q

What possible contributing factors need to be considered when assessing pain?

A
  • Psychological
  • Spiritual
  • Social
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9
Q

What do pain assessment tools need to be appropriate to?

A

Age and cognitive ability of the child

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10
Q

What might be a sign of pain in a non-verbal child?

A
  • Crying and changing in vocalisation
  • Quietening/becoming withdrawn
  • Frowning/grimacing on passive movement
  • Increasing seizure or spasm frequency
  • Change in feeding pattern
  • Hypersensitivity to stimuli
  • Change in posture or behaviour, e.g. head banging, rubbing a limb
  • Increased flexion or extension
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11
Q

What are the most commonly used types of pain scale?

A
  • ‘Faces’-type tools

- Scales based on observation of behaviour patterns associated with pain in non-verbal children

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12
Q

Give an example of a scale based tool for assessing pain?

A

The Paediatric Pain Profile

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13
Q

What are Faces-type tools for assessing pain based on?

A

Likert scale (the agree, neutral, disagree thing)

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14
Q

Who are most ‘faces’-type scales for pain assessment validated in?

A

Acute pain in cognitively normal children

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15
Q

What are the steps in pain management?

A
  1. Consider and treat specific reversible causes
  2. Consider non-pharmacological measures
  3. Pharmacological approach
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16
Q

Give 3 specific reversible causes that should be considered in the management of pain?

A
  • Constipation
  • Gastro-oesophageal reflux
  • Orthopaedic, especially hip dislocation
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17
Q

What non-pharmacological measures should be considered in the management of pain?

A
  • Attention to reversible sources of fear and anxiety
  • Counterirritants and distraction techniques
  • Behavioural techniques
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18
Q

Give 3 examples of counter-irritants that can be considered in the non-pharmacological management of pain?

A
  • Hot or cold packs
  • Acupuncture
  • TENS
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19
Q

What behavioural techniques can be considered in the non-pharmacological management of pain?

A
  • Cognitive behavioural therapy
  • Relaxation
  • Visualisation or art therapy
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20
Q

What is the WHO pain ladder the basis for?

A

The rational management of palliative pain

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21
Q

What does the WHO pain ladder express the concept of?

A

That increases in the intensity of pain should be matched by changes both in the type of analgesic and manner in which they are prescribed

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22
Q

What are the steps in the WHO analgesic ladder?

A
  1. Simple analgesics
  2. PRN opioids
  3. Regular opioids
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23
Q

When should you move up a step in the WHO analgesic ladder?

A

When the pain intensity increases and the effect of prescribing on one step becomes inadequate

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24
Q

What is each step on the WHO analgesic ladder characterised by?

A
  • A specific class of analgesic
  • A specific approach to dosing (regular vs. PRN)
  • Need to consider adjuvants appropriate to the nature of the pain
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25
Q

What is an adjuvant?

A

A medication or other intervention that is not an analgesic but, used alongside analgesics, its actions can reduce pain in certain specific situations

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26
Q

What is step 1 in the WHO analgesic ladder?

A

Simple analgesics

27
Q

What is step 1 on the WHO analgesic ladder used to treat?

A

Mild pain

28
Q

Is step 1 on the WHO analgesic ladder regular or PRN?

A

PRN

29
Q

What is step 2 on the WHO analgesic ladder?

A

PRN opioids

30
Q

What is step 2 on the WHO analgesic ladder used to treat?

A

Moderate pain

31
Q

What dose is used in step 2 on the WHO analgesic ladder?

A

0.1mg/kg OME (oral morphine equivalent) 1-4hrly

32
Q

What is step 3 on the WHO analgesic ladder?

A

Regular opioids

33
Q

What is step 3 on the WHO analgesic ladder used to treat?

A

Severe pain

34
Q

What is the regular dose of oral morphine in step 3 of the WHO analgesic ladder?

A

Starting dose 1mg/kg/24h OME, then increased as determined by breakthrough requirements

35
Q

What is the breakthrough dose in step 3 of the WHO analgesic ladder?

A

1/10 to 1/6 of the total daily background dose, given 1-4hrly

36
Q

Why is the WHO analgesic ladder no longer divided into weak and strong opioids?

A

As a high dose of weak opioid is equivalent to a low dose of a strong one

37
Q

Give 3 examples of simple analgesics

A
  • NSAIDs
  • Paracetamol
  • Aspirin (where appropriate)
38
Q

Give 5 examples of opioids?

A
  • Morphine
  • Diamorphine
  • Fentanyl
  • Buprenorphine
  • Methadone
39
Q

Why is codeine no longer recommended in the management of paediatric pain?

A

Due to pharmacogenetic variation in its hepatic activation to morphine, leading to inconsistent effectiveness

40
Q

Is tramadol an analgesic?

A

Yes, but it has additional non-opioid analgesic properties

41
Q

What is the problem with tramadol?

A

It is often poorly tolerated

42
Q

What are the phases in prescription of major opioids?

A
  • Initiation
  • Titration
  • Maintenance
43
Q

Give 2 examples of immediate release opioids?

A
  • Oramorph

- Buccal diamorphine

44
Q

Give 3 examples of continuous release opioids?

A
  • MST
  • Transcutaneous patch
  • Syringe driver
45
Q

What are the common fears about morphine?

A
  • Respiratory depression
  • Side effects
  • Addiction
  • Tolerance
46
Q

What can you tell a parent who is concerned about respiratory depression with morphine?

A

It is extremely rare when opioids are used for pain, and can be avoided with careful titration of the dose

47
Q

What are the most common side effects of morphine?

A
  • Drowsiness
  • Nausea and vomiting
  • Constipation
48
Q

When is a child likely to be drowsy with morphine?

A

For 3-5 days when first starting strong opioids or when doses are increased

49
Q

When might nausea and vomiting occur with morphine?

A

When first starting

50
Q

Is nausea and vomiting as significant a side effect of morphine in children compared to adult?

A

No, it is less common and wears off

51
Q

How can constipation with opioids be prevented?

A

Laxatives should be started and titration to need

52
Q

What are the other, rarer side effects of morphine?

A
  • Pruritis
  • Urinary retention
  • Nightmares
53
Q

What should a parent/patient be told if they are concerned about addiction to morphine?

A

Physical dependence is not usually a primary concern in the palliative care setting, but opioids should always be weaned slowly if the pain resolves to avoid withdrawal

54
Q

What should you tell a parent/patient who is concerned about tolerance to morphine?

A

Tolerance probably occurs if opioids are used for long periods, but the remedy is to increase the dose of opioids. Families may find it beneficial to understand the principle of tolerance rather than assuming escalating doses of analgesia imply disease progression

55
Q

What adjuvants to analgesics might be used for bone pain?

A
  • NSAIDS
  • Radiotherapy
  • Bisphosphonates
  • Steroids
56
Q

When is radiotherapy useful for bone pain?

A

If metastatic cause

57
Q

When are bisphosphonates particularly good for bone pain?

A

Osteopenia

58
Q

When are steroids useful for bone pain?

A

If metastatic cause

59
Q

What adjuvants are used for nerve pain?

A
  • Anticonvulsants
  • Antidepressants
  • NMDA antagonists
  • Baclofen
  • Steroids
60
Q

Give 2 examples of NMDA antagonists?

A
  • Ketamine

- Methadone

61
Q

When are steroids useful as an adjunct in nerve pain?

A

If the cause is pressured e.g. tumour oedema

62
Q

What adjuvants can be useful in muscle spasm pain?

A
  • Baclofen
  • Benzodiazepines
  • Botulinum toxin
63
Q

What adjuvants can be useful in pain from cerebral irritation?

A
  • Phenobarbital

- Benzodiazepines

TAS Palliative Medicine (1 decks)

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