Pain Management ✅ Flashcards
What does good pain management require?
Assessment, communication, planning, and a good knowledge of pharmacology and physiology
Who is pain often under-recognised in?
Children with disability
What is pain defined as?
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
What is pain influenced by?
- Past pain experiences
- Concerns about personal wellbeing or that of others
- Context
What is total pain?
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
Are all children able to feel pain?
Yes
What does assessment of pain in children require?
- 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
What possible contributing factors need to be considered when assessing pain?
- Psychological
- Spiritual
- Social
What do pain assessment tools need to be appropriate to?
Age and cognitive ability of the child
What might be a sign of pain in a non-verbal child?
- 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- Quietening/becoming withdrawn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
What are the most commonly used types of pain scale?
- ‘Faces’-type tools
- Scales based on observation of behaviour patterns associated with pain in non-verbal children
Give an example of a scale based tool for assessing pain?
The Paediatric Pain Profile
What are Faces-type tools for assessing pain based on?
Likert scale (the agree, neutral, disagree thing)
Who are most ‘faces’-type scales for pain assessment validated in?
Acute pain in cognitively normal children
What are the steps in pain management?
- Consider and treat specific reversible causes
- Consider non-pharmacological measures
- Pharmacological approach
Give 3 specific reversible causes that should be considered in the management of pain?
- Constipation
- Gastro-oesophageal reflux
- Orthopaedic, especially hip dislocation
What non-pharmacological measures should be considered in the management of pain?
- Attention to reversible sources of fear and anxiety
- Counterirritants and distraction techniques
- Behavioural techniques
Give 3 examples of counter-irritants that can be considered in the non-pharmacological management of pain?
- Hot or cold packs
- Acupuncture
- TENS
What behavioural techniques can be considered in the non-pharmacological management of pain?
- Cognitive behavioural therapy
- Relaxation
- Visualisation or art therapy
What is the WHO pain ladder the basis for?
The rational management of palliative pain
What does the WHO pain ladder express the concept of?
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
What are the steps in the WHO analgesic ladder?
- Simple analgesics
- PRN opioids
- Regular opioids
When should you move up a step in the WHO analgesic ladder?
When the pain intensity increases and the effect of prescribing on one step becomes inadequate
What is each step on the WHO analgesic ladder characterised by?
- A specific class of analgesic
- A specific approach to dosing (regular vs. PRN)
- Need to consider adjuvants appropriate to the nature of the pain
What is an adjuvant?
A medication or other intervention that is not an analgesic but, used alongside analgesics, its actions can reduce pain in certain specific situations
What is step 1 in the WHO analgesic ladder?
Simple analgesics
What is step 1 on the WHO analgesic ladder used to treat?
Mild pain
Is step 1 on the WHO analgesic ladder regular or PRN?
PRN
What is step 2 on the WHO analgesic ladder?
PRN opioids
What is step 2 on the WHO analgesic ladder used to treat?
Moderate pain
What dose is used in step 2 on the WHO analgesic ladder?
0.1mg/kg OME (oral morphine equivalent) 1-4hrly
What is step 3 on the WHO analgesic ladder?
Regular opioids
What is step 3 on the WHO analgesic ladder used to treat?
Severe pain
What is the regular dose of oral morphine in step 3 of the WHO analgesic ladder?
Starting dose 1mg/kg/24h OME, then increased as determined by breakthrough requirements
What is the breakthrough dose in step 3 of the WHO analgesic ladder?
1/10 to 1/6 of the total daily background dose, given 1-4hrly
Why is the WHO analgesic ladder no longer divided into weak and strong opioids?
As a high dose of weak opioid is equivalent to a low dose of a strong one
Give 3 examples of simple analgesics
- NSAIDs
- Paracetamol
- Aspirin (where appropriate)
Give 5 examples of opioids?
- Morphine
- Diamorphine
- Fentanyl
- Buprenorphine
- Methadone
Why is codeine no longer recommended in the management of paediatric pain?
Due to pharmacogenetic variation in its hepatic activation to morphine, leading to inconsistent effectiveness
Is tramadol an analgesic?
Yes, but it has additional non-opioid analgesic properties
What is the problem with tramadol?
It is often poorly tolerated
What are the phases in prescription of major opioids?
- Initiation
- Titration
- Maintenance
Give 2 examples of immediate release opioids?
- Oramorph
- Buccal diamorphine
Give 3 examples of continuous release opioids?
- MST
- Transcutaneous patch
- Syringe driver
What are the common fears about morphine?
- Respiratory depression
- Side effects
- Addiction
- Tolerance
What can you tell a parent who is concerned about respiratory depression with morphine?
It is extremely rare when opioids are used for pain, and can be avoided with careful titration of the dose
What are the most common side effects of morphine?
- Drowsiness
- Nausea and vomiting
- Constipation
When is a child likely to be drowsy with morphine?
For 3-5 days when first starting strong opioids or when doses are increased
When might nausea and vomiting occur with morphine?
When first starting
Is nausea and vomiting as significant a side effect of morphine in children compared to adult?
No, it is less common and wears off
How can constipation with opioids be prevented?
Laxatives should be started and titration to need
What are the other, rarer side effects of morphine?
- Pruritis
- Urinary retention
- Nightmares
What should a parent/patient be told if they are concerned about addiction to morphine?
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
What should you tell a parent/patient who is concerned about tolerance to morphine?
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
What adjuvants to analgesics might be used for bone pain?
- NSAIDS
- Radiotherapy
- Bisphosphonates
- Steroids
When is radiotherapy useful for bone pain?
If metastatic cause
When are bisphosphonates particularly good for bone pain?
Osteopenia
When are steroids useful for bone pain?
If metastatic cause
What adjuvants are used for nerve pain?
- Anticonvulsants
- Antidepressants
- NMDA antagonists
- Baclofen
- Steroids
Give 2 examples of NMDA antagonists?
- Ketamine
- Methadone
When are steroids useful as an adjunct in nerve pain?
If the cause is pressured e.g. tumour oedema
What adjuvants can be useful in muscle spasm pain?
- Baclofen
- Benzodiazepines
- Botulinum toxin
What adjuvants can be useful in pain from cerebral irritation?
- Phenobarbital
- Benzodiazepines
