Pain Management (Part 1)

Question 1

What are the different types of pain?

Answer 1

1. Nociceptive (somatic and visceral) pain
2. Neuropathic pain
3. Referred pain
4. Ischemic pain

Question 2

What is somatic pain?

Answer 2

• pain that arises from damage to body tissues
• can be superficial (skin) or deep (muscle and bone).
• triggered by noxious chemical, mechanical or thermal stimuli
• A delta fibers (for mechanical and thermal stimuli), C fibers (for all stimuli)
• tender and localized at site of injury, is constant
• aching, stabbing, throbbing pressure

Question 3

What is visceral pain?

Answer 3

• arises from the viscera
• poorly localised, distant
• gnawing, cramping, aching, or sharp pain

Question 4

What is neuropathic pain?

Answer 4

• originates from nerve damage (central and/or peripheral)
• no area of tenderness or exquisite sensitivity
• burning, tingling, shooting, squeezing, lancinating electric pain
• most resistant to opioids, making it the most difficult to treat.

Question 5

What is referred pain?

Answer 5

• pain located from its point of origin (e.g. hip injury pain referred to the knee)

Question 6

What is ischemic pain?

Answer 6

• loss of blood flow to tissue (often due to blockade of arteries)
• e.g. angina pain

Question 7

What are the various principles of pain ASSESSMENT?

Answer 7

1. Believe the patient’s complain of pain (even if the patient looks distressed, but does not appear to be in actual pain)
2. Use open-ended questions (no yes/no)
3. Take history of EACH pain
4. Look out for psychological distress

Question 8

Describe the FLACC scale

Answer 8

• FLACC stands for Face, Legs, Activity, Cry, Consolability
• used for children below the age of 3 who may not be able to self-report pain.
• each component scored 0-2, total up to 10.

Question 9

What are the principles of pain TREATMENT?

Answer 9

1. treat the underlying cause where possible
2. ask what are the pain mechanisms behind the pain
3. pharmacological treatments via the WHO ladder.
   » mild pain: non-opioids +/- adjuvants
   » moderate pain: weak opioid +/- adjuvants
   » severe pain: strong opioids +/- adjuvants

Question 10

Examples of non-opioids

Answer 10

NSAIDs, COXIBs, paracetamol

Question 11

Examples of weak opioids

Answer 11

Codeine, tramadol, tapentadol

Question 12

Examples of strong opioids

Answer 12

Morphine, fentanyl, oxycodone, methadone, pethidine

Question 13

What are the 5 WHO treatment guideline recommendations for cancer pain?

Answer 13

1. Administer oral analgesics whenever possible.
2. Analgesics should be given at regular intervals.
3. Dosing of pain medication should be adapted to the individual.
   » rapid titration for severe pain, slower titration for moderate pain, even slower titration for mild pain.
4. Analgesics should be prescribed according to pain intensity by a scale of intensity of pain.
5. Analgesics should be prescribed with a constant attention for detail

Question 14

Pain rating scale and general treatment guidelines

Answer 14

Mild pain (1-3): patient not on analgesics

Moderate pain (4-6): start with weak, opioid agonists

Severe pain (7-10): begin with strong, opioid agonists