Pain therapeutics

Question 1

Pain can be classified into several categories which are not mutually exclusive

Answer 1

Acute
Chronic
Nociceptive
Somatic
Visceral
Neuropathic
Breakthrough

Question 2

Pain is defined as acute if

Answer 2

Pain is defined as acute if it has been present for three months or less

Question 3

Nociceptive pain

Answer 3

Nociceptive pain occurs when a nerve ending is stimulated producing a pain response in the central nervous system.

Question 4

Somatic pain

Answer 4

Somatic pain is that which is transmitted by skin, bone, joints and muscles. The pain is usually described as aching, throbbing, constant and localised.

Question 5

Visceral pain

Answer 5

Visceral pain is that which is transmitted by the internal organs. It is often poorly localised (e.g. general abdominal pain due to appendicitis) and can even be referred to other parts of the body (e.g. jaw pain in myocardial infarction). It is usually described as constant and sharp.

Infiltration of organs by tumours may produce a visceral pain response due to pressure upon the organs and resulting ischaemia. The visceral pain due to tumour infiltration usually responds well to opioid analgesics but simple analgesia should be tried first (see WHO pain ladder described in a later section.

Question 6

Neuropathic pain

Answer 6

Neuropathic pain occurs when there is damage to, or a change within, the central or peripheral nervous systems. This may occur with Herpes zoster infections (the pain of shingles), direct damage to, or compression of, a nerve (e.g. sciatica), tumour infiltration of a nerve or as the result of chemotherapy for cancer. The pain may be continuous or consist of unpredictable episodes, the latter often being likened to having an electric shock.

The pain is often described as:

Tingling
Burning
Electrical
Stabbing
Pins & needles
Itching

Question 7

Tactile allodynia

Answer 7

his is when even a very light touch on the skin of the patient will result in the sensation of severe pain in the area and the patient may find the touch of clothing or bedclothes intolerable.

Question 8

Neuropathic pain often responds very poorly to

Answer 8

Neuropathic pain often responds very poorly to conventional analgesia and drugs which work centrally may be more effective. These include (not an exhaustive list): amitriptyline, carbamazepine, clonazepam, dexamethasone, gabapentin, pregabalin, tramadol.

Other, non‐drug, methods have been shown to be effective in relieving chronic neuropathic pain. These include psychological therapies to cope with depression, anxiety and the pain itself (e.g. distraction therapy, expressive arts, hypnosis, relaxation, prayer, meditation)

Question 9

breakthrough pain

Answer 9

This pain is associated with palliative conditions such as cancer. About 90% of cancer patients in advanced stages experience pain. This is generally managed with strong opioids and adjuvants. However these patients can experience pain that ‘breaks’ through this analgesia, occurring with fast-onset and short duration. This is known as breakthrough pain.

Question 10

The three steps in the WHO pain ladder are:

Answer 10

1. Non‐opioid analgesic (e.g. paracetamol, aspirin, ibuprofen) + adjuvant
2. Mild/ Weak opioid (e.g. dihydrocodeine, codeine) + non‐opioid + adjuvant
3. Strong opioid (e.g. morphine, oxycodone) + non‐opioid + adjuvant

Question 11

Non-opioid analgesics include:

Answer 11

Aspirin
Ibuprofen and other NSAIDs
Paracetamol
Nefopam
Ziconotide

Question 12

Weak opioids include

Answer 12

Weak opioids include codeine and dihydrocodeine

Question 13

Strong opioids

Answer 13

include morphine, fentanyl, oxycodone.

Question 14

Schedule for codein, tramadol, buprenorphine, fentanyl, oxycodone, morphine

Answer 14

Opioid analgesics are subject to controlled drug regulations. These range from Schedule 5 for codeine to Schedule 3 for Tramadol and Buprenorphine to Schedule 2 for strong opioids like fentanyl and oxycodone. Morphine, depending on its strength, can be either schedule 2 or 5. Revisit your stage 2 notes on controlled drugs.

Question 15

Adjuvant medications

Answer 15

Added to therapy.

These may include antidepressants, antiepileptics, muscle relaxants, or Botox

Question 16

The following pharmacotherapy should NOT be offered for managing low back pain:

Answer 16

• Paracetamol alone
• Opioids (routinely)
• Opioids for chronic low back pain
• SSRI, TCA, and SNRI antidepressants
• Anticonvulsants

Question 17

muscle spasm treatment

Answer 17

NICE CKS recommends the use of diazepam 2mg (up to three times daily for up to five days) if the patient has muscle spasm

Question 18

Examples of invasive therapies for lower back pain include:

Answer 18

• Radiofrequency denervation
• Epidurals with local anaesthetic or steroid
• Surgery e.g. spinal decompression

Question 19

There are three- four stages to a migraine:

Answer 19

• Prodrome
• Aura (not experienced by all suffers)
• Headache
• Postdrome

Question 20

Episodic migraines

Chronic migraines

Answer 20

Episodic migraines are classified as less than 15 migraines per month.

Chronic migraines are classified as greater than 15 migraines per month for more than three months.

Question 21

Management of acute migraine

Answer 21

The management of migraine with or without aura is based simple analgesics or triptans. Opioids are not recommended for migraine. Antiemetics can be a useful addition.

Question 22

Prophylaxis of Migraine

Answer 22

NICE recommend Propranolol and Topiramate as first line for prophylaxis of migraine. Amitriptyline can also be used for prophylaxis. Acupuncture and Riboflavin are also recommended by NICE.

Question 23

Classification and diagnosis TTH

Answer 23

There are three main types of TTH:

Infrequent Episodic Tension Type Headache
Frequent Episodic Tension Type Headache
Chronic Tension Type Headache

Question 24

Acute treatment of all types of TTH

Answer 24

Acute treatment of all types of TTH include the use of paracetamol, aspirin (over 16s only), or NSAIDs. Opioids or Triptans should not be used for TTH.

Question 25

Prophylactic treatment of chronic TTH

Answer 25

NICE recommends acupuncture. It does not recommend pharmacological treatment. NICE CKS however discusses the use of Amitriptyline in chronic TTH as an established treatment. NICE CKS also discuss treating underlying stress or depression and managing trigger factors.

Question 26

Signs and symptoms and diagnosis

Cluster headache

Answer 26

luster headache is characterized by recurrent attacks of one-sided pain, in or around the eye or temporal region, and associated with signs of autonomic dysfunction on the same side.

Attacks of pain:

Usually last for 15–180 minutes.
Are almost always described as the most severe pain known. Women who have cluster headache typically describe the pain as significantly worse than childbirth.
Tend to recur at the same time each day, often waking the person shortly after falling asleep.
Symptoms and signs of autonomic dysfunction include:
Rhinorrhoea or nasal congestion.
Red eye and/or lacrimation.
Facial or forehead sweating or flushing.
Constriction of the pupil and/or ptosis.
Eyelid oedema.
A sense of fullness in the ear.

Episodic cluster headaches are described as attacks occurring in periods lasting from seven days to one year, separated by pain-free periods lasting at least one month.

Chronic cluster headaches are described as attacks occurring for more than one year without remission, or with remission periods lasting less than one month.

Question 27

Acute cluster headache treatment

Answer 27

Acute cluster headache is managed with oxygen, or subcuteous or nasal triptans. Oral triptans, paracetamol, NSAIDs, opioids, and ergots should not be offered for cluster headache

Question 28

Prophylaxis for cluster headache and

Non-Pharmacological treatment

Answer 28

Verapamil is recommended by NICE for use in prophylaxis of cluster headache (off-label).

Non-Pharmacological treatment
To avoid inducing an attack, during a cluster period patients should:
Avoid alcohol as much as possible
Avoid volatile fumes
Avoid warm environments

Question 29

Medicines over use headaches

Answer 29

Medicines over use headaches are secondary headaches that are chronic in nature (occuring on more than 15 days per month). They usually occur when:

Triptans, opioids, ergots or combination analgesia are used 10 or more days per month
Paracetamol, Aspirin, NSAIDs or combinations of these are used on 15 or more days per month.
They often occur in people in suffering from episodic migraine or TTH but can occur in patients taking analgesics for other conditions.

Symptoms can resemble migraine or TTH.

Question 30

Primary dysmenorrhoea is the most likely diagnosis when:

Answer 30

Menstrual pain starts 6–12 months after the menarche, once cycles are regular.
Pain starts shortly before the onset of menstruation, and lasts for up to 72 hours, improving as the menses progresses.
Non-gynaecological symptoms such as nausea, vomiting, migraine, bloating, and emotional symptoms are present.
Other gynaecological symptoms are not present.
Pelvic examination is normal.

Question 31

dental pain treat

Answer 31

Amoxicillin and phenoxymethylpenicillin are usually effective for dental infections, but the absorption of amoxicillin may be better. Metronidazole is active against anaerobic bacteria

Question 32

A 27 year old woman who suffers chronic migraines requires prophylactic treatment for it?

Answer 32

NICE recommends Topiramate or Propranolol. Warning with Topiramate and pregnancy.

Question 33

A 35 year old woman with asthma who suffers infrequent episodic tension type headaches requires acute treatment?

Answer 33

NICE recommends Aspirin, Paracetamol or NSAIDs. Discuss use of NSAIDs and Aspirin in asthma.

Question 34

A 40 year old man who requires prophylactic treatment for chronic cluster headache?

Answer 34

NICE recommends Verapamil. Discuss off-label use

Question 35

A 55 year old woman who requires prophylactic treatment for chronic tension type headaches associated with the stress in her job?

Answer 35

NICE recommends up to 10 sessions of acupuncture over 5–8 weeks. NICE CKS also recommends relaxation techniques and addressing stress.

Question 36

A 26 year old man requires acute treatment for cluster headache?

Answer 36

NICE recommends oxygen and/or a subcutaneous or nasal triptan Sumatriptan(S/C) licenced. BNF gives doses for Zolmitriptan and Sumatriptan (intranasal) however unlicenced.

Question 37

After a further two weeks, Mrs. TN returns to your pharmacy saying that she is still in some discomfort. You therefore refer her to her GP for a review. She is still
complaining of stiffness and soreness and wonders what should be done next. The GP recommends that Mrs. TN undertake a course of manual therapy and exercise.

Answer 37

Manual Therapy
Collective term to include spinal manipulation, spinal mobilization and massage. Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy.

Exercise
Consider a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches) within the NHS for people with a specific episode or
flare-up of low back pain with or without sciatica. Take people’s specific needs, preferences and capabilities into account when choosing the type of exercise.
Biomechanical exercise includes any exercise intervention that is primarily directed at altering or improving spinal mechanics. This includes muscle strengthening, stretching, range of motion exercise, motor control exercise (including core stability
programmes and Pilates) or programmes aimed at addressing specific problem movements (including McKenzie exercise and the Feldenkrais method).
Aerobic exercise includes any exercise intervention that is primarily directed at improving cardiovascular fitness and endurance.
Mind–body exercise includes any exercise intervention that includes a combined physical, mental and spiritual focus, often with connection to metaphysical and
cultural philosophies. Examples include the various forms of Yoga and Tai Chi.
Mixed modality exercise includes any exercise intervention that incorporates a combination of any of the previous three categories.

Question 38

Dental pain:

• epidemiology,
• potential causes,
• red flags,
• referral criteria
• management of these conditions.

Answer 38

-epidemiology,

-potential causes,
Dental abscesses occur as a result of bacterial infection affecting the structures around a tooth and the tooth itself (tooth decay can enable bacteria to invade the dental pulp inside the tooth).
Bacteria associated with dental infection include oral streptococci and anaerobes (including Prevotella, Bacteroides, and Fusobacterium species).
Periapical abscess formation is usually secondary to dental caries (tooth decay), but can also occur as a result of trauma. Compromise of the enamel (outer coating of the tooth) enables bacteria to pass from the oral cavity into the pulp of the tooth. Inflammation and death of pulp tissue can occur and infection can spread to the periapical area around the tip of the tooth’s root, the surrounding dentoalveolar bone, and soft tissues.
Periodontal abscess formation is associated with chronic periodontitis. If a periodontal pocket occurs due to loss of supporting bone and periodontal ligament compromise and is not able to drain, an abscess can develop

-referral criteria and red flags
Admit a person to hospital as an emergency if they have a dental abscess and:
Signs of airway compromise (for example difficulty breathing or speaking, unable to swallow their own saliva, drooling, uvular deviation, trismus, or unable to push their tongue forward out of their mouth).
Are unwell with a high temperature and cardio-respiratory compromise (rapid pulse rate or low blood pressure, high respiratory rate).
Significant mandibular, submandibular, or infraorbital swelling (or difficulty opening the eye).
‘Floor of mouth’ swelling.
A spreading facial infection or orbital cellulitis.
Neurological signs (for example decreased level of consciousness, headache, eye signs [such as diplopia, papilloedema, pupil dilation, proptosis]).
Dehydration.
Use clinical judgement regarding admission to hospital or seeking specialist advice for people who:
Have signs and symptoms of systemic infection (for example nausea, malaise, pyrexia, or rigors).
Are immunocompromised.
Are very young or elderly.
Experience severe pain despite analgesia prescribed in primary care.

-management of these conditions.
Use a soft toothbrush to reduce discomfort. Avoid flossing the tooth with the abscess.
Consume soft foods and try eating on the other side of the mouth to reduce discomfort and irritation to the abscess.
Avoid food or drink that may be too hot or cold.
Advise the use of an analgesic to relieve symptoms.
Ibuprofen, or paracetamol if ibuprofen is contraindicated or unsuitable, is recommended first-line.

Question 39

Dysmenorrhoea:

• epidemiology,
• potential causes,
• red flags,
• referral criteria
• management of these conditions.

Answer 39

-epidemiology
Most common gynaecological symptom reported by women. Affects between 50% and 90% of menstruating women. The wide variation in reported prevalence rates are probably due to differences in definition. In a longitudinal survey of 404 nurses with primary dysmenorrhoea, mild symptoms were present in 53%, moderate symptoms in 20%, and severe symptoms in 2%. Despite the high prevalence of dysmenorrhoea and the impact it has on quality of life and general well-being, few women seek medical treatment.

-potential causes,
Primary dysmenorrhoea occurs in the absence of any identifiable underlying pelvic pathology.
Secondary dysmenorrhoea is caused by an underlying pelvic pathology such as endometriosis, fibroids, or endometrial polyps

-red flags:
Red flag symptoms (which may indicate a serious underlying pathology) include:
Abnormal cervix on examination.
Persistent intermenstrual bleeding.
A palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids nor of gastrointestinal or urological origin.

-referral criteria
Refer if symptoms are severe and have not responded to initial treatment within 3 to 6 months, or if there is doubt about the diagnosis.

-management of these conditions.
NSAID such as ibuprofen, naproxen, or mefenamic acid unless contraindicated.
Offer paracetamol if NSAIDs are contraindicated or not tolerated, or in addition to an NSAID if the response is insufficient.
If the woman does not wish to conceive, consider prescribing a 3–6 month trial of hormonal contraception.
Monophasic combined oral contraceptive (COC) preparations containing 30–35 micrograms of ethinylestradiol and norethisterone, norgestimate, or levonorgestrel are usually first choice.

Non-drug measures to reduce pain

• Locally-applied heat
• Transcutaneous electrical nerve stimulation (TENS)

Question 40

Treatments not recommended for dysmenorrhoea

Answer 40

• Weak opioids

- Herbal remedies, dietary supplements, acupuncture, acupressure, spinal manipulation, behavioural therapy, and exercise

Question 41

The prodrome is a warning that a migraine is imminent. Symtoms include

Answer 41

Euphoria
Depression
Irritability
Food cravings
Constipation
Neck stiffness
Increased yawning

Question 42

The symptoms of TTH include:

Answer 42

Bilateral pain
Pressing or tightening (non-pulsating) quality
Mild-to-moderate intensity
Not aggravated by routine physical activity
Photophobia or phonophobia, but not both, may be present
Episodes of headache are not associated with nausea or vomiting.
TTH is not caused by other conditions, such as a pyrexial illness or medication overuse. It may last from 30 minutes to 7 days.

Question 43

Migraine may or may not be associated by aura which usually precedes the headache, although in some people they run concurrently. Aura symptoms include:

Answer 43

Visual disturbances e.g flashing lights and zigzag lines
Loss of vision
Dysphagia
Sensory symptoms such as numbness or pins and needles

Aura symptoms tend to last 5-60 minutes.

Question 44

Examples of adjuvant drugs

Answer 44

Anti-epileptics - Carbamazepine, gabapentin, pregabalin

Antidepressants - Amitryptyline, venlafazine

IV anaesthetic agents - Ketamine

Skeletal Muscle relaxants - Baclofen

Steroids - Prednisolone

Antibiotics

Hyoscine, Loperamide

Cacitonin

Biphosphatones - Pamidronate

Question 45

Treatment for neuropathic pain

Answer 45

Anti-epileptics - Carbamazepine, gabapentin,

Antidepressants - Amitryptyline

IV anaesthetic agents - Ketamine

Question 46

Treatment for malignant bone pain

Answer 46

Biphosphatones - Pamidronate

Question 47

Treatment for muscle spasm

Answer 47

Muscle relaxants - Baclofen

Question 48

Treatment for raised intracranial pressure

Answer 48

Corticosteroids - Prednisolone

Question 49

Treatment for nausea with morphine

Answer 49

Antiemetic - Cyclizine, ondansetron

Use an alternative route of admin - topical or s/c

Question 50

Treatment for constipation

Answer 50

Is it drug induced (opiods, TCA) - Laxatives (senna)

Question 51

Treatment for renal failure

Answer 51

As morphine accumulates use lower dose or use a drug not eliminated by kidney - Fentanyl, Burprenorphine