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Part 3 – PM3B > (PM3B) Pain & Analgesia > Flashcards

(PM3B) Pain & Analgesia Flashcards

1
Q

What are the components of pain?

A

(1) Sensory
(2) Emotional

Hence why it is subjective

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2
Q

What are some different methods to rate pain?

A

(1) Numeric rating scale
- 1-10
- functional scale

(2) Visual analogue scale
- No pain to worst possible pain

(3) Verbal Pain Intensity Scale
- for young/ disabled patients
- no pain to unimaginable/ unspeakable pain
- also a 1-10 scale

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3
Q

What do the different numbers (1-5) of a functional pain scale correspond to?

A

0 = no pain

1 = tolerable + pain does not prevent activities

2 = tolerable + pain prevents some activities

3 = Intolerable + pain does not prevent use of phone/ TV/ reading

4 = Intolerable + pain prevents use of phone/ TV/ reading

5 = Intolerable + pain prevents verbal communication

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4
Q

What is the purpose of acute pain?

A

Protective mechanism

e.g. thermal burns

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5
Q

What are the types of pain?

A

(1) Nociceptive pain

(2) Neuropathic pain

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6
Q

What type of pain is caused by a tissue injury?

A

Nociceptive pain

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7
Q

How long does acute nociceptive pain last?

A

<3-6 months

Desirable

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8
Q

How long does chronic nociceptive pain last?

A

> 6 months

Undesirable

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9
Q

What is allodynia?

A

Pain after stimulation

Not normally painful

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10
Q

What is hyperalgesia?

A

Increased pain from a stimulus that normally causes pain

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11
Q

What is neuropathic pain?

A

Nerve injury

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12
Q

What are some conditions that are associated with neuropathic pain?

A

(1) Diabetic neuropathy
(2) Phantom limb pain
(3) Cancer pain
(4) Chemotherapy-induced peripheral neuropathy
(5) Postherapeutic neuralgia

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13
Q

How may neuropathic pain be described?

A

(1) Severe
(2) Sharp
(3) Burning
(4) Cold
(5) Numb
(6) Tingling
(7) Weakness

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14
Q

What is the pain pathway?

A

(1) Detection of pain in the periphery
(2) Transmission of pain signals from periphery to spinal cord
(3) Reception of signal by higher central brain centres

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15
Q

Describe the role of local neuronal circuits and descending inhibitory pathways from higher brain centres.

A

Signals are amplified or inhibited

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16
Q

Describe the myelination state of non-nociceptive Aß.

A

Myelinated

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17
Q

Describe the myelination state of nociceptive C.

A

Unmyelinated

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18
Q

What sensation do non-nociceptive Aß fibres produce?

A

Touch + pressure

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19
Q

What sensation do nociceptive C fibres produce?

A

Dull + burning pain

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20
Q

What sensation do nociceptive A-delta produce?

A

Sharp pain

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21
Q

What is the gate control theory of pain?

A

Melzack + Wall’s theory

Inhibitory interneurons in spinal cord control incoming sensory information before it’s transmitted to the brain

(1) Activation of C/ A-∂ fibres open gate (increased pain)
- direct excitation of gate OR inhibition of SG interneurons

(2) SG interneurons inhibit
- close the gate
- reduce pain

(3) Activation of Aß fibres close gate by excitation of Sg interneurons

(4) Descending inhibitory pathways from CNS close gate
- inhibit the gate OR direct activation of SG interneurons

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22
Q

What are some inflammatory mediators of peripheral pain?

A

(1) Bradykinin
(2) Substance P
(3) ATP
(4) Protons

(5) Prostaglandins
- particularly PGE2 + PGF2

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23
Q

What is the role of bradykinin as an inflammatory mediator of peripheral pain?

A

Activates B2 receptors in nociceptive neurones + B1 receptors via a metabolite

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24
Q

What is the role of substance P as an inflammatory mediator of peripheral pain?

A

Activates NKA (neurokinin) receptors in nociceptive neurones

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25
What is the role of ATP as an inflammatory mediator of peripheral pain?
Activates P2X3 receptors
26
What is the role of protons (H+) as an inflammatory mediator of peripheral pain?
Activate acid-sensing ion channels (ASICs)
27
What is the role of prostaglandins as an inflammatory mediator of peripheral pain?
PGE2 + PGF2 Greatly increase responses to bradykinin and 5-HT Increase sensitisation
28
What are prostanoids?
Prostaglandins + thromboxane Produced from precursors in cell membrane
29
What are some important neurotransmitters in hyperalgesia?
(1) Glutamate - acts at AMPA to mediate acute pain - acts at NMDA receptors (delayed) (2) Substance P - acts at NK1 receptors - enhances NMDA action (hypersensitivity) (3) Nitric oxide - enhances further transmission of pain signal
30
What factor limits non-opioids?
Ceiling effect Dose above which there is no further pharmacological action
31
What is the mechanism of action of opiates?
Increase descending inhibitory pathways Decrease neuropeptide release
32
What is acetylsalicylic acid?
Aspirin
33
Which analgesic is most appropriate for dysmenorrhoea?
Aspirin
34
Give some examples of indoles.
(1) Diclofenac | (2) Indomethacin
35
Give some examples of propionic acid derivatives.
(1) Ibuprofen (2) Naproxen (3) Ketoprofen
36
What is etoricoxib licensed for?
(1) Ankylosing spondylitis (2) Osteoarthritis (3) Rheumatoid arthritis (4) Acute gout
37
What is celecoxib licensed for?
(1) Ankylosing spondylitis (2) Osteoarthritis (3) Rheumatoid arthritis
38
Why were rofecoxib and valdecoxib withdrawn?
Cardiovascular side effects
39
Why was lumiracoxib withdrawn?
Hepatotoxicity problems
40
What is nefopam?
Non-opioid For persistent pain if NSAIDs or opioids are not suitable Causes little-no respiratory depression Can have sympathomimetic + antimuscarinic side effects
41
What is paracetamol?
Non-opioid Reduces the production of prostaglandins in CNS
42
For which type of pain are NSAIDs and opioids most effective?
Nociceptive pain
43
How is neuropathic pain most commonly treated?
(1) Anti-epileptics | (2) Tricyclic antidepressants
44
What are some anti-epileptics used to treat neuropathic pain?
(1) Sodium channel blockers - Carbamazepine - Phenytoin (2) via effects on Calcium channels - gabapentin - pregabalin
45
What are some tricyclic antidepressants used to treat neuropathic pain?
(1) Duloxetine (SSRI/ SNRI) (2) Imipramine/ amitriptyline - for diabetic neuropathy
46
Name some less commonly used drugs to treat neuropathic pain.
(1) Ketamine - binds to NMDA receptor (2) Lidocaine/ bupivacaine - blocks sodium channels (3) Ziconotide - new generation calcium channel blockers - administered intrathecally (4) Cannabinoid agonists - e.g. sativex - for multiple sclerosis (5) Botulinum toxin - reduces muscular hyperactivity
47
What are opioids?
Highly effective analgesic Act spinally + supraspinally Produce analgesia in mild-moderate pain
48
Is morphine an agonist/ antagonist?
Agonist
49
Is naloxone an agonist/ antagonist?
Antagonist
50
Is methadone an agonist/ antagonist?
Agonist
51
Is pethidine an agonist/ antagonist?
Agonist
52
What are the different opioid receptors?
(1) M-receptor (2) ∂-receptor (3) k-receptor (4) ORL1-receptor
53
Which drugs bind to the ORL1-receptor?
None Endogenous opioid peptide (nociceptin) only
54
To which opioid receptor does morphine bind?
M-receptor
55
To which opioid receptor does fentanyl bind?
M-receptor
56
To which opioid receptor does buprenorphine bind?
k-receptor
57
Which endogenous opioid peptides bind to the opioid M-receptor?
(1) ß-endorphin | (2) enkephalin
58
Which endogenous opioid peptides bind to the opioid ∂-receptor?
(1) Met-enkephalin | (2) Leu-enkephalin
59
Which endogenous opioid peptides bind to the opioid k-receptor?
(1) dynorphin A | (2) dynorphin B
60
Describe the supra-spinal action of opioid-induced analgesia.
(1) Opioid action at µ (∂ + k) receptors (2) Enhances descending inhibitory pathway in brain (3) Involves noradrenaline + serotonin (5-HT) release (4) via GABA inhibition
61
Describe the spinal action of opioid-induced analgesia.
(1) Activation of pre-synaptic receptors - µ > ∂ (2) Reduces transmitter release
62
Where do opioid agonists act?
All at µ receptors Except pentazocine - k agonist
63
What is morphine?
Gold-standard to which all opioids are compared Metabolised to potent analgesic morphine-6-glucuronide IV or PO as morphine sulphate tablets (MST)
64
What do fentanyl, alfentanil, sufentanil, and remifentanil have in common?
Opioid agonists Very potent Short-duration Often as a transdermal patch
65
What is oxycodone?
Opioid agonist Primarily used for control of pain in palliative care
66
What is pethidine?
Opioid agonist Used during labour - due to lack of effect on uterine contraction
67
What is codeine?
Opioid agonist Low efficacy + orally effective Not addictive Causes constipation with long-term use
68
What is dihydrocodeine?
Opioid agonist Similar efficacy to codeine Can cause more nausea + vomiting
69
What is diamorphine (heroin)?
Opioid agonist Metabolised to morphine High lipid solubility - leads to rapid action Higher efficacy
70
What do tramadol and tapentadol have in common?
Opioid agonist Weak opioids Inhibitors of noradrenaline uptake/ transport system
71
What is buprenorphine?
Partial opioid agonist Long duration Can be given sublingually
72
What are some common side effects of opioid agonist use?
(1) Euphoria (2) Respiratory depression (3) Cough suppression (4) Nausea (5) Constipation
73
What is euphoria, with relation to opioid use?
Common side effect of opioid agonist use Action on reward pathway - increases dopamine release k-agonists (pentazocine) causes dysphoria - nightmares - hallucinations
74
What is respiratory depression, with relation to opioid use?
Common side effect of opioid agonist use Reduced sensitivity of respiratory centre Most common cause of death from overdose Treated with naloxone
75
What is cough suppression, with relation to opioid use?
Common side effect of opioid agonist use Anti-tussive effect Can be therapeutically useful
76
What is nausea, with relation to opioid use?
Common side effect of opioid agonist use Activation of chemoreceptor trigger zone - in turn activates vomiting centre Treated with anti-emetics
77
What is constipation, with relation to opioid use?
Common side effect of opioid agonist use Due to maintained contraction of smooth muscle
78
What is the neuropathic pain ladder?
(1) TCA/ SNRI/ voltage-gated calcium channel subunit ligand - TCA = amitryptyline - SNRI = duloxetine - voltage-gated calcium channel ligand = pregabalin/ gabapentin (2) Consider tramadol or capsaicin cream - or add SNRI if not already used in first line
79
What is the nociceptive (analgesic) pain ladder?
(1) Non-opioid/ NSAID (2) Weak opioid for mild-moderate pain (e.g. codeine) + non-opioid + adjuvant (3) Strong opioid for moderate-severe pain (e.g. morphine) + non-opioid + adjuvant

Part 3 – PM3B (32 decks)

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