T2 - Pain

Question 1

What path does pain travel to get to the somatosensory cortex?

Answer 1

Anteriolateral system (ALSTT)
Thalamus
Cortex
Decussates in cervical spinal cord

Question 2

What is substance P?

Answer 2

A NT involved in nociception transmission

Question 3

What types of nerves carry fast pain and slow pain?

Answer 3

Fast = Group III A delta (small, medium conduction velocity)
Slow = Group IV unmyelinated C fibers (smallest, slower conduction velocity)

Question 4

When is pain considered “chronic”?

Answer 4

If it persists for >90 days after the reasonable healing time

Question 5

T/F: Complete pain relief is unlikely for patients with chronic pain

Answer 5

True

Question 6

Place these terms in order: Perception, transmission, transduction, modulation.

Answer 6

Transduction (noxious Stim converted into AP)
Transmission (AP conducted through NS)
Modulation (inhibition or augmentation)
Perception (somatosensory cortex and limbic interpret the painful input)

Question 7

What effects can poorly controlled pain have on the following body systems? Cardiovascular, pulmonary, GI, renal, coagulation, immunologic, MSK and psych?

Answer 7

Cardiovascular - tachycardia, HTN, increased cardiac workload
Pulmonary - atelectasis, hypoxia, increased r/o pulmonary infx
GI - ileus
Renal - urinary retention
Coag - increased r/o thromboembolism
Immunologic - impaired fxn
MSK - immobility, weakness, fatigue
Psych - anxiety, fear, frustration

Question 8

What’s the difference between hyperalgesia and allodynia?

Answer 8

Hyperalgesia - previously painful stimulus perceived as MORE painful
Allodynia - non-noxious stimuli (such as brushing a towel against your arm) is perceived as painful.

Question 9

Chronic pain is under diagnosed. Some clues in a health record may be: radiographic tests w./in past 6 months, medication for pain and non pharm modalities, depression, anxiety, sleep issues, overuse of medications, relationship issues, isolation and low physical activity.

Question 10

What are some imaging tests that can be done for chronic pain?

Answer 10

X-ray, CT, MRI
Myelogram (looking at nerve roots with radiographic dye)
Bone scans
US
EMG, nerve conduction velocity, Quantitative sensory testing.
Check for inflammatory markers in the blood.

Question 11

What are the 3 primary goals with chronic pain patients?

Answer 11

Manage expectations
Improve function
Maintain therapeutic relationship with patient.

Question 12

What are some medications that can be used for STEP 1 on the analgesic ladder?

Answer 12

Non-Opioid and Adjuvant

NSAIDS - don’t forget the topical patches and gel!
TCAs - SE -constipation, dry mouth, sedation, caution in older, try a variety
SSRIs - takes weeks to reach effective dose.
Adjuvants = anticonvulsants.

Question 13

Your chronic pain patient has tried NSAIDs and a TCA and it is not helping. What is your next step?

Answer 13

Try NSAIDs and SSRI +/- adjuvant (anticonvulsant)

Question 14

What are some therapies on STEP 2 of the analgesic ladder

Answer 14

Mixed Opioid Medications

Hydrocodone and Tylenol (Vicodin, Lortab)
Oxy and Tylenol (Percocet)
Codeine, Tylenol and Codeine phos (Tylenol 3)
Tramadol (Ultram)
SEs - constipation, sedation, n/v, itching and resp depression.

Question 15

Your chronic pain patient has tried NSAIDs, a few TCAs and SSRIs and has allergies to anticonvulsants. What is your next option for pain control?

Answer 15

Mixed Opioids (step2)
Vicodin, Percocet, ultram, Tylenol3

Question 16

What are some medications on STEP 3 of the analgesic ladder?

Answer 16

Pure Opioid compounds
For moderate or severe pain or when step 2 compounds are not effective
Morphine
Fentanyl
Oxycodone
Methadone
Hydromorphone.

Question 17

What medications are good for low back pain or anxiety or insomnia associated with chronic pain?

Answer 17

Muscle relaxants
Benzodiazepines.

Question 18

What is the upper limit of safe dose per day of opioids according to research? Even so, at this dose there is a _______ risk for overdose compared to ______/day

Answer 18

50MME (morphine milligram equivalents) per day. Over 50 and approaching 100 has higher incidence of death related to overdose.

2x, <20MME/day .

Question 19

How should opioids be tapered?

Answer 19

Slowly

Question 20

Patients who have been using opioids for more than a year should taper by _______ per __________.

Answer 20

10% per month

Question 21

Patients who have been using opioids for weeks to months should taper by _____ per _______

Answer 21

10% per week

Question 22

When can opioids be safely stopped?

Answer 22

Once you get down to the lowest dose less than x1/day, then you can fully stop.

Question 23

Non-pharm therapy for chronic pain

Answer 23

Acupuncture - proven to help!
Tai Chi - proven to reduce LBP and helps with PTSD
Osteopathic Manipulation (OMT) - effective in short term for LBP, not studied long term. Low evidence for help with migraines.
Chairopractic manipulation - no supporting literature for LBP, migraines or neck pain.

Question 24

Other non-pharm measures for chronic pain

Answer 24

Bed rest (infrequent and limit to <48hours)
Heat/cold therapy,
TENS
Exercise therapy
Yoga.