TBL-Pain Clinical Correlates Flashcards by michelle granstrom

T/F Pain is often over-treated.

False. It is often under-treated

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T/F Psychological & emotional aspects of pain are always present.

True.

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T/F The nervous system is the system with the least plasticity.

False. It is very plastic.

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T/F The best treatment plans commit to one pain pathway, rather than trying multimodal treatments.

False. Multimodal treatments are the most effective.

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T/F With pain, it is important to take a comprehensive history of the pt.

Why yes, that is true.

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What is the definition of pain, according to the International Association for the Study of Pain?

“An unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of such damage, or both”

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What is an example of acute pain? What is chronic pain?

Acute pain examples–>surgery

Chronic pain is pain that persists past expected time of healing.

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Where does nociceptive pain come from?

nociceptors in skin, muscle, joints, and visceral tissues

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What causes neuropathic pain? What is an example of this?

primary lesion or dysfunction in the nervous system, ex- diabetic neuropathy

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What is the definition Falkenberg gave for sympathetic pain?

maintained pain- reflex sympathetic dystrophy. triad-sensory, autonomic and motor

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What is the example he gave as to what sympathetic pain looks like in a pt?

He said that one form of anesthesia (Bier Block) has the pt awake & cuts off blood flow to the area being operated on w/ a blood pressure cuff or something. They also inject some lidocaine into the area or something. Pretty soon, the appendage is numb & the pt can’t feel the surgery. About an hour in pts often complain about uncomfortable pain throughout the area but they can’t describe at all how it feels. Sympathetic pain.

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What is idiopathic pain?

poorly understood pain

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What is hyperesthesia? Which concept is it very similar to?

the idea of something that doesn’t normally provoke pain will provoke pain
this is similar to the concept of allodynia

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What is hyperalgesia?

an increased sensitivity to pain

something that might hurt a little before hurts a lot after.

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What is the phenomenon of windup?

this is the idea that you feel extra stimulation after a pain stimulus
Extra NT & fibers are recruited after the initial injury
this actually happens with almost every type of pain

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What are some examples of the plasticity of the nervous system?

windup etc.
NT can change
phenotype of neural fibers can change
sprouting can occur
glial cells are involved in pain, communication b/w cells

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Which drugs are considered first line of defense for pain?

NSAIDs
Tylenol
Adjuvants

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Which drugs are considered second line, pain out of control, for pain?

Opioids (sustained release & immediate release)

Maybe NSAIDs & adjuvants too

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Which drugs are considered third line, refractory pain, treatments?

Spinal/Epidural Opioids (maybe w/ clonidine & a local anesthetic)
Selective nerve blocks
Neuroablative Procedures
Ketamine
Total Sedation: trying to block windup & recruitment of more fibers.

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What are the major classes of analgesics?

NSAIDs
P-aminophenol
Opiates
Local Anesthetics

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What are some examples of NSAIDs?

ibuprofen
naproxen
ketoprofen
COX 2 inhibitors

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What is an example of P-aminophenol analgesic?

Tylenol!

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What are some examples of opiates?

morphine
oxycodone
fentanyl

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What is an example of a local anesthetic?

lidocaine

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What are some other up & coming classes of analgesics?

``` Calcium channel blockers- ziconotide Anticonvulsants Selective serotonin reuptake inhibitors Alpha-agonists Multi-receptor drugs- Tapentadol (NE) TRPV-1- antagonists ```

What are some drugs or treatments for pain management that target the cortex?

``` Anxiolytics Hypnotics Opioids Psychostimulants Anticonvulsants ```

What are some drugs or treatments for pain management that target the thalamus?

SSRIs | Anticonvulsants

What are some drugs or treatments for pain management that target the Spinal cord?

Opioids Adrenergic Agonists SSRIs MORE

What are some drugs or treatments for pain management that target the Peripheral Receptors?

NSAIDs | Local Anesthetics

What is something that targets b/w the spinal cord & peripheral receptors?

nerve block

So...often you get less systemic side effects of pain drugs if you can administer them close to where you need them to act...What are some different routes of administration of analgesics?

``` P.O.- oral I.V.- Intravenous P.R.- Rectal Sub. Q.- subcutaneous Transdermal Inhaled- aerosolized Nasal Epidural Spinal Transmucosal- sublingual lollipops Nerve Blocks ```

Describe some of the things that are triggered w/ the itch/scratch reflex.

1. the cortex is triggered-this tells you where on the body it itches 2. area of the brain that is associated with unpleasant sensations is also triggered * *itching is associated w/ a higher level of the brain than the reflex to remove your hand from a flame.

What is the main goal of treating acute surgical pain?

greatest pain relief with the fewest side effects

Why is it so important to treat surgical acute pain in patients?

it really helps speed their recovery | it improves their pulmonary & cardiovascular function & their mobility

What is preemptive analgesia & why is it a good idea?

this is where you giver the treatment before you even feel the pain. you prevent the recruitment of more nerve fibers, sprouting etc. If you do this, you get lower incidences of chronic pain. Ex: Give Tylenol in pre-op Put pt asleep with narcotics Ask surgeons to use long-actin local anesthetics before each cut at every level. Stop the nerves from even firing! this will last for like 12 hours! Give general anesthesia & an epidural. It is difficult to get insurance companies to cover all of this but this multimodal treatment plan prevents windup & is better for the pt.

What is additive & synergistic analgesia?

same idea as multimodal treatments that prevent windup

What is the idea behind patient controlled analgesia (PCA) or on-demand analgesia? Does it work with pediatric patients?

This is where you give the patient a pump that they can click for pain medication. It helps you to stay on top of the pain. It does work with pediatric patients, but you just have to be careful that the parents don't use it-->hit too many times or not enough.

What are the possible components of chronic pain?

nociceptive neuropathic sympathetic idiopathic

What is the goal of a multimodal chronic pain treatment plan?

not to completely get rid of pain, not complete analgesia | but to increase the pt's function

What are some temporal questions you want to ask with a pain hx?

onset duration daily variation

What are some intensity questions you want to ask with a pain hx?

pain on average least amount of pain use pain scales

What are some topography questions you want to ask with a pain hx?

focal multifocal deep superficial

What are some quality questions you want to ask with a pain hx?

aching throbbing burning stabbing

T/F It is important to ask about exacerbating & relieving factors in a pain hx.

TRUE of course : )

What are some pain scales that you can use with patients?

verbal pain intensity scale visual analog scale 0-10 numeric pain intensity scale faces pain scale

What are 2 common adjunct medications given to patients with chronic pain?

anti-depressants | anti-epileptics

Aside from anti-depressants & anti-epileptics what are other pharmacological adjunct drugs used?

``` Steroids Muscle relaxants Nerve blocks Epidural injections Spinal injections Clonidine ```

What is clonidine usu used to treat?

High BP | but it also seems to work well in the central system to alleviate pain

What are some non-pharmacological adjuncts used to treat chronic pain?

``` Physical Therapy Massage Acupuncture- gate theory? TENS units- (transcutaneous nerve stimulation) Vibration Biofeedback Psychological / behavioral therapy Radio frequency treatments ```

What are some reasons for under treating pain?

``` Misunderstanding of pain physiology Misunderstanding of pharmacology Side effects Fear of children/ elderly Fear of narcotics-addiction (doesn’t usu happen) Legal considerations ```

When they make narcotics...what do they do to prevent abuse?

they put an antagonist to the narcotic in the cap. If you take it orally, this won't affect the action of the drug. If you crush it up to inject it-->it will prevent it from working.

What are potential side effects that are feared from narcotics?

respiratory depression or apnea nausea, although this is easily treated w/ meds constipation

What is a drug given to counteract the constipation caused by opioids?

methylnaltrexone

A new drug that is being developed is adlea. What is its effect?

this is capsaicin | it inhibits TRPV1 receptors in certain doses

Bicifadine is a new drug being developed for pain. What is it?

inhibits norepi & serotonin reuptake

RTX is a pain med that acts on which receptor?

TRPV1 again!

What is CB2?

this is an up & Coming pain med that is a cannabinoid receptor agonist acts on glial cells

What are 2 other up & coming drugs for pain management?

P-saporin | IL-2/IL-10 activators

T/F In pain management, it is important to begin with a loading dose.

True.

What are some implantable devices you can use for pain treatment?

dorsal column stimulators | intrathecal pump

What can you do to kill ganglions in an attempt to reduce pain?

ganglion blocks neurotoxic meds ganglionectomy

What are some surgical things you can do as a last attempt to reduce pain?

``` Neurosurgical: ganglionectomy thalamotomy nerve decompression gamma knife Surgical: sympathectomy Warning: doing these things could eventually make the pain worse. ```