Week 12 - Chronic Pain and Ways of Management Flashcards
What is pain
A sensory and emotional experience with actual or potential tissue damage
Pain can be described in many ways:
1. Neuropathic = nerves affected (shooting / tingling pain)
2. Noiciceptive = tissues affected (sharp, throbbing, ache)
- can be somatic (soft tissue / m.skeletal) or visceral (internal organs)
3. Nociplastic = pain pathway is altered / no evidnec of damage
4. Acute or chronic
5. Primary (has no reason / underlying cause for pain)
6. Secondary (has underlying cause)
- treatment based on targeting this cause
Primary and secondary pain can exist together
What is the WHO pain ladder
Step 1 (MILD PAIN) = non-opioids
- paracetamol
- ibuprofen, aspirin, other NSAIDs
Step 2 (MODERATE PAIN) = weak opioids
- codeine
- tarmadol
Step 3 (SEVERE PAIN) = potent opioids
- morphine
- fentanyl
- oxycodone
- buprenophine
Can also ADD IN ADJUVANTS (in all steps)
- Anti-depressants
- e.g. TCA and SSRI
- Anticonvulsants
- e.g. pregablin
- corticosteroids
- to reduce inflamttion associated with pain
- ketamine
- can get hallucinations as it dissacoiates you from pain
- topical agents (NSAIDs, anaesthetics etc.)
- anxiolytics
- Benzodiazepine
- it reduces anxiety, helps you sleep
- relaxes muscle (which may be adding to pain)
What is Chronic Pain - NICE
Pain thats last >3 months
- diagnsosis requires investigation + clinical judgement
- ICD definition - is pain in one or more anatomical regions whcih causes significat emotional distress or functional disability, many factors contibute to primary pain
Have 2 types of pain:
1. Primary (no clear cause OR unprroportionate response)
2. Secondary ( has underlying condition causing pain)
3 Most common types:
- Back pain, Headache and Joint pain
What are the 4 types of primary chronic pain
Types of chronic primary pain:
- Visceral pain - internal central region of body
- Somatic pain - musculoskeletal pain (muscles, bone, joint)
- Headache
- Widespread pain - 4 or 5 regions
What are the 6 types of secondary pain
- Cancer related
- Neuropathic
- Post surgical / post-traumatic
- Secondary headache (e.g. migraine)
- Secondary visceral (e.g. IBS, endometriosis)
- Secondary somatic (musculoskeletal e.g. arthiritis)
How to asses chronic pain (primary and secondary)
- Person-centred assessment
- how pain impacts their life
- identify factors which may contribute to pain
- shared decision making (explain benefits, risks of diff. treatment options)
- give advice + info. on how they can manage it + improve QoL
- develop care + support plans (with person, family, carer to meet set goals) - Identify cause of pain
- primary or secondary
- injury or disease - Impact of pain (gain more info.)
- impact family life, day to day activities
- impact physical + psychological well-being, relationships
- consider socioeconomic status, ethnicity, age
- acknowlege that they’re in pain, don’t invalidate their feelings
How to manage primary chronic pain: non-pharmacological - NICE guidelines
- Start with Non-pharmacological options
1. Excercise programmes: 2-3 months (short-term)
- encourage patient to carry on doing excercise learnt in supervised groups
- excercise can ↓ pain + ↑ QoL (has both short and long-term impacts) - Psychological Therapy
1. Acceptance and commitment therapy (ACT) - helps you accept you have pain + to live with it
- MOST effective: ↑ QoL, sleep, pain + distress
2. Cognitive behaviour therapy (CBT) - finding ways to cope with whats going on
- ↑ QoL
(risk of harm is minimal for both) - Acupuncture (dry needling)
- NO more than 5 hours (repeated courses dont have any benefits)
- MUST be in community by approptiate HCP
- short-term; ↓ pain (up to 3 months) then can do more long term options like excercise / therapy
OTHER:
Pain management programme (PMP)
Delivered with aseries of group sessions
- ↑ QoL BUT doenst reduce pain
- just advice on how to cope with pain; excercise, relaxtion, midfulness, group discussions
How to manage primary chronic pain: pharmacological - NICE guidelines
6 Anti-depressants
Anti-depressant
- For 18+ (16-17 need specialist advice)
- Takes 2-3 weeks to kick in (review in 4-6 weeks)
- Has many side effects at start
- ↑ risk of withdrawal the longer you are on it
- ↑ QoL, pain, sleep and distress (even without depression)
- PROBLEM: can have low sodium (with SSRis / SNRIs)
- need to do many blood tests to monitor
NOTE: NO evidence that adjuvants (in WHO pain ladder) will help treat primary chronic pain
- opioids, analgesics etc. no longer recommeneded as treatment by NICE
1st Line anti-depressants:
1. Amitriptyline
- blocks reuptake of seretonin + noradrenaline at pre-synaptic terminals
- has most anti-cholinergic side effects e.g. dry mouth, drowsiness
- start with lowest dose possible (5-10mg) then gradually ↑ dose
2. Citalopram
- 20mg daily, cheapest
3. Duloxetine
- 60mg most expenisve, has most benefit, less anti-cholinergic effects
OTHER OPTIONS
4. Fluoxetine
- 20mg daily
5. Sertraline
- 50mg daily
6. Paroxetine
- 20mg daily
NOTE: need to look at local guidelines
How to manage primary chronic pain: folowing up - NICE guidelines
6 Anti-depressants
- If patient has been taking treatment for primary pain that is no longer recommened by NICE (opioids, adjuveants):
- use shared decision making to agree on a new shared plan
- if report benefit of the medicine agree a plan to continue safely
- if report lack of benefit explain risks of continuing + encouraging reducing / stopping medicine i.e. develop a staged reduction plan
- explore other options
- discuss withdrawal symptoms - If taking analgesics or pain or comobidities alter:
- check for adverse effects
- adjsut dose or discontinue drug
- confirm need + effectiveness of drug
- review patients using anti-depressants regularly to ensure benefits outweigh risks
Requires multiple consultations
Provide patients with resources e.g. my pains concerns form, charities
How to manage secondary chronic pain - NICE guidelines
Treated according to its own NICE guideline
e.g. if pain is caused by arthirits treat according to arthiritis guidelines
What is Fibromyalgia
Long term conditon causing widespread pain (chronic pain all over body)
- CAUSE: malfunctioning CNS
- ↑ pain perception + ineffective pain inhibiton
- TRIGGERS: physical (infection/injury) + emotional (stress)
- TREATMENT: excercise, anti-depressants, physcological therapy
- can have genetic links
- more common in women
- develops between 25-55
- Multiple body regions affected
- Widespread pain; increasd sensitivity to pain, stifness, anxiety/depression, digestive issues
- No inflammation
- Symptoms can change
- Difficult to diagnose
- have no specific tests
- DIAGNOSIS: min. 4-5 regions affected, pain scores, >3 months
