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Medicine Year 2 > Week 230 - Pain > Flashcards

Week 230 - Pain Flashcards

1
Q

What three elements are typical of ‘chronic pain syndrome’?

A

1) fatigue (sleep disturbance - query what causes their waking)
2) depression
3) huge impact on social and family life

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2
Q

What type of pain are these symptoms describing:

Stinging/tingling/electric shocks/ burning pain?

A

Neuropathic

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3
Q

How is neuropathic pain pathophysiologically different to nociceptive pain?

A 
Neuropathic = nerve damage which doesn't require nociceptor stimulation (can be stimulated by central or peripheral NS)
Nociceptive = detected by nociceptors and activation of pain pathways
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4
Q

What sort of relief does oromorph supply?

A

Short-acting, fast release

Not appropriate for chronic pain

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5
Q

Name 4 first line pharmacological treatments for neuropathic pain?

A

Gabapentin
Pregabalin
Amitriptyline
Duloxetine

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6
Q

Name 2 second line pharmacological treatments for neuropathic pain?

A

Tramadol or anti-epileptics (e.g. Carbamazepine)

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7
Q

Which of the following are non-opioids?
Codeine Morphine Paracetamol Naproxen Tramadol Fentanyl

Gabapentin Dihydrocodeine Ibuprofen Amitriptyline Oxycodone

A 
Paracetamol
Ibuprofen 
Naproxen 
Gabapentin (for neuropathic pain / epilepsy)
Amitriptyline (tricyclic AD)
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8
Q

What are the 3 steps on he analgesic ladder and what sort of pain is the ladder suitable for?

A

The WHO analgesic ladder is appropriate for nociceptive pain.

1) non-opioid +/- adjuvants
2) weak opioid + non-opioid +/- adjuvants
3) strong opioid + non-opioid +/- adjuvants

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9
Q

What is meant by an “adjuvant” analgesic?

A

A drug that was not initially intended to be used in the management of pain, but for other conditions such as depression and seizures

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10
Q

Give 4 different types of adjuvant analgesics

A 
Bisphosphonates
Steroids
Muscle relaxants
Antidepressants
Anticonvulsants
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11
Q

Give 2 weak opioid examples

A

Codeine

Dihydrocodeine

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12
Q

Is Tramadol a weak or strong opioid?

A

Moderate

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13
Q

Give 3 examples of strong opioids

A

Morphine
Oxycodone
Fentanyl

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14
Q

How does paracetamol act

A

Acts as analgesic and antipyretic
Largely unknown mechanism ?COX3
Minimal anitinflammatory effect

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15
Q

How much IM morphine is equal to 1g IV paracetamol?

A

10mg

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16
Q

What is the antidote to paracetamol poisoning?

A

N-acetylcysteine (acts against metabolite N-acetyl-p-benzoquinoneimine

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17
Q

Who should not have paracetamol?

A

Virtually no groups who cannot have!

Ok for those sensitive to aspirin and NSAIDs, children and elderly

18
Q

What drug is first line for treatment of Diabetic Sensory Neuropathic Pain?

A

Duloxetine (SSRI)

19
Q

What type of plaster/cream might you add if Duloxetine wasn’t effective in diabetic sensory neuropathic pain?

A

Capsaicin (though can cause strong burning pain on initial use which reduces its use clinically)

20
Q

Suggest some good medications for Phantom Limb Pain

A

Paracetamol
Tramadol
Perhaps MST
Amitriptyline to help sleep at night if worst through night

21
Q

Suggest possible management for Central Post-Stroke Neuropathic Pain

A

Meds: 1st line gabapentin, pregabalin, Amitriptyline or Duloxetine
2nd line anti-epileptic or Tramadol
Consider electrical stimulation to strengthen muscles, nerve blocks (suprascapular is shoulder subluxation) and psysio to realign legs if circumduction /equinovarus deformity

22
Q

If mixed nerve root L5/S1 and nociceptive pain and already in codeine sulphate, paracetamol and Tramadol PRN how would you manage?

A

Neuropathic agent: Amitriptyline or Gabapentin
Slow release opioid: Tramadol or codeine (should not be on both)
Consider nerve root block
Then physio e.g. Core strengthening and stability exercises
ONLY MAKE ONE CHANGE TO MEDS AT A TIME

23
Q

What sort of plaster might you use for post-herpatic pain e.g. Shingles?

A

Lidocaine 5% +/- capsaicin

On for 12 hrs, off for 12 hrs

24
Q

What is a common pattern for fibromyalgia (generalised pain) and how would you distinguish it from polyarthritis?

A

Previously high- achieving then life event which results in a loss of control
Differentiate from polyarthritis but enquire ping about location of pain, if not specifically in joints then NOT arthritis

25
Q

What does NICE suggest should be ruled out with migraine sufferers before pharmacological treatment begins. Which 3 drug types should then be tried before Botox injections considered?

A 
Ensure migraines are not caused by a current medication first 
Then try (in turn) beta blockers, high dose aspirin (or other NSAIDs e.g. Diclofenac Potassium / ibuprofen / naproxen) and 'Tripans' (5HT-1 agonists)
26
Q

Which group of drugs are COX2-selective? What is the main advantage and disadvantage of their use over the more (not entirely selective) COX1 selective NSAIDs?

A

The “-coxib” meds
Advantage is reduced adverse GI effects
Disadvantage possible higher risk or MI

27
Q

What is the major difference between COX1 and COX2 enzymes?

A

COX1 produces “house-keeping” prostaglandins e.g. PgI2 (upper GI) and PgE2 (kidney prostaglandins) which stim. mucus production and regulate gastric acid and water excretion.
COX2 produce PGs for inflammatory response stim by inflam cytokines and GFs (part of immune response)

28
Q

If any risk factors for GI adverse effects with NSAID mx what should you do?

A

Prescribe a PPI also

29
Q

Which NSAID has least thrombotic risk?

A

Naproxen

(By that means most balanced between not causing GI bleeds/ulcers - as aspirin and ibuprofen do and not increasing CV risks - as -coxibs do)

30
Q

List 5 beneficial effects of opioids

A

Analgesia
Euphoria
Cough suppression
Sedation and antidiarrohoeal activity (could both potentially be adverse)

31
Q

Besides opioid effects what other actions does Tramadol have therapeutically and what does this implicate in case of OD?

A

Stimulation of serotonin
Inhibits reuptake if noradrenaline
Naloxone only partially reverses its analgesic action

32
Q

Why is diamorphine more likely to be abused than morphine?

A

Faster onset and shorter acting

Hence methadone used in withdrawal programmes as long acting

33
Q

Which strong opioid has affinity for all 3 opioid receptor types (Mu, Delta and Kappa)?

A

Oxycodone

34
Q

Why is buprenorphine also good in withdrawal programmes?

A

No euphoric effect

35
Q

If strong opioid necessary which is most appropriate to start with?

A

Morphine (oral route whenever possible)

36
Q

What adjuvants would you use with bone pain and muscle spasm?

A

Bone pain - bisphosphonates

Muscle spasm - baclofen

37
Q

Which anti-epileptics Re appropriate for use in pain management?

A

Gabapentin and Carbemazepine

38
Q

What would NiCE recommend over Gabapentin? Why do other groups disagree?

A

Pregabalin

Gabapentin is cheaper

39
Q

What side effects might you get from Amitriptyline used as pain mx adjunct?

A

Drowsiness
Arrhythmias
Blurred vision
Dry mouth

40
Q

What type of drug is ketamine? What is it used for in paeds and why might clinicians avoid its use in analgesia?

A

NMDA receptor antagonist
Anaesthesia in paeds
Psychotropic SEs inc: hallucinations and amnesia

41
Q

What constitutes chronic pain?

A

Generally >3-4 months

“That which lasts longer than healing process”

Medicine Year 2 (28 decks)

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