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NUR2229 > Week 6 > Flashcards

Week 6 Flashcards

1
Q

Choice of medication

A

Based on underlying pain mechanisms
* Acute pain: regulated by the opioidergic system
* Persistent pain: associated with a neuropathic component where central sensitisation requires:
– a reduced role of opioids
– an increased contribution of adjuvant/other types of medications

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2
Q

Adjuvant Agents

A
  • Used as supplements to make analgesics more effective,
    or
  • As distinct primary therapy in certain painful conditions.
  • May reduce opioid side effects by reducing the dosage used to obtain acceptable pain control.
  • May also control symptoms and reduce analgesic requirements.
    *Amitriptyline (Tryptanol)
    *Carbemazepine (Tegretol)
    *Pregabalin (Lyrica)
    *Gabapentin (Neurontin)
    *Diazepam (Valium)
    *Dexamethasone
    *Imipramine (Tofranil)
    *Phenytoin (Dilantin)
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3
Q

Paracetamol

A
  • Effective analgesic for Mild‐moderate pain
  • Oral, IV, PR
  • Soft tissue and musculoskeletal origin
    Also:
  • Supplementation of opioids when managing moderate
    to severe pain with opioid sparing effect
    Evidence for effects on various central mechanisms:
  • prostaglandin production
  • serotonergic, opioid, nitric oxide (NO) & cannabinoid
    pathways
  • probable combination of interrelated pathways
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4
Q

Non‐Steroidal Anti‐Inflammatory Drugs (NSAIDs)

A

Mild‐to‐moderate pain
* Muscular‐skeletal inflammation and tissue injury e.g.
* Muscular aches
* Tissue sprains
* Osteoarthritis
* Rheumatoid arthritis
* Low back pain
* Headache

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5
Q

NSAIDs non selective

A
  • Ibuprofen (Nurofen - oral)
  • Naproxen (Naprosyn - oral)
  • Diclofenac (Voltaren - oral)
  • Indomethacin (Indocid -
    oral/PR)
  • Ketorolac (Toradol - IM / IV)
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6
Q

NSAIDs cox-2 specific

A
  • Celecoxib
    (Celebrex – Oral)
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7
Q

NSAIDs long acting

A
  • Meloxicam (Mobic - Oral)
  • Preferential but not Cox 2
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8
Q

Opioids

A
  • Moderate to severe pain: acute or persistent
  • Act as agonists at receptor sites in the brain,
    spinal cord and other sites outside of the CNS
    3 Primary receptors:
  • mu (μ), delta (δ) and kappa (Ќ)
  • Analgesia is mediated mainly via the μ receptor
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9
Q

Opioids types

A

Morphine: most commonly used, various routes
* Fentanyl: rapid action; strong; various routes
* Oxycodone: oral; used as a step down agent from IV opioids
* Hydromorphone: 5 x potent as morphine; various routes
* Methadone: oral, long action; for persistent pain
* Pethidine: less used, offers no advantage over other opioids
* Codeine: oral with other drugs e.g. paracetamol
* Buprenorphine: SL, IM, SC, TD; long action

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10
Q

Tramadol

A
  • Synthetic, weak mu opioid receptor agonist
  • Enhances noradrenergic (40%) and serotonergic (20%)
    inhibition
  • Reduced incidence of respiratory depression
  • Lower abuse potential
  • Less constipating
  • Oral/parenteral
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11
Q

Ketamine

A
  • NMDA antagonist (N‐methyl‐D‐aspartate)
  • Dissociative anaesthetic agent
  • Ketamine treatment effective for relief of
    postoperative pain
  • For acute and persistent pain
  • Often used with an opioid for improved analgesia
    & opioid sparing
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12
Q

Cannabis

A
  • Cannabinoid and endocannabinoid systems: special
    receptor molecules embedded in the brain and neural
    pathways.
  • The receptors influence the flow of chemical signals to
    the brain.
  • Cannabinoids bind with the endocannabinoid
    receptors, suppress signals such as pain, nausea and
    depression, boost signals of appetite and euphoria.
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13
Q

Anticonvulsants

A

Example: Gabapentin or Pregabalin
- Modulates neurotransmitter release by binding to voltage
gated Ca++ channels
- Closes pre-synaptic Ca++ channels
- Diminishes excessive neuronal activity and neurotransmitter
release
- Used for neuropathic pain, post-heretic neuralgia, diabetic
neuropathy, fibromyalgia

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14
Q

Antidepressants

A

 Can exert their analgesic action without any effects on mood
in patients with persistent pain
 Lower dose and shorter delay to achieve optimal analgesic
action than required for antidepressant action
 Central blockade of serotonin and noradrenaline reuptake
process.
 Category includes: tricyclic antidepressants (TCAs),
selective serotonin reuptake inhibitors (SSRI) and serotoninnorepinephrine reuptake inhibitors (SNRIs).

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15
Q

MORNRI: Tapentadol

A

 Mu-opioid receptor agonist (MOR)/noradrenaline
reuptake inhibition(NRI) (MOR-NRI)
 Both mechanisms contribute to the analgesic activity
to produce analgesia in a synergistic manner
 Relatively moderate activity at the two target sites is
sufficient to produce strong analgesic effects.
 Used for both nociceptive and neuropathic pain

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16
Q

Local anaesthetic

A

Lignocaine
 Relieves pain by acting directly on damaged pain fibers under the patch
 Reduces aberrant firing of sodium channels.
 Lignocaine patches are generally safe and lack systemic side effects.
 Effective in PHN, post-stroke pain and complex regional pain syndrome (CRPS)

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17
Q

Capsaicin

A

 Capsaicin is an alkylamide found in capsicum
 Selectively stimulates primary afferent C fibers.
 These C fibers express TRV1, capsaicin receptors that
nonselectively gate cations, including Na+ & Ca++ which
depolarize axons.
 Primary mechanism is depletion of substance P:
neuropeptide involved in the transmission of pain signals
 Pain relief is not instantaneous: cumulative depletion of
substance P over a period of weeks brings full effect

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18
Q

Balanced analgesia

A
  • Class of medication used should be determined by
    the pathology of the pain and effect of Tx
  • The medication is optimised with dosage and timing:
    –Pre‐emptive
    –Regular analgesics
    –Break through analgesics
  • Note: treat side‐effects promptly
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19
Q

WHO: Pharma treatment strategy

A

 Underlying cause of pain should be treated whenever
possible
 Individualised therapy
 Use a systematic approach
- a two or three step strategy
 Oral administration in most patients with persistent
medical illness
 Regular administration of analgesics (“by the clock”)
combined with a rescue strategy for breakthrough and
intermittent pain
 Monitor and evaluate for therapeutic and adverse
effects
 Need to prevent/limit unwanted effects

20
Q

WHO guidelines

A

 non‐pharmacological
 non‐opioid medicines
 opioid analgesics
 co‐analgesics and
adjuvant medicines
 rescue doses
 routes of administration
 efficacy
 safety (including risks)
 cost effectiveness
 limitations
 benefits
 side effects and their
prevention

21
Q

Administration modalities

A
  • Oral
  • Rectal
  • Intermittent IM or SC injection
  • Transdermal
  • SC infusion
  • IV infusion
  • Patient Controlled Analgesia (PCA)
  • Epidural
  • Intrathecal
  • Other regional technique
22
Q

Acute pain

A

Various modalities
* Patient‐controlled analgesia
* Epidural and intrathecal analgesia
* Other regional analgesic procedures
* Continuous infusions of opioids, local anaesthetics,
ketamine and other drugs
* Limited trajectory: healing process
* An individually tailored approach
Predominantly nociceptive pain:
* Paracetamol/NSAIDs
* Opioids
* Adjuvant drugs
* Non‐pharmacological & psychological intervention

The following groups may have special needs that require particular
attention:
* Children
* Pregnant patients
* Elderly patients
* Aboriginal and cultural groups
* non‐English speaking people
* Patients with cognitive behavioural and/or sensory impairments

23
Q

Management Plan: Three phases

A
  • Assessment
    – History and physical examination +/‐ further investigations
  • Management
    –Discuss pain management options
    –Provide information, assurance and advice encouraging
    return to normal activity
  • Review
    –Reassess and revise
24
Q

Consider patient co‐morbidities

A
  • Age
  • Renal or liver impairment
  • Opioid tolerance
  • Substance abuse
  • Respiratory compromise
  • Insulin dependent diabetes
  • Cardiac Disease
25
Q

Persistent pain treatment

A
  • Pain is often multifactorial, includes both nociceptive
    and neuropathic pain
  • Requires a multimodal approach (MMA): includes
    pharmacological and non‐pharmacological therapy
  • MMA should be based on the underlying mechanisms of
    the disease or condition
  • Like acute pain, individualised approach offers best
    opportunity for pain reduction and control
26
Q

Rationale for multi‐modal medications

A

Target multiple mechanisms of pain conditions, addressing both
nociceptive and neuropathic components of pain
* Two or more agents can be used in lower doses, reduces risk of
treatment‐related side effects
* Opioids:
– potent analgesic activity against nociceptive components of pain
– less effective against neuropathic pain
* Antidepressants
– Offer activity against neuropathic pain components

27
Q

Tailoring treatment

A

 Patient involvement
 Regular assessments of adequacy of analgesia
 Any adverse effects noted/documented
 Re-assessment of pain & effect of intervention
 Trial of other interventions if needed

28
Q

Complementary/Alternative Medicine

A
  • Therapeutic modalities or activities to augment
    orthodox approaches (western medicine)
  • The term alternative therapies infers that they
    are outside of traditional medicine
  • Complementary therapies are becoming more
    widely used in health care
29
Q

Principles of CAM

A
  • The human body‐mind can promote healing
  • Energy is crucial to the body to repair itself
  • Whole person treatment – health depends upon physical,
    personal, social and environmental factors
  • Illness affects the whole person
  • Underlying cause and predisposing factors are important
  • Therapies should not cause harm but be supportive
30
Q

CAM = Person‐centred care

A
  • Seeks to treat the whole person, rather than a
    particular disease process
  • Includes consideration of the person’s social
    and environmental factors
  • Complementary therapies may assist with
    provision of holistic approaches to care
31
Q

Classifications of CAM

A

Whole medical systems:
– e.g. Traditional Chinese Medicine
* Mind‐body medicine:
– e.g. meditation
* Biologically based practices:
– e.g. herbs, vitamins
* Manipulative and body‐based practices:
– e.g. chiropractic, massage

32
Q

Acupuncture

A
  • Ancient Chinese medical procedure involving insertion
    and manipulation of needles
  • Believed to stimulate secretion of endorphins,
    serotonin, and noradrenaline in the CNS
  • Potentially also works by constricting or dilating
    blood vessels due to release of vasodilators
    such as histamine.
33
Q

Cognitive Therapies

A

The aim of the therapy is
* To alter
a person’s belief system and modify
undesirable behaviour patterns and perceptions
* To encourage the formation of behaviours and
attitudes that are well adapted and productive in order
that problems can be eliminated

34
Q

CBT

A
  • A psychological technique that can be taught to patients to reframe thoughts and change the pattern of
    thinking:
  • Identify negative thoughts and then change them
  • Studies of CBT for distress and pain in patients with breast cancer have shown significant improvements in these symptoms
  • CBT interventions are usually aimed at reducing the distress or threat value of pain
  • Enhancing a patient’s sense of their own ability to cope with pain.
  • Coping usually refers to acceptance of pain rather than pain control or relief.
35
Q

CBT requirements

A
  • Define specific and concrete goals for functional activities and moods
  • Identify steps towards achieving desired goals
  • Consistently reinforce efforts towards goal achievement
  • Actively involve the patient in:
    – selecting their goals and monitoring progress
    – identifying and modifying unhelpful patterns of thought and behaviour
36
Q

Hypnosis

A

 Creates a trancelike state that resembles normal sleep
during which perception and memory are altered
 Results in increased responsiveness to suggestion.
 For example, may be used for
* burns dressings
* assistance with childbirth pain
* preparation of patients for surgery

37
Q

Nutrition

A
  • Protein required
    – Specific amino acids for neurotransmitters
    – tissue building and maintenance, e.g. muscles
  • Reduce sugar and starchy carbohydrates
  • May need to review certain foods e.g. arthritis and
    nightshade family, such as eggplant, capsicums
  • Opioids and constipation: increase fibre & hydration
  • Vitamin D: muscle weakness
38
Q

Herbal/other medicines

A
  • Neuropathic pain
  • Capsaicin
  • Rheumatoid Arthritis
  • Gamma linolenic acid (GLA): evening primrose oil
  • Osteoarthritis
  • Fish oils/Krill oil
39
Q

Massage Therapy

A
  • Touch is the most instinctive response to pain.
  • Used as
    a form of therapy for thousands of years
  • A systematic, therapeutic stroking and kneading of the
    soft tissues of the body.
    Modalities vary:
  • Some focus on the physical effects that the massage
    techniques have on the body
  • Others focus attention on the flow of ‘energy’ within
    the body
40
Q

Massage

A
  • Stimulation of the body surface can have a corresponding
    effect on various organs and systems:
    – relaxation of voluntary muscles
    – sedation of nerve sensors
    – improved blood circulation to the area
  • Endorphins are also released
    – Help to counter the sensation of pain
    – Give a feeling of well‐being and relaxation
41
Q

Meditation/mindfulness

A

Principle: if you can calm and focus your mind and body, you
may be able to control your pain and degree of feeling
Major study:
* USA:
8 week program for chronic pain showed moderate to
great improvement over long term:
> four years
* “mindfulness meditation training significantly reduce[d] pain
unpleasantness by 57% and pain intensity ratings by 40%
when compared to rest” (Zeidan et al., 2011).

42
Q

Music therapy

A
  • The use of certain music to divert attention from pain
    and to promote a sense of relaxation and well‐being.
  • Evidence:
  • reduced pain intensity and opioid requirements in
    the peri‐operative period/after surgery
  • anxiety and pain reduced in children undergoing
    medical and dental procedures
43
Q

Spinal and joint manipulation

A

Includes massage, stretching and joint manipulation
Used by:
* Chiropractors
* Osteopaths
* Physiotherapists
* Used to treat a range of musculoskeletal problems
* E.g. low back pain

44
Q

Transcutaneous Electrical Nerve Stimulation

A
  • Electrical stimuli on the skin preferentially activate low‐
    threshold, myelinated nerve fibres
  • Inhibits nociception by blocking transmission along
    fibres to the dorsal horn
  • low back pain
  • arthritic pain
  • visceral pain/postsurgical pain
  • Delivery/labour pain
45
Q

Yoga

A
  • Ancient practice using physical postures to obtain
    harmony of mind, body and spirit
  • Shifts balance of the autonomic nervous system from
    the sympathetic to parasympathetic response
  • Strengthen weak muscles and increase flexibility
  • Improve oxygenation to body tissue
  • Help support the musculoskeletal system
  • Regular practice may bring about benefits, including:
  • increased oxygenation of the blood
  • muscle toning throughout the body
  • a clearer and more relaxed mind
  • improved posture
  • improved circulation of blood and lymph
  • regulation of bodily functions
46
Q

Acute pain: PQRST/OPQRSTUV

A
  • P = Provocation/Palliation
  • Q = Quality/Quantity
  • R = Region/Radiation
  • S = Severity Scale
  • T = Timing
  • O = Onset
  • P = Provocation/Palliation
  • Q = Quality
  • R = Region/Radiation
  • S = Severity Scale
  • T = Treatment
  • U = Understanding impact
  • V = Values
47
Q

Other pain tools

A
  • Behavioural Pain assessment scale
  • Functional assessment: The Physical Functional Ability
    Questionnaire
  • Pain Catastrophising scale
  • PASS: pain anxiety symptom scale
  • DN4: neuropathic/nociceptive discrimination
  • Chronic pain grade: pain activity questionnaire

NUR2229 (6 decks)

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