WEEK 6 Pain Management Flashcards
Identify 5 principles for optimal pain management
- Balanced analgesia
- Dosage and timing
- Consider patient co morbidities
- Utilise administration modalities
- Tailor treatment
Describe the concept of balanced analgesia (Principle for optimal pain management)
Class of medication should be determined by the pathology of the pain and the effect
Describe the concept of dosage and timing (Principle for optimal pain management)
Pre emptive (Don’t wait until they tell you they are in pain)
Regular analgesia
Break through analgesics
Treat side effects promptly
Describe the concept of considering co morbidities (Principle for optimal pain management)
Age, opioid tolerance, substance abuse, respiratory compromise
Describe the concept of tailoring treatment (Principle for optimal pain management)
Patient involvement, regular assessments of adequacy of analgesia, reassessment of pain
Describe acute pain in terms of pain management
Limited trajectory (Healing process), individually tailored approach, predominantly nociceptive pain
Describe persistent pain in terms of pain management
Often multifactorial, neuropathic and nociceptive, requires multimodal approach, individualised approach
Identify 3 populations why may require particular attention within pain management
Children
Pregnant patients
ATSI/CALD groups
Outline the components of the biopsychosocial model in terms of pain management
BIO: Assess for changes/injury in physical body
PSYCHO: Address anxiety/stress
SOCIAL: Consider social situation/home environment
Outline the 3 components of a pain management plan
- Assessment (History, Physical exam, further investigations)
- Management (Pain management options, information, assurance and advice encouraging normal activity)
- Review (Reassess and revise plan)
Identify the 3 WHO strategies
- WHO: Pharmacological Treatment Strategy
- WHO: Guidelines for pain management
- WHO: Analgesic Ladder
Describe the WHO: Pharmacological Treatment Strategy
Underlying cause of pain should be treated where possible , Individualised therapy, use a systematic approach (Ladder)
WHO: Guidelines for pain management
Non pharmacological approach first, non opioid medicines first, co analgesics and adjuvant medicines
Describe the WHO: Analgesic Ladder
Idea is that you start from the bottom and build up as required
Describe step 1 of the WHO: Analgesic Ladder
Non opioids (With or without adjuvants), Non pharmacological approaches and or Paracetamol
Describe step 2 of the WHO: Analgesic Ladder
Weak opioid (With non-opioid) (With or without adjuvants) NSAID and/or oral opioid
Describe step 3 of the WHO: Analgesic Ladder
Strong opioid and non-opioid (With or without adjuvants) with increased dose of oral opioid or an IV/IN Fentanyl
Discuss how choice of medication should be made
Based on underlying pain mechanisms
Acute pain: Regulated by opioidergic system
Persistent pain: Associated with neuropathic componenet were central sensitisation requires a reduced role of opioids/increased contribution of adjuvant
Identify the recommended medications for nociceptive pain
NSAIDS and Opioids
Identify the reccomended medications for neuropathic pain
1st line: Antidepressants, anticonvulsants and topical agents
2nd line: Opioids
Describe simple analgesics for pain management
Paracetamol for soft tissue/musculoskeletal origin and NSAIDS for muscular skeletal inflammation and tissue injury
Identify the 3 types of NSAIDS with example for each
NON selective: Ibuprofen
COX-2 Specific: Celecoxib
Long Acting: Meloxicam
Describe opioids for pain management and an example
For moderate to severe pain, 3 primary receptors (Mu, Delta and Kappa), morphine and oxycodone
Describe Tramadol for pain management
Opioid receptor agonist, Enhances noradrenergic and serotonergic inhibition, less constipating
Describe Ketamine for pain management
NDMA Antagonist, for acute and persistent pain, post op pain effective
Describe Cannabis for pain management
Bind with endocannabinoid receptors and suppress signals such as pain, nausea, depression and boost appetite, euphoria
Describe anticonvulsants for pain management and an example
Used for neuropathic pain, fibromyalgia, modulates neurotransmitter release e.g. Pregablin
Describe Antidepressants for pain management
Can exert analgesic action without any effects on mood in patients with persistent pain
Describe Tapentadol for pain management
Mu opioid receptor agonist/Noradrenaline reuptake inhibition (MORNRI), used for nociceptive and neuropathic pain, contribute to analgesic activity
Describe Adjuvant agents for pain management
Meds that are not typically used for pain but may be helpful for its management. They have a primary indication other than pain. Used to make analegsics more effective e.g. Diazepam
Describe Local anaesthetic agents for pain management
Relieves pain by acting directly on damaged pain fibres under the patch, e.g. Lignocaine
Describe Capsacin for pain management
Depletion of substance P = decreased transmission of pain signals, period of weeks brings in full effect
Describe topical agents for pain management
Applied directly to the skin
Describe the rationale for multimodal analgesia
Target multiple mechanisms of pain conditions, used to lower risk of treatment related side effects
Describe the use of a multimodal approach for persistent pain management
Aim is to help patients improve functionality and to promote patient responsibility for managing disease
What may be required to achieve optimal pain management
- Peripheral stimulation and interventional activity e.g. accupuncture
- Active physiotherapy and movement therapy
- Psychological therapy (relaxation, CBT)
- Education of patient and relatives
Identify 3 aspects of non pharmacological measures for pain management
Environment: Controlling stimulus e.g. loud noise
Physical comfort: Distraction, heat pack
Emotional elements: Empathy
What are complementary and alternative therapies used for?
Therapeutic modalities used to augment orthodox approaches e.g. western medicine
Define alternative therapies
Therapies used outside of traditional medicine
Define Complementary Alternative Medicine (CAM)
Diagnosis, treatment and/or prevention that complements mainstream medicine by contributing to a common whole
Identify 3 principles of CAM
Human mind body can promote healing
Illness affects the whole person
Therapies should be supportive not cause harm
Identify the 4 classifcations of CAM
- Whole medical systems e.g. Traditonal chinese medicine
- Mind body medicine e.g. meditation
- Biologically based practice e,g, herbs, vitamins
- Manipulative and body based practices e.g. Chiropractor, massage
Describe Accupuncture (CAM)
Ancient chinese medical procedure involving insertion and manipulation of needles, believed to stimulate endirphins, serotonin and noradrenaline in CNS
Describe Cognitive Therapies (CAM)
Aim is to alter a persons belief system and modify undesirable behaviour patterns/perceptions
Describe CBT (CAM)
Cognitive Behavioural Therapy, helps to reframe thoughts and change patterns of thinking, usually aimed at reducing stress or threat value of pain and enhancing ability to cope with pain
Define coping in CBT (CAM)
Acceptance of pain rather than pain control or relief
Identify 3 requirements of CBT
Identify steps towards achieving goals, consistently reinforce efforts towards goal achievement, actively involve patient in process of modifying thoughts
Describe Hypnosis (CAM)
Creates a trancelike state that resembles normal sleep during which perception and memory are altered, resulting in increased responsiveness to suggestion e.g. burns dressings
Describe Nutrition (CAM)
Protein required, reduce sugar and starchy carbs, may need to review certain foods, vitamin D and opioids and constipation = Increase fluids and fibre
Describe Herbal/other medicines (CAM)
Capsacin (neuropathic pain), fish oils for OA
Describe Massage therapy (CAM)
Relaxation of voluntary muscles, sedation of nerve sensors and improved circulation to area, endorphins are also released = feeling of relaxation
Describe Meditation (CAM)
If you can calm and focus your mind, you may be able to control your pain and degree of feeling
Describe Music therapy (CAM)
Used to divert attention away from pain to promote relaxation and wellbeing = Reduced pain intensity and opioid requirements
Describe Spinal and Joint Manipulation (CAM)
Massage, stretching and joint manipulation used by chiropractors etc.
What does TENS stand for?
Transcutaenous Electrical Nerve Stimulation
Describe TENS machine (CAM)
Electrical stimuli on the skin preferentially activate low threshold myelinated nerve fibres inhibiting nociception by blocking transmission along fibres to dorsal horn
Describe Yoga (CAM)
Uses physical postures to obtain harmony of the mind body and spirit, shifts balance from sympathetic NS to parasympathetic NS, improve oxygenation to body tissues, clear and relaxed mind
