Workshop 9 - Chronic pain: focus on neuropathic pain & the place of opioids in chronic pain

Question 1

What is the biopsychosocial approach in pain management?

Answer 1

Cosiders the biological, psychological, and social factors that play a role in the treatment of pain.

Biological:
- gender
- physical illness
- disability
- Genetic vulnerability
- immune function
- neurochemistry
- stress reactivity
- medication effects

Psychology:
- Learning/memory
- Attitudes/ beliefs
- Personality
- Behaviours
- Emotions
- Coping skills
- Past trauma

Social context:
- Education
- Social/economic status
- Cultural traditions
- Family background
- Social supports

Question 2

What are nociceptive, neuropathic, inflammatory and nociplastic pain and how can they be differentiated in practice? Include common causes, signs and symptoms.

Answer 2

Nociceptive: pain due to activation of specialised sensory nerve fibres. Causes include sprained muscles, arthritis, kidney stones. Signs and symptoms; localised pain, sharp, stabbing, throbbing

Neuropathic: results from damage to nerves. Causes; injuried, diseases, infection. Signs and symptoms include; burning sensation, sudden, shrap, electric shock like pains, numbness, pins and needles

Nociplastic: Alterations in the processing of pain signals in the nervoius system. Common causes may include stress, anxiety, trauma, changes in the way the brain processes pain signals. Sings and symptoms include; widespread pain, undefines location, burning, throbbing, stinging, numbness

Inflammatory: results from inflammation or tissue damage

Question 3

How is neuropathic pain effectively managed?

Answer 3

1. Amytriptaline
   In frail and elderly:
   Start with 10mg in frail, elderly and increase in 10mg increments every 3-7 days to maximum
   of 50mg per day.
   In younger patients:
   Start with 10-25mg and increase in steps of 25mg every 3-7 days to 100mg maximum per
   day
   Managing side effects:
   To minimise morning sedation or hangover effects take at night or take medication 12hrs
   before the patient scheduled wake up time.
   Nortriptyline may be less sedating than amitriptyline; consider prior to amitriptyline in eldery
   patients.
2. Gabapentin:
   Start at 300mg at night and increase in 300mg increments at weekly intervals aiming for a
   dose of between 1200mg and 1800mg daily. Doses of up to 3600mg in 24 hours have been
   used, where beneficial and tolerated.
3. Pregablin:
   When no benifit seen with amytriptaline or gabapentin
   Start at dose of 75mg twice a day; Titrate up to a maximum dose of 300mg twice a day using
   the most cost effective preparation. (One capsule twice daily is always the most cost
   effective regimen).
   Dont take if pregnant

Question 4

What questions would you ask to identify neuropathic pain?

Answer 4

Can you describe your pain? Is it burning, shooting, stabbing, electric shock-like, tingling, or numbness

Where is the pain?