Understanding The Causes of Pain and Pain Management
Summary
TLDRThis educational video delves into pain management, distinguishing between acute and chronic pain and emphasizing the importance of following local guidelines and consulting specialists. It covers the sensory and affective aspects of pain, the physiology of pain transmission, and the complexities of pain perception. The script also discusses methods for measuring pain, the WHO analgesic ladder, side effects of analgesics, opioid use in palliative care, and strategies for managing chronic and neuropathic pain, including the DN4 questionnaire and first-line treatments.
Takeaways
- 💊 The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
- 🩹 Pain is categorized into acute (new onset) and chronic (lasting more than three months), with management guided by local protocols and specialist advice.
- 🧠 Pain consists of sensory (physical sensation) and affective (emotional reaction) components, and it is subjective, meaning that individual experiences of pain must be respected.
- 🔍 Pain can be measured using the Visual Analog Scale (VAS) or Numerical Rating Scale (NRS), with chronic pain being defined as pain persisting or recurring for more than three months.
- 📉 The WHO analgesic ladder suggests starting with non-opioids for mild pain, progressing to weak opioids for moderate pain, and strong opioids for severe pain.
- 💥 Neuropathic pain arises from nerve damage or abnormal nerve function and can present with burning, tingling, or electric shock sensations.
- 🧪 Chronic pain is multifactorial, influenced by biological, psychological, and social factors, and can be primary (without an identifiable cause) or secondary (with an underlying condition).
- 🧬 Treatment for neuropathic pain includes medications like amitriptyline, Duloxetine, Gabapentin, and Pregabalin, with other options like Tramadol for flares and Capsaicin cream for localized pain.
- 💉 Post-operative analgesia is critical for patient recovery, often involving a combination of regular paracetamol, NSAIDs, and opioids, with analgesia started in theater by the anesthetist.
- 🔄 Opioid conversion is essential for safe dosing, with approximate conversions provided in the script (e.g., 10 mg oral morphine ≈ 100 mg oral codeine).
Q & A
What is the definition of pain according to the International Association for the Study of Pain (IASP)?
-The IASP defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
What are the two main categories of pain?
-The two main categories of pain are acute pain, which is a new onset of pain, and chronic pain, where the pain has been present for three months or more.
Why is it important to distinguish between acute and chronic pain when managing it?
-It is important to distinguish between acute and chronic pain because different management strategies and approaches may be required for each type, and the duration and nature of the pain can influence treatment options.
What are the two aspects of the experience of pain?
-The two aspects of the experience of pain are the sensory experience, which refers to the sensory signal transmitted from the pain receptor, and the affective experience, which is the emotional reaction to the pain.
What is the difference between pain threshold and pain tolerance?
-Pain threshold refers to the point at which a sensory input is reported as painful, while pain tolerance refers to a patient's response to pain, including how much pain they can endure before seeking relief or altering their activities.
What are the two groups of nerve fibers that transmit pain signals?
-The two groups of nerve fibers that transmit pain signals are C fibers, which are unmyelinated and transmit signals slowly, producing dull and diffuse pain sensations, and Delta fibers, which are myelinated and transmit signals fast, producing sharp and localized pain sensations.
What is referred pain and how does it occur?
-Referred pain is pain experienced in a location away from the site of tissue damage. It can occur due to shared nerve pathways, amplification of spinal cord sensitivity to signals from other areas, and activation of the sympathetic nervous system in response to pain.
What are the two common methods used to measure pain?
-The two common methods used to measure pain are the visual analog scale (VAS) and the numerical rating scale (NRS), both of which ask the patient to self-report their pain on a scale.
What is the World Health Organization's analgesic ladder and how is it used?
-The WHO analgesic ladder is a stepwise approach to managing pain, starting with non-opioid medications for mild pain and progressing to weak and then strong opioids for more severe or unresponsive pain. It can be used for acute, chronic, and cancer-related pain.
What are some side effects of NSAIDs and opioids?
-NSAIDs can cause gastritis, dyspepsia, stomach ulcers, exacerbations of asthma, hypertension, renal impairment, and coronary artery disease. Opioids can cause constipation, pruritus (itching), nausea, sedation, cognitive impairment, confusion, and respiratory depression.
How is patient-controlled analgesia (PCA) different from other forms of pain management?
-PCA involves a patient administering a bolus of a strong opioid medication through a pump when they feel pain, rather than receiving medication on a fixed schedule. It requires patient activation of the pump and is designed to provide more immediate and personalized pain relief.
Outlines
📚 Pain Management Basics
This paragraph introduces the topic of pain management, referencing the International Association for the Study of Pain's definition from 2020. It distinguishes between acute and chronic pain, emphasizing the importance of following local guidelines and consulting specialists. The paragraph also explains the sensory and affective experiences of pain, the concept of pain being subjective, and the physiological aspects of pain transmission from nociceptors to the brain. It covers pain threshold, allodynia, and pain tolerance, noting their variability among individuals.
🧬 Pain Physiology and Measurement
This section delves deeper into the physiology of pain, discussing the generation and transmission of pain signals, including the roles of mechanical, heat, and chemical stimuli. It explains the complexity of pain perception, where pain can be felt without corresponding nerve activity and vice versa. Referred pain, neuropathic pain, and the challenges of objectively measuring pain are also covered. The paragraph outlines common methods for assessing pain, such as the visual analog scale (VAS), numerical rating scale (NRS), and graphical rating scales, especially useful for children or those with cognitive impairments.
🛑 Analgesic Ladder and Medication Side Effects
The World Health Organization's analgesic ladder is introduced as a framework for managing pain, starting with non-opioid medications and escalating to strong opioids as needed. Adjuvants are mentioned as additional medications for neuropathic pain. The paragraph also discusses the side effects of analgesic medications, particularly NSAIDs, which can include gastritis, ulcers, asthma exacerbations, hypertension, renal impairment, and cardiovascular issues. Opioid side effects such as constipation, pruritus, nausea, sedation, cognitive impairment, and respiratory depression are highlighted, with naloxone as a countermeasure for severe opioid reactions.
💊 Opioid Use in Palliative Care and Post-operative Analgesia
This paragraph focuses on the use of opioids in palliative care, detailing the titration and optimization of doses for pain management. It explains the concept of background opioids and rescue doses for breakthrough pain, providing a specific example of dose calculations. The paragraph also touches on opioid conversion, referencing the British National Formulary for approximate conversions between different opiates. Post-operative analgesia is discussed in terms of its importance for patient recovery, mentioning the initiation of analgesia by anesthetists and the use of local anesthetics, paracetamol, NSAIDs, and opiates.
🔄 Chronic Pain Management
Chronic pain is defined as pain present or recurring over more than three months, affecting a significant portion of the adult population. The paragraph outlines the distinction between chronic primary and secondary pain, with examples of potential causes. It discusses the multifactorial nature of chronic pain, including biological, psychological, and social factors, and the importance of good communication in its management. The NICE guidelines on chronic pain are summarized, highlighting non-pharmacological approaches such as exercise programs, acceptance and commitment therapy, cognitive behavioral therapy, acupuncture, and the use of antidepressants.
🌐 Neuropathic Pain and Treatment Guidelines
The paragraph addresses neuropathic pain, introducing the DN4 questionnaire as a tool for assessing the likelihood of neuropathic pain. It lists the four first-line treatments recommended by NICE for neuropathic pain, including tricyclic antidepressants, SNRI antidepressants, and anti-convulsants. The management of trigeminal neuralgia is specifically mentioned, with carbamazepine as the first-line treatment. The paragraph concludes with a note on the importance of recent guidelines for medical professionals and students, particularly regarding the limited use of analgesics in chronic primary pain.
Mindmap
Keywords
💡Pain Management
💡IASP Definition of Pain
💡Acute Pain
💡Chronic Pain
💡Pain Threshold
💡Allodynia
💡Analgesic Ladder
💡Neuropathic Pain
💡Patient-Controlled Analgesia (PCA)
💡Chronic Primary Pain
💡Chronic Secondary Pain
💡DN4 Questionnaire
Highlights
The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Pain is categorized into acute, which is new onset, and chronic, present for over three months.
Pain management should follow local guidelines and consult seniors or specialists when necessary.
Pain has two aspects: the sensory experience and the affective experience.
Pain is subjective, and its threshold can vary between individuals.
Allodynia is pain experienced from normally non-painful sensory inputs, indicating a low pain threshold.
Pain tolerance is influenced by biological, psychological, and social factors and differs significantly among individuals.
Pain receptors, or nociceptors, detect damage or potential damage to tissues and transmit signals along afferent nerves.
C-fibers and Delta fibers are two types of nerve fibers that transmit pain signals differently.
Referred pain is experienced in a location away from the site of tissue damage, such as heart attack pain in the left arm.
Neuropathic pain is caused by abnormal functioning or damage to sensory nerves.
Pain measurement is subjective and commonly done using the Visual Analog Scale (VAS) or the Numerical Rating Scale (NRS).
The WHO analgesic ladder is a stepwise approach to managing pain, starting with non-opioids and escalating to strong opioids if needed.
Adjuvants are additional medications that can be combined with the analgesic ladder for extra effect or used to manage neuropathic pain.
Analgesic medications can have side effects, such as gastritis, hypertension, and respiratory depression, especially with long-term use.
Opioids in palliative care are titrated and optimized over time, with background and rescue doses.
Opioid conversion is based on approximate equivalents, and the BNF provides guidance on conversions between different opiates.
Post-operative analgesia is crucial for patient recovery, encouraging mobilization and reducing infection risk.
Patient-controlled analgesia (PCA) allows patients to self-administer opioid medication through a pump for pain management.
Chronic pain is diagnosed when pain persists or recurs over more than three months and affects up to 50% of adults in the UK.
Chronic pain management involves a holistic approach, considering biological, psychological, and social factors.
NICE guidelines differentiate between chronic primary and secondary pain and recommend different management strategies for each.
Neuropathic pain can be assessed using the DN4 questionnaire, and first-line treatments include specific medications like amitriptyline and pregabalin.
Trigeminal neuralgia, a type of neuropathic pain, is treated with carbamazepine as a first-line medication.
Transcripts
foreign
[Applause]
[Music]
tyfinals.com in this video I'm going to
be going through pain management and you
can find written notes on this topic at
zerothefinals.com slash pain management
or in the anesthetics and ICU section of
the zero to finals surgery book
so let's jump straight in
the International Association for the
study of pain or iasp publishes a
definition of pain and this is from
2020.
their definition of pain is an
unpleasant sensory and emotional
experience associated with or resembling
that associated with actual or potential
tissue damage
it's important to distinguish between
two categories of pain acute pain which
is a new onset of pain and chronic pain
where the pain has been present for
three months or more
when you're managing pain see the local
guidelines and seek advice from Seniors
and pain or palliative care Specialists
when in doubt
this section aims to help students
prepare for exams and should not be used
as a reference for managing pain in
patients
let's talk about some basic pain
physiology there are two aspects to the
experience of pain
the sensory experience and the affective
experience
the sensory experience refers to the
sensory signal transmitted from the pain
receptor
an example of this is when the patient
says it's a sharp sensation like a
needle
the affective experience is the
unpleasant emotional reaction to the
pain and an example of this would be
when a patient says it's excruciating I
can't bear it
pain is supposed to indicate underlying
or potential damage to tissues
but it can occur without any tissue
damage
the physiology of pain is quite complex
and there's still a lot that's not fully
understood about the experience of pain
pain is subjective meaning that when
someone indicates they're in pain we
need to accept their experience even
when there's no apparent underlying
cause
pain threshold refers to the point at
which a sensory input is reported as
painful
for example different temperatures can
be applied to the skin to measure the
point at which heat is interpreted as
pain
if someone experiences pain at a higher
temperature this indicates a higher
sensory threshold for pain or a higher
pain threshold
allodynia refers to when pain is
experienced with sensory inputs that do
not normally cause pain for example
light touch of the skin
this indicates a low pain threshold
where even normal sensory inputs are
interpreted as pain
pain tolerance is different to pain
threshold it's more difficult to Define
pain tolerance and generally refers to a
patient's response to pain
one person may experience pain and think
little of it and carry on with their
activities as normal
another person may experience a similar
pain but worry that it indicates a
serious underlying illness take time
away from work and seek medical
investigations and treatment
pain tolerance varies massively between
individuals and is influenced by many
biological psychological and social
factors
at the most basic level pain receptors
which can be called nociceptors at the
ends of nerves detect damage or
potential damage to the tissues
nerve signals are transmitted along the
afferent nerves to the spinal cord
afferent sensory nerves that transmit
pain signals are part of the peripheral
nervous system and they're called
primary afferent nociceptus
two groups of nerve fibers transmit pain
C fibers which are unmyelinated and have
a small diameter transmit signals slowly
and produce dull and diffuse pain
Sensations
a Delta fibers which are myelinated and
a larger diameter transmit signals fast
and produce sharp and localized pain
Sensations
the signal then travels to the central
nervous system up the spinal cord mainly
in the spinothalamic tract and the
spinal reticular tract to the brain
where it's interpreted as pain mainly in
the thalamus and the cortex
the main sensory inputs that generate a
pain signal are mechanical for example
pressure
heat and chemical for example
prostaglandins
having gone through that basic
physiology of a pain signal being
generated and transmitted to the brain
it's actually more complicated
when directly measuring activity in the
peripheral afferent sensory nerves pain
can be experienced without any activity
in the primary afferent nociceptors
equally activity in the primary afferent
noticeptors can be detected without the
patient experiencing any pain
essentially patients can experience pain
without any clear nervous signal that
should cause pain
and equally patients with a nervous
signal that should cause pain may not
experience any pain
referred pain refers to a pain
experienced in a location away from the
site of tissue damage for example
patients with a heart attack may have
pain in their left arm
there are several possible explanations
for referred pain including nerves that
may share the innovation of multiple
parts of the body for example the heart
and the arm
pain in one area amplifies the
sensitivity in the spinal cord to
signals coming from other areas
and activation of the sympathetic
nervous system in response to pain
results in pain in other areas
neuropathic pain is caused by abnormal
functioning or damage to the sensory
nerves resulting in pain signals being
transmitted to the brain
typical features suggestive of
neuropathic pain are burning tingling
pins and needles electric shocks and a
loss of sensation to stimulation of the
affected area
best talk about measuring pain there are
no simple reliable ways to objectively
measure the pain that somebody is
experiencing
as pain is a subjective experience it's
measured by asking the patient about
their perception of the pain the two
ways commonly used to measure pain are
the visual analog scale vas or the
numerical rating scale NRS
the visual analog scale involves asking
the patient to rate their pain on a
horizontal line where the Left End
indicates no pain and the Right End
indicates the worst pain imaginable
the distance along this line can be
measured to get a numerical value to
represent the pain for example 75
millimeters along a 100 millimeter line
the numerical rating system involves
asking the patient to rate their pain on
a numerical scale from 0 to 10. with
zero being no pain at all and 10 being
the worst pain imaginable
pain can also be rated on a graphical
rating scale with a series of faces
going from happy to very unhappy
this can be helpful in children or in
patients with a learning disability
let's talk about the analgesic ladder
the World Health Organization or who
analgesic ladder was originally
developed to help manage cancer-related
pain
it's also often used for acute and
chronic painful conditions
the idea is that patients with mild pain
start on the first step of the ladder
and when the pain is more severe or does
not respond to the lower steps higher
steps on the ladder can be used until
the pain is adequately managed
there are three steps to the analgesic
ladder step one involves non-opioid
medications such as paracetamol and
NSAIDs like ibuprofen
step two involves weak opioids such as
codeine and Tramadol
and step three involves strong opioids
such as morphine oxycodone Fentanyl and
buprenorphine
other medications may be combined with
the analgesic ladder for additional
effect and these are called adjuvants
or they can be used separately to manage
neuropathic pain
and these medications include
amitriptyline which is a tricyclic
antidepressant
Duloxetine which is an snri
antidepressant
Gabapentin which is an anti-convulsant
pregabalin which is also an
anticonvulsant
and capsaicin cream which is a topical
treatment from Chili Peppers
let's talk about the side effects of
analgesia
medication overuse headache is a common
side effect of the long-term use of
analgesic medications
the key side effects of NSAIDs or
non-steroidal anti-inflammatory drugs
are gastritis with dyspepsia or
indigestion
stomach ulcers
exacerbations of asthma
hypertension or high blood pressure
renal impairment
and coronary artery disease heart
failure and strokes which can all be
rarely associated with NSAIDs
NSAIDs may be inappropriate or
contraindicated in patients with asthma
renal impairment heart disease
uncontrolled hypertension or peptic
ulcers
proton pump inhibitors for example
Omeprazole or Lansoprazole are often
co-prescribed with NSAIDs to reduce the
risk of gastrointestinal side effects
for example acid reflux gastritis and
peptic ulcers
the key side effects of opioids are
constipation skin itching which is
called pruritus
nausea altered mental state with
sedation cognitive impairment or
confusion
and respiratory depression usually only
with larger doses in opioid naive
patients
naloxone is used to reverse the effects
of opioids in a life-threatening
overdose usually when the patient has
respiratory depression
next let's talk about the use of opioids
in palliative care
using opioids to control pain in
palliative patients is a specific
scenario where the doses are titrated
and optimized over time
this involves using a combination of
background opioids for example 12 hourly
modified release oral morphine
and rescue doses for breakthrough pain
for example immediate release oral
morphine solution
the rescue dose is usually one-sixth of
the background 24-hour dose
for example if a patient is getting 30
milligrams in 24 hours of modified
release morphine for example 15
milligrams every 12 hours
each rescue dose will be 5 milligrams
given every two to four hours as
required
the five milligram rescue dose is
one-sixth of the 30 milligram 24-hour
background dose
if the patient requires regular rescue
doses for breakthrough pain the dose of
the background opioid can be increased
the rescue doses will also need
increasing so that they remain one-sixth
of the background 24-hour dose
a term tip for you remember that each
rescue dose is one-sixth of the 24-hour
background dose
this is a very common exam question and
something that seniors will commonly ask
to test your knowledge
the question may be something like this
patient is on 30 milligrams of modified
release morphine every 12 hours what
would be the correct breakthrough dose
in this scenario 10 milligrams is the
correct answer as the patient is getting
60 milligrams background morphine every
24 hours based on the fact they're
getting 30 milligrams twice a day
next let's go through opioid conversion
the information here is based on the BNF
which gives approximate conversions
between different opiates it's helpful
to remember the dose equivalent to 10
milligrams of oral morphine
the conversions are not exact and
patients can respond differently to
different opioids always check the BNF
and other official reference material
for accurate conversion figures the
information here may not be up to date
or accurate and is only intended for
studying purposes
10 milligrams of oral morphine is
approximately equivalent to a hundred
milligrams of oral codeine a hundred
milligrams of oral Tramadol
6.6 milligrams of oral oxycodone
five milligrams of IV IM or subcut
morphine
and three milligrams of IV IM or subcut
diamorphine
it's also possible to use opioid patches
for background analgesia
for example buprenorphine patches where
5 microgram per hour patches are roughly
equivalent to 12 milligrams per 24 hours
of oral morphine
and Fentanyl patches where 12 microgram
per hour patches are roughly equivalent
to 30 milligrams per 24 hours of oral
morphine
next let's talk about post-operative
analgesia
adequate analgesia in the post-operative
period is vital to encourage the patient
to mobilize ventilate their lungs fully
reducing the risk of chest infections
and atelectasis
and to maintain an adequate oral intake
through eating and drinking
analgesia is usually started in theater
by the anesthetist with regular
paracetamol NSAIDs and opiates if
required for example regular modified
release Oxycodone with immediate release
oxycodone is required for breakthrough
pain
the surgeon may put a local anesthetic
into the wound to help with the initial
pain after the procedure analgesia
should be reduced and stopped as the
symptoms improve
next let's talk about patient controlled
analgesia
patient-controlled analgesia or a PCA
involves an intravenous infusion of a
strong opioid for example morphine
oxycodone or fentanyl which is attached
to a patient-controlled pump
a patient-controlled analgesia involves
the patient pressing a button as the
pain develops to administer a bolus of
the opioid medication
after the patient pushes the button and
administers a bolus the button will stop
responding for a set time to prevent
overuse
only the patient should press the button
not the nurse or the doctor
patient-controlled analgesia requires
careful monitoring and there needs to be
input from an anesa test and facilities
in place if Adverse Events occur this
includes access to naloxone for
respiratory depression antiemetics for
nausea and atropine for bradycardia
the anesa test May prescribe background
opiates for example patches in addition
to the patient-controlled analgesia
other as required opioids need to be
avoided whilst a PCA is in use
the machine is locked to prevent
tampering
next let's talk about chronic pain
chronic pain can be diagnosed when pain
has been present or reoccurs in one or
more areas over more than three months
some studies suggest up to 50 percent of
adults in the UK are affected by chronic
pain
common areas of chronic pain include
headaches lower back pain neck pain and
joint pain for example in the hips or
the knees
the nice guidelines on chronic pain
updated in April 2021 separates chronic
pain into chronic primary pain where no
underlying condition can adequately
explain the pain
and chronic secondary pain where there
is an underlying condition that can
explain the pain
there is a long list of potential causes
of chronic secondary pain
a few examples are osteoarthritis
lasting pain after a traumatic injury
for example a bone fracture
migraines
irritable bowel syndrome
endometriosis cancer
neuropathic pain for example due to
diabetes nerve impingement multiple
sclerosis or post-herpetic neuralgia
and complex regional pain syndrome
biological psychological and social
factors all contribute to the
Persistence of the pain
the physical processes that can lead to
chronic pain include sensitization of
the primary afferent nociceptors by
frequent stimulation
increased activity of the sympathetic
nervous system
and increased muscle contraction in
response to the pain
chronic pain is a complex condition that
can be challenging to manage
analgesia is often inadequate and can
lead to side effects and dependence
good communication and building a
relationship with the patient is an
important part of managing chronic pain
in chronic primary pain and underlying
physical cause of the pain may never be
found
chronic pain may not improve and it may
get worse with time
it often fluctuates with flare-ups where
the pain gets worse
a big part of management is maintaining
and improving the quality of life
despite the pain
patients with chronic pain require a
holistic person-centered approach to
assessing and managing their condition
this involves exploring the impact on
their life discussing what they already
do to manage the pain and their ideas
concerns and expectations about the pain
the options for managing chronic pain
detailed in the nice guidelines from
2021 are supervised group exercise
programs acceptance and commitment
therapy or act
cognitive behavioral therapy or CBT
acupuncture and antidepressants for
example amitriptyline Duloxetine or an
SSRI antidepressant
it's worth noting that the nice
guidelines from 2021 advise that for
chronic primary pain where no underlying
condition can adequately explain the
pain patients should not be started on
paracetamol NSAIDs opiates pregabalin or
Gabapentin
in chronic secondary pain analgesia may
be helpful depending on the underlying
cause
for example in patients with pain
secondary to osteoarthritis the use of
analgesia involves a stepwise approach
to control the symptoms
the first step is oral paracetamol and
topical NSAIDs
the second step is to consider oral
NSAIDs if they're appropriate and
consider co-prescribing a proton pump
inhibitor such as Omeprazole to protect
the stomach
and the third step is to consider
opioids such as codeine
a Tom tip for you chronic pain is
incredibly common it's worth noting
these recent guidelines that clearly
state to avoid basically all forms of
analgesia other than antidepressants in
patients with chronic primary pain
these guidelines may come up in exams
potentially asking you the most
appropriate medication for a patient
with chronic primary pain and the answer
would be antidepressants
this is different to Chronic secondary
pain where there is an underlying
condition that explains the pain
finally let's talk about neuropathic
pain
the dn4 questionnaire can be used to
assess the characteristics of the pain
and the likelihood that it's neuropathic
in nature
patients are scored out of 10 a score of
four or more indicates neuropathic pain
there are four first-line treatments for
neuropathic pain amitriptyline which is
a tricyclic antidepressant
Duloxetine which is an snri
antidepressant
Gabapentin which is an anti-convulsant
and pregabalin which is also an
anti-convulsant
nice recommend using one of these four
medications to help control neuropathic
pain
if it does not help it can be slowly
withdrawn and an alternative can be
tried
all four of these medications can be
tried in turn only one neuropathic
medication should be used at a time
other options for managing neuropathic
pain are Tramadol only as a rescue for
short-term control of flares
capsaicin cream or chili pepper cream
for localized areas of pain
physiotherapy to maintain strength and
psychological input to help with
understanding and coping with the pain
trigeminal neuralgia is a specific type
of neuropathic pain
however rather than using the typical
medications for neuropathic pain nice
recommend using carbamazepine first line
for treating trigeminal neuralgia and if
carbamazepine does not work to refer the
patient to a specialist
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