Understanding The Causes of Pain and Pain Management

Summary

This 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

00:00

📚 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.

05:01

🧬 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.

10:01

🛑 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.

15:04

💊 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.

20:05

🔄 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.

Keywords

💡Pain Management

Pain management refers to the medical discipline focused on alleviating pain and improving a patient's quality of life. In the video, pain management is the central theme, with a detailed discussion on the different types of pain, their physiological basis, and various strategies for treating them.

💡IASP Definition of Pain

The International Association for the Study of Pain (IASP) provides a comprehensive definition of pain as an 'unpleasant sensory and emotional experience associated with actual or potential tissue damage.' This definition is crucial in the video as it sets the stage for understanding the complexity and subjective nature of pain.

💡Acute Pain

Acute pain is defined in the video as a new onset of pain and is distinguished from chronic pain. It is an important concept as it helps differentiate the types of pain and their management approaches, with acute pain often being a more immediate concern requiring swift intervention.

💡Chronic Pain

Chronic pain is described as pain that has been present for three months or more. The video emphasizes the distinction between chronic and acute pain, highlighting the long-term nature of chronic pain and the need for different management strategies compared to acute pain.

💡Pain Threshold

The pain threshold is the point at which a sensory input is perceived as painful. The video uses the example of different temperatures applied to the skin to measure this threshold, indicating that a higher threshold means a person feels pain at higher temperatures, which is a key aspect of understanding individual pain experiences.

💡Allodynia

Allodynia is a condition where pain is experienced with sensory inputs that do not normally cause pain, such as light touch. The video explains this as an example of a low pain threshold, which is an important concept in understanding abnormal pain perception.

💡Analgesic Ladder

The analgesic ladder, as discussed in the video, is a stepwise approach to managing pain, starting with non-opioid medications and escalating to stronger opioids as needed. This concept is central to the video's discussion on pain management strategies, particularly for chronic and severe pain conditions.

💡Neuropathic Pain

Neuropathic pain is caused by abnormal functioning or damage to the sensory nerves. The video describes it with specific symptoms like burning, tingling, and electric shocks, and it is a key concept in understanding pain that arises from the nervous system itself rather than tissue damage.

💡Patient-Controlled Analgesia (PCA)

PCA is a method of pain management where patients self-administer doses of opioid medication through a pump. The video explains how this allows for personalized pain control and is an important concept in the context of post-operative pain management.

💡Chronic Primary Pain

Chronic primary pain is a type of pain where no underlying condition can adequately explain it. The video discusses this in the context of the NICE guidelines, emphasizing the unique approach to managing this type of pain without the use of common analgesics.

💡Chronic Secondary Pain

Chronic secondary pain is pain that has an identifiable underlying condition, such as osteoarthritis or cancer. The video differentiates this from chronic primary pain and discusses the management strategies, which may include a stepwise approach to analgesia.

💡DN4 Questionnaire

The DN4 questionnaire is a tool used to assess the likelihood that a patient's pain is neuropathic in nature. The video mentions it as part of the diagnostic process for neuropathic pain, with a score of four or more indicating such pain.

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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