Pain lecture for 3rd year medical college students.

1. Pain Dr.Mohammad Shaikhani.

6. Acute vs. Chronic Acute Chronic Onset Abrupt Gradual Duration 1 second to 6 months Longer than 6 months Intensity Mild, moderate, severe Mild, moderate, severe Etiology Biologically identifiable May not be easily identified Physical response Increased BP, HR, RR, dilated pupils, pallor, nausea and vomiting, increase muscle tension and dry mouth No autonomic nervous system symptoms

11. Referred Pain:

12. Pain Assessment

16. Example Of A Numbered Scale

22. Pain Treatment

24. +/- adjuvant Non-opioid Weak opioid Strong opioid Pain persists or increases W.H.O . ANALGESIC LADDER +/- adjuvant +/- adjuvant By the Clock 1 2 3

27. Drug Equipotency with Morphine (Morphine:Drug) Hydromorphone 5:1 Oxycodone 1.5:1 to 2:1 Codeine 1:12 Methadone Daily Morphine Dose 30 – 90 mg 3.7:1 90 – 300 mg 7.75:1 > 300 mg 12.75:1 Fentanyl 80:1 to 100:1 (for subcutaneous dosing of each)

29. TOLERANCE PHYSICAL DEPENDENCE PSYCHOLOGICAL DEPENDENCE / ADDICTION

30. TOLERANCE A normal physiological phenomenon in which increasing doses are required to produce the same effect Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

31. PHYSICAL DEPENDENCE A normal physiological phenomenon in which a withdrawal syndrome occurs when an opioid is abruptly discontinued or an opioid antagonist is administered Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

32. PSYCHOLOGICAL DEPENDENCE and ADDICTION A pattern of drug use characterized by a continued craving for an opioid which is manifest as compulsive drug-seeking behaviour leading to an overwhelming involvement in the use and procurement of the drug Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

44. Incident Pain Pain occurring as a direct and immediate consequence of a movement or activity

46. Time Pain Having a steady level of enough opioid to treat the peaks of incident pain... ...would result in excessive dosing for the periods between incidents Incident Incident Incident

48. INCIDENT PAIN PROTOCOL (see also http://palliative.info) Step # Medication (50  g/ml) # Micrograms Sublingually 1 Fentanyl 50 2 Sufentanil 25 3 Sufentanil 50 4 Sufentanil 100