Lec 2

Question 1

Trephination

Answer 1

-the belief that there were bad spirits in the head that cause pain (or a multitude of disorders)
-so people would make holes in the skull for the bad spirits would escape

Question 2

Theriac

Answer 2

-mixture of roots, leaves, barks, flowers, seeds, fruits, oils, animal products and minerals
-actually worked to help pain bc it contained opium

Question 3

Willow Bark/Opium Poppy

Answer 3

-main 2 treatments for pain come 1500 CE
-people figured out that these things reduced pain based on trail and error of everything
-we have known about them for a long time, and stilk essentially used in medicines today

Question 4

Morphine and Pharmaceutical Company

Answer 4

-1668 the first pharmaceutical was formed, Merch KGaA was the first company
-in the 1600s chemists had figured out how to derive opium from poppies, but you never knew how much you were going to get, too little pain wouldnt go away, too much you would die
-Merck hired chemists to extract opium in a standardised way to get the same amt of opium each time

Question 5

Anesthesia

Answer 5

-1846 was the first public demonstrantation to watch the first surgery under anthestisia
-showed what ether could do, dentist took out a tumour from the mouth, the patient was out cold and upon awakening had minor complaints

Question 6

Anesthesia Death Rate

Answer 6

-since ether, anthestisia has really progressed, the death rate of modern general anestheisa is approx 1/100 000, ether was easy to overdose on

Question 7

Morphine milligram equivalent

Answer 7

doses of these drugs equivalent to giving 10mg of morphine intramuscularly (IM) and orally (PO) and how long these drugs last (half-life for 50% and duration of action
-the transdermal system will release the drug slower, therefore will last longer

Question 8

Subcutenous

Answer 8

inject into dermal layers of skin

Question 9

Intramuscular

Answer 9

inject into muscle

Question 10

Intravenous

Answer 10

inject into vein

Question 11

Transdermal

Answer 11

film over the skin, allowing molecules will absorb into skin/muscle/blood

Question 12

Drug Admin

Answer 12

-across these methods there is variations in speed and precision (if you want effects to be local or general)
-if you want to target organ rapidly, intravenous is best
-pills take longer as they must be absorbed into body before being absorbed into bloodstream for bloodstream carry to target organ
-sometimes only trained professionals can inject, sometimes older ppl cant swallow pills

Question 13

Pharmacodynamics

Answer 13

what the drug does to the body

Question 14

Pharmacokenetics

Answer 14

-what the body does to the drug
-absorption, distribution, metabolism, elimination
-things must be absorbed in the small intestine to enter the body/bloodstream
-most metabolism occurs in the liver

Question 15

Patient-Controlled Analgesia

Answer 15

-giving ppl the option to give themselves painkillers allows them to take control of their pain in a timely fashion, obv controlled only allowing them to give themselves only so much at a time, the ppl actually end up taking less opiates

Question 16

Opiate Side Effects

Answer 16

-opiates have many and problematic side effects (esp respiratory depression)
-constipation is the most common side effect, sometimes the pain of constipation becomes worse than the pain og prescribed for
-ways to alleviate this is finding the right does for the individual, or giving them a different kind of drug

Question 17

Over-the-Counter Analgesics

Answer 17

-only made if shown to be safe over time
-drugs you can freely buy
-stuff gets grandfathered in, if the same drugs were introduced today, they would be prescription

Question 18

interventionlists

Answer 18

either cut out or stimulate the pain producing part

Question 19

Ectomy

Answer 19

cut out

Question 20

Otomy

Answer 20

cut into

Question 21

Complementary and Alternative Medicine for Pain

Answer 21

-there are full systems of medicine that differ from the one that we are used to, there are western alternatives and alternatives from the east and globally
-we need to measure all types of medical practices with the same/similar standards and criteria

Question 22

Unconventional Analgesic Modalities

Answer 22

-ppl who are listening to music experience less pain than control
-ppl who swear when experience the pain stimulus reportedly experienced less pain than those who were speaking regular words
-some patients push back on pain self-management bc they are seeking external help, refusal to believe external medicine wont help and doubt of effectiveness at the internal levels

Question 23

Analgesia for Babies

Answer 23

-babies get pain the most in the NICU bc they have a lot of blood taken constantly for testing, the only way to get blood from a baby that size is taking a small capillary tube to the heel, prick the heel and pulpate it to get enough blood, (heel-lance method), this happens many many times to a baby during a NICU stay
-3 things to help the babies throught this is sugar, breastfeeding, or kangaroo care

Question 24

Multidisciplinary Pain Clinics

Answer 24

-John Bonica, father of the study of pain
-the idea that pain care involves more than doctors (MD)
-bonic realised that if the therapists, physical therapists, social workers etc should be involved from the start in addition to medical doctors, thats what multidisciplinary pain clinics are, you are seen by a group of specialists
-the treatment efficacy at a MPC is higher

Question 25

Cancer Pain

Answer 25

-cancer pain relief is effective bc eventually it becomes just large doses of opioids for the pain, becomes sedative -when cancer can no longer be fought, patients enter palliative care, focus on relieving symptoms and pain, can be at a hospital or at home, and eventually a hospice -ppl only go to hospice if they are very close to dying -have to consider not giving them a dose that just makes them sleep all the time while still relieving the pain

Question 26

Vital Signs

Answer 26

-Vital Signs: pulse, BP, temperature, respiratory rate, pain -being a vital sign is something that nurses are required to write down everytime the check on a patient, by law

Question 27

Pain as a Vital Sign

Answer 27

-pain has recently been recognised as a vital sign --paitient is asked to rate their pain on a pain score -differs from the other vital signs bc if the other vital signs where to disappear, the person would be dead, if pain went away, you wouldnt want to be dead -allows pain to be taken more seriously -recieved pushback bc the experience and rating of pain is too subjective bc its a self report

Question 28

Evidence Based Medicine

Answer 28

-before this was developed, the treatments were completely up to the physician and doctors relied solely on anecdote and opinion for widespread pain treatment -the problem is defining who the “expert” of pain is, even surgeons and medical doctors may be experts of medicine when compared to personal opinion, but not necessarily an expert in pain

Question 29

Case Reports

Answer 29

written description of a case with a particular treatment

Question 30

Case Series

Answer 30

a doctor saying they have had a series of patients with the same diagnosis, trying the same treatment on all of them with positive results for most

Question 31

Meta Analysis

Answer 31

-the statistical analysis done on the entire collection of RCTs -should exclude people who are already on other treatments for pain to ensure effects are coming from treatment being tested

Question 32

3-arm parallel design

Answer 32

has the inclusion of active control

Question 33

Enriched Designed

Answer 33

you weed out ppl who want to leave bc drug isnt working/ side effects are too bad, then randomise those who stay and actually begin experiment

Question 34

Only One Significant Study

Answer 34

-what would happen if only one study was statistically significant? Drug companies would just take which studies supported the drug, now they must premptively decide and declare which primary outcome measure they choose before the study starts, if the study they chose fails while another successded, then their study failed, and must declare that

Question 35

Odds Ratio

Answer 35

supporting the relationship/ supporting no relationship

Question 36

Confidence Interval

Answer 36

time the true mean will fall in this range

Question 37

Forest Plots

Answer 37

meta analysing the results of multiple studies on the same treatment

Question 38

NNT

Answer 38

-if its 4, it means that means that 4 patients must be treated before finding 1 that will respond to the experimental intervention -NNT is actually the number of patients you would need to treat with the drug to get 1 to respond that wouldnt have responded in any way to placebo -only ¼ is gonna get better bc of the drug -measure of how the drug works not about how many ppl get better

Question 39

Gabapentinin NNT

Answer 39

-so many more patients have been tested for gabapentin is bc pfizer made gabapentin and sometimes they did extra studies on its already approved drug bc since it got approved it will probably work so the company can publish a paper saying the drug works in a advertising sense -the gold standard for an NNT for neuropathic pain is about 6 -but realistically, nothing really works well for neuropathic pain

Question 40

NNT for Low-Does Asprin

Answer 40

-if the NNT for low-dose aspirin for heart attacks so high, why is it used (as a preventative) - bc it doesnt help anyone on an individual level but it does help society, heart attacks are expensive and a huge part of overall healthcare, it is a public health measure to prevent 1/40th of heart attacks for society at large, expenses will go down -sometimes high NNTs are not a reason to not use it

Question 41

NNH

Answer 41

-low NNH is bad number needed to cause harm

Question 42

International Association for the Study of Pain

Answer 42

-dominated by anesthisiologists started by them -but this creates a problem, medical research needs to be more interdisciplinary, but each discipline tend to stay within their own associations

Question 43

PAIN Journal

Answer 43

-studies chronic pain and back pain the most, neuropathic pain is only 6% of pain papers and arthritis is only 4% -if arthritis is much more common than neuropathic pain, there are more papers on neuropathic pain the animal models are much better

Question 44

GRADE Recommendations for the Treatment of Chronic Neuropathic Pain

Answer 44

-according to whatever weighting systems they want the board make recommendations of treatments, based on number of strong vs med vs weak recommendation they categorize treatments into 1st line, 2nd line, 3rd line and so on treatments -try first line drugs first, if not responding to any, move on the 2nd, if not responding to any, then and only then can you use 3rd line -the recommendations are an average of the opinions of the experts -weighs efficacy, cost, side effects, safety, quality, method of adminsitration

Question 45

Pyramid of Evidence based Medicine

Answer 45

1. personal opinion 2. Expert opinion 3.case reports 4. case series 5. case control studies 6. cohort studies 7. randomized controlled double blind studies 8. systematic reviews and meta analysis

Question 46

Prevalence of Side Effects

Answer 46

1. Constipation: 80% 2. Vomiting: 15-30% 3. Sedation: 20-60% 4.Respiratory Depression: rare in chronic dosing 5.Dry mouth: common 6. Urine retnetion: rare 7. Itching: 2-10% for spinal route