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Dealing with Pain and Fever in the Pharmacy

Dealing with Pain and Fever in the Pharmacy. Pain:. “ unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage ” International Association for the Study of Pain. Mechanism of Perception of Pain:.

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Dealing with Pain and Fever in the Pharmacy

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  1. Dealing with Pain and Fever in the Pharmacy

  2. Pain: “ unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage ” International Association for the Study of Pain

  3. Mechanism of Perception of Pain: • The sensory component of pain results from transmission of peripheral pain impulses to the CNS by nociceptors and nociceptive nerve fibers.

  4. Mechanism of Perception of Pain: Through the dorsal route ganglion dorsal horn of spinal cord • Afferent pain impulses • Many substances involved: NE, 5-HT, GABA, glycine, endorphin and enkephalin Synapse with Ascending fibres to the brain Efferent fibres to the periphery- complete the circle

  5. Pain due to Noxious stimuli (e.g.mechanical, thermal) Ongoing tissue damage/diseases Release of pain-facilitating mediators: prostaglandins, histamine, bradykinen “fight-or-flight” epinephrine release Acute (immediate) Chronic

  6. OTC useful in all 3 categories Categories of Pain: • Acute: immediate reaction to noxious stimuli.   Analgesics prevent progression. • Chronic malignant: ~ associated with any advanced, progressive disorder, not just cancer: MS, AIDS, end-stage renal/hepatic failure, end-stage respiratory disease. • Chronic non-malignant: most complex, most misunderstood and least well managed. Related to a progressive debilitating process. e.g low back pain, arthritis, neuropathic pain, headache

  7. Types of Pain • Somatic—Cutaneous, MS tissue (deep) • Visceral—Internal areas of the body • Neuropathic—injury to the nervous system

  8. Pain-associated conditions responsive to OTC analgesics: • Headache • Myalgia • Periarticular pain • Arthralgia

  9. Headache (HA) • Many HA patients use self-treatment rather than seek medical attention • HA amenable to self-treatment: tension type, diagnosed migraine & sinus HA

  10. Headache: A symptom: primary or secondary • Results from dysfunction, injury or displacement of pain-sensitive cranial structures. • Headache Muscle contraction.Tension HA Vascular HA / Migraine Vascular/ Muscle Contraction HA Other Types of HA e.g. Side effect, sinus HA, eye strain, dental pain Traction HA Chronic daily HA (medication overuse)

  11. Your homework! • The International Headache Society (IHS) classification

  12. Headache: • Muscle Contraction / Tension HA: • Results from tight muscles at upper back, neck, occiput or scalp. • Bilateral, diffuse- at top of head- extend. Aching ‘tight’ pressing- gradual in onset, worsens through the day. • Associated with emotional stress/anxiety- may last several days (Acute or chronic) •   OTC analgesics for acute types • Chronic types: physical therapy + relaxation

  13. NEW! • Recently, neurological research has isolated the temporalis muscle as the primary center of tension headache pain and possibly common migraine pain (Boyd, 2005)

  14. 2. Migraine HA (vascular HA) • Mainly women (3 times more) • Attack: 3 hrs--- up to 3 days (av. 24 hrs) • Migraine: recurrent, hemicranial, throbbing • Triggers: stress, fatigue, oversleeping, fasting, vasoactive substances in food, caffeine, alcohol. Menses and changes in BP; • Maybe caused by medications: nitrates, OCPs, indomethacin, HRTs) • IHS: recognises 7 types of migraine BUT for practicality classical OR common

  15. Classic Migraine (with aura) • Accounts for < 25% of migraine cases • Visual or neurological aura •  over 5-20 minutes and can last for up to 1 hour • Within 60 min of aura ending HA starts • Pain unilateral, throbbing, moderate to severe, sometimes generalized and diffuse. Physical activity and movement intensify pain. Nausea (1/3 sickness). Photophobia, Phonophobia, fatigue, concentrating difficulty.

  16. Common Migraine (without aura) • 75% of sufferers • No aura • All other symptoms the same

  17. 3. Cluster headache • Predominantly affects men aged 40-60 • HA occurs same time each day, last 10 min-3h • 50% of patients: night-time • Woken 2-3 h after sleep with steady intense unilateral orbital pain. • Conjunctivitis and nasal congestion (watery) is experienced at same side of head as HA • Ch.ch: periods of acute attack, typically a number of weeks- few months (1-3 attacks per week) • Nausea is usually absent and family history uncommon Referral to the doctor. OTC unlikely to be effective

  18. 4. Vascular- Muscle contraction HA: • Patients with daily tension headaches and occasional migraines • Either type can precipitate the other 5. Other Causes of HA **Sinus Headache: • infection/blockage of the paranasal sinuses > inflammation/distension of the sensitive sinus walls. • Localised: peri-orbital, forehead area • with stooping, blowing nose. Upon awakening, subside after a while • OTC analgesics + decongestants • Persistent > bacterial infection> Dr.

  19. Headache: • All secondary causes of HA except sinusitis need to be referred. • Fever, hangover, some NSAIDS (like what?) • eye strain, infection (e.g. meningitis), depression, anxiety, glucoma > OTC not effective • Temporal arteritis, raised ICP • ‘weekend’HA

  20. Self-care of HA

  21. Nonpharmacological treatment of HA

  22. C/I to aspirin

  23. Aspirin intolerance

  24. Before surgery…

  25. Myalgia • OTC analgesics should be started soon after the injury. Adjunctive: heat, massage. • Remobilisation after injury healed is important, otherwise: weak, tight, overly contracted muscles, trigger points may arise

  26. Periarticular Pain: • Injury or inflammation to the tissues surrounding the joint ( joint capsule, ligaments, tendons, bursae) • Localised tenderness, pain associated with movement of structure. knee, shoulder, elbow • Responds well to OTC analgesics and limitation of movement

  27. Arthralgia: • Joint pain often caused by synovitis(inflammation of synovial membrane). Cartilage loss may occur(e.g. in DJD, RA). • Osteoarthritis (DJD) • In wt bearing joints: hips, knee, lumbar spine • Paracetamol is analgesic of choice, wt loss • For acute flares: NSAIDs, local heat • Reumatoid Arthritis (RA) • mainly: multiple joints, fingers, hands, wrist and feet • joints warm, red, swollen, motion limited > deformity • more than OTC (NSAIDs): education, physical therapy,

  28. Assessment of Pain: • Pharmacist should enquire about: • Aetiology • Duration • Location • Severity • Factors that or pain • When to use OTC analgesics?

  29. Acute Pain “The Patient’s Pain Is What They Say It Is”

  30. Measuring Acute Pain Adults Verbal Rating Scales None MildModerate Severe Numerical Rating Scales 0 = no pain 10 = worst pain ever Visual Analogue Scales

  31. Measuring Acute Pain Children 3-7 year-old

  32. Fever • Fever is defined as a body temperature that is higher than the normal core temperature of 37.8ºC (average 36.4ºC –37.2ºC ) • Rectal > 38.0 ºC • Oral >37.6 ºC • Axillary > 37.4 ºC • Tympanic > 37.8 ºC • Hyperpyrexia: > 41.1 ºC – mental & physical consequences

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