1. pain:vjthevjmostvjcommonvjsymptomvjpromptingvjpatientsvjtovjvisitvjprimaryvjcarevjproviders.vjMorevjthanvj80%vjofvjpatien
tsvjwhovjvisitvjphysiciansvjreportvjpain.vjOftenvjremainsvjundervjtreated.
2. nociceptivevjpain:vjpainvjfromvjavjnormalvjprocessvjthatvjresultsvjinvjnoxiousvjstimulivjbeingvjperceivedvjasvjpainfu
l.vjExplainedvjbyvjongoingvjtissuevjinjury.
thermal,vjmechanicalvjandvjchemicalvjnociceptorsvjthatvjengagevj"withdrawal"vjreflexvjfollowedvjbyvjinflammatoryvjresponsevjtovjp
rotectvjinjuredvjtissue
3. functionalvjpain:vjpainvjsensitivityvjduevjtovjanvjabnormalvjprocessingvjorvjfunctionvjofvjthevjcentralvjnervousvjsystemvjin
responsevjtovjnormalvjstimuli
4. neruopathicvjpain:vjPainvjcausedvjbyvjlesionsvjorvjothervjdamagevjtovjthevjnervousvjsystem.
5. Diabeticvjperipheralvjneuropathy:vjprogressivevjdeteriorationvjofvjnervevjfunctionvjthatvjresultsvjinvjlossvj
ofvjsensoryvjperception
6. acutevjpain:vjisvjpainvjthatvjoccursvjasvjavjresultvjofvjinjuryvjorvjsurgery,vjundervj3vjmonths.vjPoorlyvjtreatedvjacutevjpainvjca
nvjcausevjpsychologicalvjstressvjandvjcompromisevjthevjimmunevjsystem.vjSomaticvjacutevjpainvjisvjanvjinjuryvjtovjskin,vjbone,vj
joint,vjmusclevjandvjconnectivevjtissue.vjVisceralvjpainvjinvolvesvjinjuryvjtovjnervesvjonvjinternalvjorgans.vjTreatvjaggressively.vjE
xamples:vjcutvjhand,vjmenstrualvjcramps.
7. chronicv j pain:v j canvjbevjintermittentvjorvjpersistent,vjmorevjthanvj3vjmonths.vjMainvjattectsvjincludevja)vjettectsvjon
physicalvjfunctionvjb)vjpsychologicalvjchangesvjc)vjsocialvjconsequencesvjandvjd)vjsocietalvjconsequences.vjUsuallyvjinvolving
vjlifevjthreateningvjdiseasesvjsuchvjasvjcancers,vjaids,vjprogressivevjneurologicalvjdiseases,vjendvjstagevjorganvjfailure,vjdementi
a.vjManagementvjshouldvjbevjmultimodalvjwithvjcognitivevjinterventions,vjphysicalvjmanipulations,vjpharmacologicalvjagen
ts,vjsurgicalvjinterventions,vjandvjregionalvjorvjspinalvjanesthesia.
8. chronicv j malignantv j pain:v j Painnvjisvjassociatedvjwithvjavjprogressivevjlife-threateningvjdiseasevjlikevjcancer,vjaids,
neurologicvjdiseases,vjendvjstagevjorganvjfailure,vjandvjdementia.vjGoalvjisvjpainvjalleviationvjandvjprevention.vjDependencevj
orvjaddictionvjisvjnotvjavjconcern.vjPainvjnotvjassociatedvjwithvjlifevjthreateningvjdiseasevjandvjlastingvjmorevjthanvj6vjmonthsvj
beyondvjthevjhealingvjperiodvjisvjreferredvjtovjasvj"chronicvjnonmalignantvjpain."
9. Whatvjarevjsomevjnon-pharmacologicalvjapproachesvjtovjpain?:vjimagery,vjdistraction,vjre-
laxation,vjpsychotherapy,vjbiofeedback,vjcognitivevjbehavioralvjtherapy,vjsupportvjgroups,vjandvjspiritualvjcounseling.vjPhysica
lvjtherapy,vjheat,vjcold,vjwater,vjultrasound,vjTENS,vjmassagevjandvjtherapeuticvjexercise.
10. WHOvj3vj stepvj analgesicvjladder:vj *vj1-vjnonopioid
* 2vj-vjopioidvjforvjmildvjtovjmoderatevjpain
* 3vj-vjopioidvjforvjmoderatevjtovjseverevjpain
11. WHOvjfirstvjstepvjpainvjladder:vjmildvjpain/nonopioidvjanalgesicsvjsuchvjasvjNSAIDSvjorvjacetaminophenvjw/
vjorvjw/outvjadjuvantsvj(suchvjasvjpregablin)vj..vj"soreness."vjMedvjexamples:vjapapvj1000mgvjqvj6hrs,vjibu600mgvjq6vjhrs
,12. NSAIDs:vjNon-steroidalvjanti-
inflammatoryvjdrugs.vjassociatedvjwithvjseveralvjclinicallyvjsignificantvjcontraindicationsvjandvjdrugvjinteractions.vjNSAIDSvj
arevjequallyvjettectivevjinvjanalgesia,vjantipyreticvjandvjanti-
inflammatoryvjettects.vjChoicevjshouldvjincludevjSTEPSvj(simplicity,vjtolerability,vjevidence,vjprice,vjsafety).vjIfvjpatientvjfailsvjther
apyvjwithvjanvjagentvjfromvjonev j classvjofvjNSAIDs,vjusevjofvjanvjagentvjfromvjanothervjclassvjisvjreasonable.
13. COX2v j inhibitors:v j Celecoxibvj(Celebrex)vjselectivevjagentsvj(celecoxib)vjhavevjidealvjindicationvjinvjpatientsvjwithvjhigh
riskvjforvjGIvjbleed,vjhighvjintolerancevjofvjnon-selectivevjNSAIDS,vjorvjtreatmentvjfailurevjwithvjnon-
selectivevjagents.vjNSAIDsvjarevjofvjminimalvjvaluevjinvjneuropathicvjpain.vjNSAIDsvjproducevjavjflatvjdosevjresponsevjcurvevj(cel
lingvjettect)vjwithvjhighervjdosesvjprovidingvjnovjgreatervjeflcacyvjthanvjmoderatevjdoses.
14. Acetaminophen:vjTylenol.vjblocksvjPGvjsynthesisvjinvjCNS,vjinhibitsvjperipheralvjpainvjimpulses.vjAPAPvjdoesvjnot
interferevjwithvjCOXvj1vjorvjCOX2vjandvjthusvjhasvjnovjanti-inflammatoryvjbenefits.
15. WHOvjpainvjladdervjstepvj2:vjmoderatevjpain:vjweakvjopioidsvj(hydrocodone,vjcodeine,vjtramadol)vjw/vjorvjw/ou
tvjnonopioidvjanalgesicsvjw/vjorvjw/outvjadjuvantsvj"everyvjtimevjIvjdovjsomething,vjitvjhurts"vjmedvjexamples:vjapa325mgvj+vjc
odvj60mgvjq4vjhrs
16. WHOvjpainvjladdervj stepvj 3:v j severevjandvjpersistentvjpain,vjpotentvjopioidsvj(morphine,vjtapentadol,vjoxycodone,
hydromorphone,vjfentanyl,vjw/vjorvjw/outvjnon-
opioidvjanalgesicsvjandvjwithvjorvjwithoutvjadjuvantsvj"novjmattervjwhatvjIvjdovjitvjhurts,vjtheresvjavjbonevjstickingvjoutvjofvjmyvjskin
!"vjExamples;vjmorphinevj10mgvjq4vjhrs,vjhydromorphonevj4mgvjq4vjhr
17. WhatvjisvjthevjmechanismvjofvjNSAIDsvjandvjprecautionsvjtovjuse?:vjNSAIDSvjarevjeither
nonselectivevj(inhibitvjcoxvj1vjandvjcoxvj2)vjorvjselectivevj(inhibitvjcoxvj2).vjCoxvj2vjinhibitionvjisvjresponsiblevjforvjanti-
inflammatoryvjettects.vj-
vjCoxvj1vjcontributesvjtovjincreasedvjGIvjandvjrenalvjtoxicityvjassocvjwithvjnonselectivevjNSAIDS.vjUsevjwithvjcautionvjinvjpatientsvj
withvjdyspepsia,vjpepticvjulcers,vjbleeding,vjandvjpatientsvjtakingvjcorticosteroids.vjNephrotoxicityvjcanvjoccurvjinvjthevjelderly.
vjAvjboxedvjwarningvjisvjnowvjrequiredvjforvjprescriptionvjnonselectivevjNSAIDsvjandvjCelecoxibvjduevjtovjthevjincreasevjriskvjofvjc
ardiovascularvjeventsvjandvjGIvjbleeding.vjGenerallyvjptsvjprescribedvjNSAIDSvjwillvjneedvjPPI's.
18. ManagmentvjforvjNSAIDvjrisks:vjPtsvjmorevjpre-disposedvjtovjGIvjtoxicityvjifvjpre-existingvjulcervjorvjdyspepsia,
HvjPylorivjinfection,vjoldervjage,vjandvjsomevjconcurrentvjmedicationsvjincreasevjrisk.vjManagementvjoptionsvjforvjGIvjsidevjettectsv
jincludevjtakingvjwithvjfoodvjorvjmilk,vjSwitchvjtovjditterentvjNSAIDvjwithvjbettervjsafetyvjprofile,vjCOX2vjselectivevjagentvj(celecoxib)v
jand/orvjgastroprotectionvj(H2RA,vjPPI,vjmisoprostol
19. Celecoxib:v j isvjrecommendedvjforvjpatientsvjatvjincreasedvjriskvjofvjgastrointestinalvjbleedingvj/vjulcervjwhovjrequirevja
NSAIDvj-Sidevjettectsvjcanvjalsovjincludevjhtn,vjandvjworseningvjasthmavjsymptoms.
20. Tordolvj(Ketorolac):vj40mg,vjmaxvj5vjdays..vjhugevjbleedingvjriskvjbeyondvjthat!
, 21. Whenv j arev j NSAIDsv j indicatedv j andv j isv j onev j NSAIDv j betterv j /v j saferv j thanv j anoth
erv j invjavjgivenvjpatient?:vjUsefulvjforvjmildvjtovjmoderatevjpainvjthatvjarevjmediatedvjbyvjprostaglandinsvj(RA,vjmenstrualvj
cramps,
tsvjwhovjvisitvjphysiciansvjreportvjpain.vjOftenvjremainsvjundervjtreated.
2. nociceptivevjpain:vjpainvjfromvjavjnormalvjprocessvjthatvjresultsvjinvjnoxiousvjstimulivjbeingvjperceivedvjasvjpainfu
l.vjExplainedvjbyvjongoingvjtissuevjinjury.
thermal,vjmechanicalvjandvjchemicalvjnociceptorsvjthatvjengagevj"withdrawal"vjreflexvjfollowedvjbyvjinflammatoryvjresponsevjtovjp
rotectvjinjuredvjtissue
3. functionalvjpain:vjpainvjsensitivityvjduevjtovjanvjabnormalvjprocessingvjorvjfunctionvjofvjthevjcentralvjnervousvjsystemvjin
responsevjtovjnormalvjstimuli
4. neruopathicvjpain:vjPainvjcausedvjbyvjlesionsvjorvjothervjdamagevjtovjthevjnervousvjsystem.
5. Diabeticvjperipheralvjneuropathy:vjprogressivevjdeteriorationvjofvjnervevjfunctionvjthatvjresultsvjinvjlossvj
ofvjsensoryvjperception
6. acutevjpain:vjisvjpainvjthatvjoccursvjasvjavjresultvjofvjinjuryvjorvjsurgery,vjundervj3vjmonths.vjPoorlyvjtreatedvjacutevjpainvjca
nvjcausevjpsychologicalvjstressvjandvjcompromisevjthevjimmunevjsystem.vjSomaticvjacutevjpainvjisvjanvjinjuryvjtovjskin,vjbone,vj
joint,vjmusclevjandvjconnectivevjtissue.vjVisceralvjpainvjinvolvesvjinjuryvjtovjnervesvjonvjinternalvjorgans.vjTreatvjaggressively.vjE
xamples:vjcutvjhand,vjmenstrualvjcramps.
7. chronicv j pain:v j canvjbevjintermittentvjorvjpersistent,vjmorevjthanvj3vjmonths.vjMainvjattectsvjincludevja)vjettectsvjon
physicalvjfunctionvjb)vjpsychologicalvjchangesvjc)vjsocialvjconsequencesvjandvjd)vjsocietalvjconsequences.vjUsuallyvjinvolving
vjlifevjthreateningvjdiseasesvjsuchvjasvjcancers,vjaids,vjprogressivevjneurologicalvjdiseases,vjendvjstagevjorganvjfailure,vjdementi
a.vjManagementvjshouldvjbevjmultimodalvjwithvjcognitivevjinterventions,vjphysicalvjmanipulations,vjpharmacologicalvjagen
ts,vjsurgicalvjinterventions,vjandvjregionalvjorvjspinalvjanesthesia.
8. chronicv j malignantv j pain:v j Painnvjisvjassociatedvjwithvjavjprogressivevjlife-threateningvjdiseasevjlikevjcancer,vjaids,
neurologicvjdiseases,vjendvjstagevjorganvjfailure,vjandvjdementia.vjGoalvjisvjpainvjalleviationvjandvjprevention.vjDependencevj
orvjaddictionvjisvjnotvjavjconcern.vjPainvjnotvjassociatedvjwithvjlifevjthreateningvjdiseasevjandvjlastingvjmorevjthanvj6vjmonthsvj
beyondvjthevjhealingvjperiodvjisvjreferredvjtovjasvj"chronicvjnonmalignantvjpain."
9. Whatvjarevjsomevjnon-pharmacologicalvjapproachesvjtovjpain?:vjimagery,vjdistraction,vjre-
laxation,vjpsychotherapy,vjbiofeedback,vjcognitivevjbehavioralvjtherapy,vjsupportvjgroups,vjandvjspiritualvjcounseling.vjPhysica
lvjtherapy,vjheat,vjcold,vjwater,vjultrasound,vjTENS,vjmassagevjandvjtherapeuticvjexercise.
10. WHOvj3vj stepvj analgesicvjladder:vj *vj1-vjnonopioid
* 2vj-vjopioidvjforvjmildvjtovjmoderatevjpain
* 3vj-vjopioidvjforvjmoderatevjtovjseverevjpain
11. WHOvjfirstvjstepvjpainvjladder:vjmildvjpain/nonopioidvjanalgesicsvjsuchvjasvjNSAIDSvjorvjacetaminophenvjw/
vjorvjw/outvjadjuvantsvj(suchvjasvjpregablin)vj..vj"soreness."vjMedvjexamples:vjapapvj1000mgvjqvj6hrs,vjibu600mgvjq6vjhrs
,12. NSAIDs:vjNon-steroidalvjanti-
inflammatoryvjdrugs.vjassociatedvjwithvjseveralvjclinicallyvjsignificantvjcontraindicationsvjandvjdrugvjinteractions.vjNSAIDSvj
arevjequallyvjettectivevjinvjanalgesia,vjantipyreticvjandvjanti-
inflammatoryvjettects.vjChoicevjshouldvjincludevjSTEPSvj(simplicity,vjtolerability,vjevidence,vjprice,vjsafety).vjIfvjpatientvjfailsvjther
apyvjwithvjanvjagentvjfromvjonev j classvjofvjNSAIDs,vjusevjofvjanvjagentvjfromvjanothervjclassvjisvjreasonable.
13. COX2v j inhibitors:v j Celecoxibvj(Celebrex)vjselectivevjagentsvj(celecoxib)vjhavevjidealvjindicationvjinvjpatientsvjwithvjhigh
riskvjforvjGIvjbleed,vjhighvjintolerancevjofvjnon-selectivevjNSAIDS,vjorvjtreatmentvjfailurevjwithvjnon-
selectivevjagents.vjNSAIDsvjarevjofvjminimalvjvaluevjinvjneuropathicvjpain.vjNSAIDsvjproducevjavjflatvjdosevjresponsevjcurvevj(cel
lingvjettect)vjwithvjhighervjdosesvjprovidingvjnovjgreatervjeflcacyvjthanvjmoderatevjdoses.
14. Acetaminophen:vjTylenol.vjblocksvjPGvjsynthesisvjinvjCNS,vjinhibitsvjperipheralvjpainvjimpulses.vjAPAPvjdoesvjnot
interferevjwithvjCOXvj1vjorvjCOX2vjandvjthusvjhasvjnovjanti-inflammatoryvjbenefits.
15. WHOvjpainvjladdervjstepvj2:vjmoderatevjpain:vjweakvjopioidsvj(hydrocodone,vjcodeine,vjtramadol)vjw/vjorvjw/ou
tvjnonopioidvjanalgesicsvjw/vjorvjw/outvjadjuvantsvj"everyvjtimevjIvjdovjsomething,vjitvjhurts"vjmedvjexamples:vjapa325mgvj+vjc
odvj60mgvjq4vjhrs
16. WHOvjpainvjladdervj stepvj 3:v j severevjandvjpersistentvjpain,vjpotentvjopioidsvj(morphine,vjtapentadol,vjoxycodone,
hydromorphone,vjfentanyl,vjw/vjorvjw/outvjnon-
opioidvjanalgesicsvjandvjwithvjorvjwithoutvjadjuvantsvj"novjmattervjwhatvjIvjdovjitvjhurts,vjtheresvjavjbonevjstickingvjoutvjofvjmyvjskin
!"vjExamples;vjmorphinevj10mgvjq4vjhrs,vjhydromorphonevj4mgvjq4vjhr
17. WhatvjisvjthevjmechanismvjofvjNSAIDsvjandvjprecautionsvjtovjuse?:vjNSAIDSvjarevjeither
nonselectivevj(inhibitvjcoxvj1vjandvjcoxvj2)vjorvjselectivevj(inhibitvjcoxvj2).vjCoxvj2vjinhibitionvjisvjresponsiblevjforvjanti-
inflammatoryvjettects.vj-
vjCoxvj1vjcontributesvjtovjincreasedvjGIvjandvjrenalvjtoxicityvjassocvjwithvjnonselectivevjNSAIDS.vjUsevjwithvjcautionvjinvjpatientsvj
withvjdyspepsia,vjpepticvjulcers,vjbleeding,vjandvjpatientsvjtakingvjcorticosteroids.vjNephrotoxicityvjcanvjoccurvjinvjthevjelderly.
vjAvjboxedvjwarningvjisvjnowvjrequiredvjforvjprescriptionvjnonselectivevjNSAIDsvjandvjCelecoxibvjduevjtovjthevjincreasevjriskvjofvjc
ardiovascularvjeventsvjandvjGIvjbleeding.vjGenerallyvjptsvjprescribedvjNSAIDSvjwillvjneedvjPPI's.
18. ManagmentvjforvjNSAIDvjrisks:vjPtsvjmorevjpre-disposedvjtovjGIvjtoxicityvjifvjpre-existingvjulcervjorvjdyspepsia,
HvjPylorivjinfection,vjoldervjage,vjandvjsomevjconcurrentvjmedicationsvjincreasevjrisk.vjManagementvjoptionsvjforvjGIvjsidevjettectsv
jincludevjtakingvjwithvjfoodvjorvjmilk,vjSwitchvjtovjditterentvjNSAIDvjwithvjbettervjsafetyvjprofile,vjCOX2vjselectivevjagentvj(celecoxib)v
jand/orvjgastroprotectionvj(H2RA,vjPPI,vjmisoprostol
19. Celecoxib:v j isvjrecommendedvjforvjpatientsvjatvjincreasedvjriskvjofvjgastrointestinalvjbleedingvj/vjulcervjwhovjrequirevja
NSAIDvj-Sidevjettectsvjcanvjalsovjincludevjhtn,vjandvjworseningvjasthmavjsymptoms.
20. Tordolvj(Ketorolac):vj40mg,vjmaxvj5vjdays..vjhugevjbleedingvjriskvjbeyondvjthat!
, 21. Whenv j arev j NSAIDsv j indicatedv j andv j isv j onev j NSAIDv j betterv j /v j saferv j thanv j anoth
erv j invjavjgivenvjpatient?:vjUsefulvjforvjmildvjtovjmoderatevjpainvjthatvjarevjmediatedvjbyvjprostaglandinsvj(RA,vjmenstrualvj
cramps,
