essential points considering better treatment in pain management

8/10/2019 Essential Points Considering Better Treatment in Pain Management

1/43

KRT Lucas Meliala

Guru Besar Luar Biasa

Bagian Ilmu Penyakit Saraf

Fakultas Kedokteran Universitas Gadjah Mada

Yogyakarta


2/43

Curriculum Vitae

Nama : Prof. Dr. KRT. Lucas Meliala, SpKJ, SpS(K)

Tempat/tanggal lahir : Membang Muda (Sumut), 22 September 1941

Alamat : Jl. Nagan Lor 70, Jogjakarta

Telepon : (0274) 450758

Fax. : (0274) 374052

Mobile : 0815 687 0584

E-mail : [email protected]

Pendidikan : Lulus Dokter tahun 1969,alumnus FK-UGM

Lulus Spesialis Saraf & Jiwa tahun 1974

alumnus FK-UI, FK-UGM, FK Unair

Pekerjaan : Staf Fakultas Kedokteran UGM

bagian IP Saraf dan Jiwa sejak

tahun 1968 sampai sekarang

Organisasi : 1999-sekarang : Ketua Pokdi Nyeri Perdossi

Anggota IASP, ENS

Ketua Governing board IPS


3/43

Dalam praktek sehari-hari, nyeri banyak

ditemukan.

Masalahnya:

Jenis nyeri apa ??


4/43

Nyeri nosiseptif

Somatik

Viseral

Nyeri non-nosiseptif

Neuropatik

Simpatetik

Nyeri fungsional


5/43

Tipe nyeri lain yang spesifik:

Functional pain

Muscle pain

Colicky pain

Reffered pain

Post-operative pain


6/43

BIOMEDIKAL(BIOMEDICAL)

BIOPSIKOSOSIAL(BIOPSYCHOSOCIAL)

NOSISEPSI(NOCICEPTION)

NYERI(PAIN)

PENDERITAAN(SUFFERING)

PERILAKU NYERI(PAIN BEHAVIOUR)

PENGERTIAN MODEL NYERI

BYERS AND BONICA, 2001MODIFIKASI PENULIS


7/43

PENYAKIT, KESAKITAN, ATAU

KEDUANYA

SAKIT

SAKITPenyakit

tanpa

kesakitan

Penyakit dan

kesakitan

Kesakitan

tanpa

penyakit

Ulkus (luka)Tanpa Ulkus

( tidak luka)

Nyeri perut

fungsional

yang kronik

BERU A M E


8/43

Three year incidence of 10 common presenting symptoms and proportion

of symptoms with a suspected organic cause in US primary care

3yearincidence(%)

4

6

8

10

Organic Cause

2

0

Mayou & Farmer, 2002


9/43

Pain of migraine differs from cancer pain

Cancer pain differs from the pain of

arthritis Arthritis pain differs from the pain of

fibromyalgia


10/43

Multiple Pain Mechanisms

Nociception

Peripheral sensitization

Central sensitization

Ectopic excitability

Decreased inhibition/

Structural reorganization


11/43

Multiple Pain Symptoms

Spontaneous Pain

Superficial/Deep

Continuous/Intermittent

Evoked Pain

Thermal/MechanicalAllodynia

Hyperalgesia


12/43

Heat

Cold

Intense

Force

Mechanical

Heat

Cold

PainAutonomic Response

Witdrawal Reflex

Nociceptor sensory neuron

NOCICEPTIVE PAIN

Noxius Pheripheral Stimuli

Spinal cord

Brain

Modifikasi Meliala, 2005


13/43

Macrophage

Neutrophil

Granulocyte

Tissue Damage

Spontaneous Pain

Pain Hypersensitivity

Reduced Threshold : AliodynaIncreased Response : Hyperalgesia

Nociceptor sensory neuron

INFLAMMATORY PAIN

Inflammation

Spinal cord

Mast Cell

Brain



14/43

PERCEPTION

MODULATION

TRANSMISSION

TRANSDUCTION

PAIN SERIES OF EVENTS

PAIN


15/43

Spontaneous Pain


Peripheral Nerve

Damage

NEUROPATHIC PAIN

Spinal cord Injury

Brain



16/43

Normal Peripheral

Tissue and Nerves

FUNCTIONAL PAIN

Abnormal Central

Processing

Spontaneous Pain


Brain



17/43

NYERI AKUT Simtom

NYERI KRONIK Disease

Sign :

MerengutPostur abnormal

Doctor shopping

Dll

Simptom :

AnsietasDepresi

Gangguan tidur

Marah, dll


18/43

Chronic Pain

The prevalence of musculoskeletal pain

increases with rising age.

Chronic pain is twice as common in peopleaged more than 75 yo compared with the

25- to 34-yo group :

Arthritis : increases tenfold Musculoskeletal condition : increases fourfold

Schnitzer, 2006


19/43

Chronic Pain

Chronic pain is often produces suffering

not only in an individual experience but

also a cultural societies and make serious

disruption of their lives.


20/43

CHRONIC PAIN

Chronic pain patient has 4x to have emotionaldisturbances:

Fear - avoidance behavior

Anxietyand sleep disturbanceDepression,helplessness, irritability, suicidal

risk

CNS toxicitydue to inappropriate drug useLoss of job,family and community status

CHRONIC PAIN IS A DISEASE ENTITY AND CAN KILL


21/43

Chronic Pain Defined by

Mechanisms

Peripheral (nociceptive)

Primarily due to

inflammation or damage

in periphery NSAID, opioid responsive

Behavioral factors minor

Examples

OA

Acute pain models (e.g.third molar, post-

surgery)

RA

Cancer pain

Central (non-nociceptive) Primarily due to a central

disturbance in painprocessing

Tricyclic responsive

Behavioral facto rs mo reprominent

Examples

Fibromyalgia

Irritable bowel syndrome

Tension and migraineheadache

Interstitial cystitis /vulvodynia, non-cardiacchest pain / etc.

Mixed

Neuropathic


22/43

BARRIERS TO PAIN MANAGEMENT

Inadequate pain assessment 76%Patient reluctance to report pain 62%

Patient reluctance to take opioids 62%

Physician reluctance to prescribe opioids 61%

Inadequate staff knowledge about pain

management

52%

Nursing staff reluctance to give opioids 38%

Excessive state regulation of analgesics 18%

Lack of psychological support services 11%

Lack of equipment 6%Lack of neurodestruction procedures 5%

Lack of access to wide range of analgesics 3%


23/43

Acute Pain (McQuay & Moore, 1999)

TREATMENT METHODS

Remove the cause

Of painMedication Regional

analgesiaPhysical

methods

Psychological

approaches

Surgery

Splinting

Low Tech

Nerve blocks

Local anaesthetic

opioid

High Tech

Epidural infusion

Local anaesthetic

opioid

physiotherapy

manipulation

TENS

Acupuncture

Ice

relaxation

psychopro-

phylaxis

hypnosis

Non-opioid

Aspirin & others

NSAIDS

Paracetamol

combinations

OpioidMorphine

others

ANALGESIC MEDICATIONS


24/43

ANALGESIC MEDICATIONSPRIMARY ANALGESICS

Acetminophen

Prostaglandin synthesis inhibitors Salicylates

Traditonal NSAIDs

COX-2-selective NSAIDs (coxibs)

Tramadol Opioids

Traditional

Mixed

ADJUVANT MEDICATIONS

Antidepressants

Anticonvulsants

Local anesthetics

Miscellaneous agents


25/43

Chronic Pain (McQuay & Moore, 1999)

TREATMENT METHODS

Analgesics Block nerve transmission Alternatives

Conventional

NSAID

Parasetamol

to opioid

Unconventional

antidepressant

anticonvulsant

others

Reversible

Local anaesthetic

steroid

opioid

Irreversible

surgery

Nerve destruction

StimulatorsAcupuncture

Hypnosis

Psychology


26/43

Treatment

Paracetamol should be used for the first line

analgesic agent due to its favourable side effect

and safety profile

COX-2 inhibitors and non selective NSAID weredeveloped with the goal of delivering pain relief

with caution on cardiovascular and or

cardiorenal risk

The additional of weak opioids is recommended

when greater analgesia desired

Schnitzer, 2006


27/43

Achieve pain control

Earlier is better


28/43

TXA2 PGI

VasokontriksiAgregasi Platelet

VasodilatasiDisagregasi Platelet

COX-2COX-1

Keamanan kardiovaskuler NSAID

tergantung dari penghambatan COX-1

dan COX-2 di platelet


29/43

Pembagian cyclooxygenase inhibitor

Acetosal

KetorolacIndomethacin

Piroxicam

IbuprofenNabumetone

Etodolac

Dexketo-profen

Diclofenac

Meloxicam

NimesulideCOXIB

COX-1selective

inhibitor

PreferentiallyCOX-1

selectiveinhibitor

DualCOX

inhibitor

PreferentiallyCOX-2

selectiveinhibitor

COX-2selective

inhibitor

CV Incidence

GIT Incidence


30/43

The task of a doctor:

TO CURE IS SOMETIMES TO TREAT IS OFTEN

TO COMFORT IS ALWAYS

A. Pare (1598)


31/43

NATURAL HEALING

All tissues, with the exception ofnerves,

heals by :

Fibrosis

Regeneration

Remodelling

Sukacita yang besar selalu didahului oleh penderitaan yang hebat


32/43

Bone :- heals well

- by remodelled over time

Muscle :- heals fairly well

- by fibrosis and no remodelling

Ligaments :- heal by fibrosis and scarring

Joint capsul :- is well innervated

- little is known of healing- scarring may reduce joint mobility

Disc :have a very limited blood supply

degenerate with repeated trauma

dehydrate fibrous replacement.


33/43

100 years ago found that aspirin be used

as :

Antiinflamation

Analgetic

Antiaggregation

65 years ago is known that aspirin havegastrotoxicity effects


34/43

NSAID

Discovered about 40 years ago

Now, NSAID (NSAIDs) is in circulation and

growing, but failed to be better than aspirin


35/43

GI effects of NSAID Nuisance symptoms

Heart-burnNausea

Dyspepsia

Abdominal pain

Mucosal lesions

Ulcerseen on endoscopy

Seriuous GI complications

Perforated ulcers

Bleeding


36/43

For Attention !!

Endoscopy results conducted on NSAID

users, 80% is the ulcer, but asymptomaticand may heal


37/43

GI Complications in OA and RA

OAHospitalizations

RAHospitalizations

RADeaths

No. of patients 1283 3883 2921

Person-year of observation 3234 19,961 12,224

Person-year taking NSAID 2199 15,638 8471

No. of GI events 19 228 25

No. of GI events while taking

NSAID

16 205 19

Rate per year while taking NSAID

(%)

0.73 1.31 0.22

Rate per year while not taking

NSAID (%)

0.29 0.19 0.05

Relative risk while taking NSAID 2.51 6.77 4.21

Singh & Triadafilopoulos, The Journal of Rheumatology 1999, Vol.26, Suppl.56


38/43

NSAID-associated GI Hospitalizations and

Deaths:National Incidence Estimates

(United State)

Diagnosis No. of

Patients

Exposed

GI

Hospitalization

Rate/Year

No.of

Hospitalization

/Year

GI Death

Rate/Year

No.of

Deaths/Year

RA 2,000,000 1.3% 26,000 0.22% 4400

Probable

RA

3,000,000 0.7%* 21,000 0.11%** 3300

OA 8,000,000 0.7% 56,000 0.11%** 8800

Total 13,000,000 103,000 16500

* Estimated

** Estimated from ratio of GI hospitalizations



39/43

Number of Deaths associated with NSAID-induced GI

Damage, Compared with Other Causes, US

Population,1997

Numberofd

eaths



40/43

Percentage of People Who Are Unaware of NSAID-

related GI Complications in a Cohort of Regular NSAID

Users. Rx:prescription; OTC:over-the-counter

Aware of complications but unconcerned

Unaware of complications NSAIDs can cause


P t f R l NSAID U Wh E t t


41/43

Percentage of Regular NSAID Users Who Expect to

Experience a Warning Sign Before a serious GI

Complication. Rx: Prescription; OTC: over-the -counter

68%

32%

44%

56%

Dont expect warning signExpect warning sign

Rx Users OTC Users



42/43

doses of each analgesic

Improved anti-nociceptiondue to synergistic/additive effects

May severity of side effects

of each drug

Adapted from Kehlet H, Dahl JB.Anesth Analg.,1993;77:10481056.

Potentiation

Opioid

NSAIDs,COX-2 inhibitors,regional blocks,2-agonist

A N E X A M P L E

Multimodal Analgesia

Berbuatlah dan cintailah tanpa memperhitungkan kebahagiaanmu sendiri, dan engkau akan berbahagia sepanjang waktu


43/43

essential points considering better treatment in pain management

Documents