PAIN MANAGEMENT

A. M. Takdir Musba

Department of Anesthesiology, Intensive Care and Pain Management

Faculty of Medicine, Hasanuddin University

MAKASSAR, INDONESIA

PAIN as a FOCUS NOW

Pain intensity as 5th vital sign

Pain Service as a part of Hospital Accreditation

Pain relief as Basic human right

Humanitarian reasons

Inadequate pain relief increased morbid and mortality

Protective Function : Withdrawal Reflex

Defensive Function : Immobilitation

Diagnostic Function : Acute Abdomen

PAIN

Functional Body System

Menurut perjalanan:1. Nyeri akut

2. Nyeri kronik

Menurut Patofisiologi:1. Nyeri nosiseptif

Nyeri somatik Nyeri viseral

2. Nyeri non-nosiseptif Nyeri neuropatik

Menurut etiologinya:1. Nyeri pasca bedah

2. Nyeri kanker

PAIN classification

PAIN CLASSIFICATION

Tissue damage – inflammation Or

nociceptive pain

Nerve damage

- Neuropathy

- Central neuropathic pain

- Peripheral neuropathic pain

Cancer pain

Acute pain

Chronic pain

Mild

Moderate

Severe

Is PAIN an important issue

in Medical Services ??

Freedom from pain is a basic human right

Patient does not know the diagnosis but only knows

the symptom – “ PAIN “

Adequate analgesia facilitates the evaluation and

subsequent treatment of underlying injury or disease

Unrelieved pain may have negative physical and

psychological consequences

Guide to Pain Management in Low-Resource Setting , IASP, Seattle, 2010

Response Cortical

Response Suprasegmental

Response Segmental

Response Local

- anxiety- fear- apprehension

- neurohumoral response- catecholamines- cortisol- dll.

- muclespasm- vasospasm- bronchospasm- decreased gastrointestinal

motility

-release pain substances-inflammation

RESPONSES TO NOXIOUS STIMULI

POINT OF VIEW

THEORY OF PAIN

PRINCIPLE OF PAIN MANAGEMENT

ANALGESIC CHOICE IN PAIN MANAGEMENT

CLINICAL CASE LEARNING

“ an unpleasant sensory and emotional experience

associated with actual or potential tissue damage or

described in term of such damage”.

IASP ( International Association for the

Study of Pain ) 1979

defined pain as :

H. Merskey, 1979

PAIN DEFINITION

Beecher

Pain perception depend on the meaning of injury

NO BRAIN, NO PAIN

Pain knowledge progress

Specificity Theory , Descartes, 17th century

Gate Controlled Theory , Melzack and Wall, 1965

Sensitization Theory, Woolf, 1992

Pain was faithfully

transmittedfrom

periphery to brain

1. Specificity theory

Descartes (17th Century)

2.GATE CONTROL THEORY by MELZACK and WALL

Ascending Action

System

Large

fibers

Central

Control

Descending

Modulation

Small

fibersDorsal Horn “Gate”

The Gate control theory of pain processing. T = Second-order transmission cell; SG = substantia

gelatinosa cell.

3.Sensitization theory by Woolf

Pain perception is the net process starting from:

Nociceptor activation

Neural conduction

Spinal transmission

Noxious modulation

Limbic & frontal – cortical perception

Spinothalamic

tractPeripheral

nerve

Dorsal Horn

Dorsal root

ganglion

Pain

Modulation

Transduction

Ascending

input

Descending

modulation

Peripheral

nociceptors

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.

Perception

Transmission

PAIN PATHWAY

Good Drug in a Right Doctor

AS A DOCTOR WE HAVE TO USE

“ LOGICAL APPROACH TO PAIN CONTROL “

Principle of Pain Management :

A Mechanism-based

DRG

•Opioids

•Gabapentinoids

•Clonidine

Modify by AHT

Ketamin

Paracetamol

Transduction

TransductionModulation

Perception

Transmission

Modulation

Safe and Effective Drug

SAFE is

low incidence of adverse reactions

low incidence of significant side effects under adequate

directions for use

low potential for harm

EFFECTIVE is

will provide clinically significant relief of the type of

pain when used appropriately

Selecting an ideal analgesic

for the management of pain

the drug’s pharmacologic profile

the patient’s medical history

the pain’s actual or expected intensity

the medication’s cost

the availability of the medication

NON – OPIOID

Paracetamol

NsNSAIDS

Coxib selective inhibitor

OPIOID

Weak opioid

• Codein

• Tramadol

Strong opioid

PARACETAMOL

It’s called COMMON ANALGESIC

Safer than NSAIDs

Have an anti pyretic effect

Safe Analgesic for Pediatric to Geriatric patient

Maximum Dose 4 gr/day

Toxic metabolite N-acetyl-p-benzoquinine imine

(NAFQI)

Paracetamol is an effective analgesic for acute pain; the incidence of adverse effects comparable to placebo (S) (Level I [Cochrane Review]).

Acute Pain Management: Scientific Evidence, 3rd edition, ANZCA, 2010

NsNSAID

Exhibit a spectrum of analgesic, anti- inflammatory, antiplatelet

and antipyretic by inhibition COX enzyme

Most commonly prescribed analgesic medications in the world.

i.e. Metamizole, Ibuprofen, Ketorolac, Diclofenac, Ketoprofen

Many used as the sole method of treatment mild to moderate pain

“Opioid sparing effect“ (20–40 %)

Adverse effects of NSAIDs are significant

and may limit their use

ARACHIDONATE

COX-1 COX-2

prostaglandins prostaglandins

• “Constitutive”• Expressed:

– GI mucosa– Kidneys– Platelets– Vascular

endothelium

• “Inducible”• Expressed:

– Site of injury– CNS

Adverse effect due to

Non-selective COX-1 and COX-2 inhibitor

cyclooxygenase inhibitor

Ibuprofen

Nabumetone

Etodolac

Dexketoprofen

Diclofenac

Meloxicam

NimesulideCelecoxib

Rofecoxib

Valdecoxib

AcetosalIndomethacin

Piroxicam

DualCOX

inhibitor

preferentially

COX-2selectiveinhibitor

COX-2selectiveinhibitor

COX-1selectiveinhibitor

preferentially

COX-1selectiveinhibitor

COXIB

GIT Incidence

CV Incidence

PCT, NSAIDs, COXIBs

J Can Dent Assoc 2002; 68(8):476-82

OPIOID

As a main drug for moderate to severe pain

Should be considered if acetaminophen or an NSAID

alone will not be sufficient

as combination with non-opioid

Strong Opioid : Morphine, Fentanyl, Pethidine

Weak Opioid : Codeine and Tramadol

OPIOPHOBIA DOCTOR ….

Opioid in Indonesia

Morphine considered to be the standard opioid analgesic, oralsustained release and IV prep. available

Fentanyl fast onset, more potent than morphine, less side effect, transdermal sustained and IV prep. available

Meperidine is not considered a first-line opioid analgesic medication, just IV preparation

Hydromorphone, semi-synthetic opioid agonist, more potent than morphine, just oral sustained release prep.

Codein, a weak opioid, is pro-drug of morphine, just oral

Tramadol, a weak opioid that acts on mu-receptors, is another reasonable alternative, oral and IV preparations

Equianalgesic Opioids Dosing

Oral dose

( mg )

Opioid Parenteral iv/sc/im (mg)

400 Meperidine 100

120 Tramadol 100

200 Codeine 130

30 Morphine 10

7.5 Hydromorphone 1.5

- Fentanyl 0.15 – 0.20

- Sufentanyl 0.02

Oral morphine (mg/day) by approximately dividing the oral morphine dose by 2.

e.q. Morphine 50 mg PO in 24 hrs = Fentanyl patch 25 mcg/hr

•McPherson ML. Demystifying Opioid Conversion Calculations: A Guide For Effective

Dosing. Amer Soc of Health-Systems Pharm, Bethesda, MD, 2010

•Vadalouca A. et al. Opioid rotation in patients with cancer. Journal of Opioid

Management 4:4 2008

Potentiation

Opioid

ParacetamolNSAIDsCoxibs

Nerve blocksGabapentinoids

Multimodal Analgesia or Balanced Analgesia

doses of each analgesic due to synergistic/additive effects

May side-effects of each drug

Optimal analgesia

Decreased costs

Kehlet & Dahl. Anesth Analg 1993;77:1048

Playford et al. Digestion. 1991;49:198

Gordon DB. Et al. Arch Intern Med. 2005; 165: 1574-1580

Rathmell JP, et al. Reg anest Pain Med. 2006;31:1-42

Rationale of Multimodal Analgesia

Synergy

Antagonism

Additive

Farmakokinetik parasetamol dan tramadol

Paracetamol

Paracetamol/Tramadol

Tramadol

0

1

2

3

4

0 2 4 6 8 10

Waktu (jam)

Parasetamol/

tramadolPara-

setamolTramadolB

eb

as

nyeri

• Onset kerja

parasetamol cepat

• Efek tramadol yang

bertahan lama

Medve RA, Wang Julia, Karim . Anesth prog 48:79-81. 2001

Choice of Analgesic Technique for Acute Pain

(Analgesic Ladder of WFSA)

Opiate

And

NSAID

and

Paracetamol

Oral route available – give orally

Oral route unavailable –Rectal paracetamol & NSAID,

Opiate: IV, PCA, IM algorithm,

Epidural infusion analgesia

Weak Opioid

and

NSAID

and

Paracetamol

ParacetamolPain decreases

as time passes

Interventional procedures for

chronic non-cancer pain

WHO Analgesic LADDER

for Cancer Pain

PAIN ASSESSMENT

INDONESIA TIDAK NYERI NYERI RINGAN NYERI SEDANG NYERI SEDANG NYERI HEBAT NYERI TAK TERTAHANKAN

kort

ikost

ero

id

NSA

ID

CO

XIB

Keta

min

e

Gabapenta

noid

(Gabapent

in, Pre

gabalin

)

PARACETAMOL

OPIOID(Morphine, Fentanyl, Tramadol, Codein

)

TAKE HOME MESSAGE ….

UNDERSTANDING ABOUT PAIN IS A PREREQUISITE

TO TREAT THE PAIN

MECHANISM-BASED PHARMACOANALGESIA

MUST TO BE CONSIDER FOR OUR PAIN PATIENT

SO MANY GUIDELINE TO RELIEF THE PAIN , BUT

SAFE AND EFFECTIVE ANALGESIA DEPEND ON THE

THE DOCTOR KNOWLEDGE

Thank you very much for your kind attention

Together against PAIN

CASE LEARNING :

ACUTE PAIN

Pasien dengan keluhan nyeri pada daerah

pinggang yang menjalar ke sisi kaki kanan.

Dialami sejak tiga minggu yang lalu pada saat

mengangkat sesuatu yang berat di rumah.

Rasa nyeri menusuk di di daerah pinggang dan

menjalar seperti kesetrum ke kaki sampai betis

Apa yang kita lakukan ?

Anamnesis

Intensitas nyeri

Jenis nyeri

Faktor yang memperparah dan mengurangi

Analgesia sebelumnya

dll

Pemeriksaan fisik

Pemeriksaan Penunjang

Penanganan awal

Diagnosis

Terapi

Pilihan Analgesia

Parasetamol

NSAIDs ( non-specific or Specific inhibitor )

Opioid

Anti neuropatik

Multimodal Analgesia

Evidence-based

Karakteristik pasien :

Comorbid pasien

Usia

Jenis Kelamin

dll

IPM Evidence,2012

IPM in Low Back pain

CASE LEARNING :

CHRONIC PAIN

Seorang ibu , umur 70 tahun datang dengan

keluhan nyeri pada lutut, yang dialami sejak

beberapa tahun namun memberat 3 bulan terakhir.

Apa yang kita lakukan ?

Anamnesis

Intensitas nyeri

Jenis nyeri

Faktor yang memperparah dan mengurangi

Analgesia sebelumnya

dll

Pemeriksaan fisik

Pemeriksaan Penunjang

Diagnosis

Terapi

Osteoarthritis

Clinical Characteristics

Deep aching pain, poorly localized

May occur in one or two joints or be generalized

Pain occurs in involved joint and is relieved by rest

Joint stiffness in morning and after periods of inactivity

Aching “night pain” is common

If pain is severe on activity and asymptomatic at rest, evaluate for neurogenic claudication

(Loesser et al, 2001)

Osteoarthritis : Diagnosis

History: age, functionality, degree of pain, stiffness, time of occurrence (e.g., morning, at rest, during activity)

Physical examination: range of motion, tenderness, bony enlargement of joint

Laboratory findings: radiograph, CBC, synovial fluid analysis

Decision making in pain management ;

Ramamurthy, James N, Alamnou. 2006

Osteoarthritis :

pain treatment considerations

Mild-to-moderate pain Acetaminophen

Moderate-to-severe pain NSAIDS, COX-2 inhibitor

Opioids ?

Non-pharmacologic treatment

Severe arthritis pain: COX-2 drugs and non-specific NSAIDs do not provide substantial relief

NSAIDS, COX-2 inhibitor

Opioids

Non-pharmacologic treatment

Drug therapy ineffective and function severely impaired

Interventional pain procedures

Surgical Treatment

(ACR, 2000; APS, 2002; Manek et al, 2000)

IPM in KNEE OA

Case Learning

Cancer Pain

Ny. M , 56 tahun datang ke poliklinik dengan

diagnosa Tumor Mammae dengan keluhan nyeri,

tanpa riwayat pengobatan. Penilaian nyeri

menunjukkan NRS 6/10. tanpa keluhan yang lain.

Bagaimana rencana penanganan nyeri pasien ini ?

a) Diberikan Parasetamol dan NSAID

b) Diberikan parasetamol, NSAIDs dan weak opioid

c) Diberikan parasetamol dan strong opioid

d) Cukup diberikan weak opioid

WHO Analgesic

LADDER

STEP-2 LADDER

MODERATE PAIN : VAS, NRS 4 - 6

NON-OPIOID

ASETOMINOPHEN

NSAID

WEAK OPIOID

CODEINE

TRAMADOL

ADJUVANT ( same in step 1 )

ANALGESIC EFFECT IN CERTAIN PAIN CONDITION

DUE TO SIDE EFFECT

DUE TO THE COMPLAIN

Case Learning

Cancer Pain

Tn. Ahmad dengan osteosarkoma daerah femur datang di

UGD RS saudara dengan keluhan nyeri luar biasa (9/10)

pada daerah tumor

Bagaimana anda menangani nyeri pasien ini ?

A. memberikan strong opioid sustained release dan non-

opioid

B. memberikan strong opioid kerja cepat dan non-opioid

C. memberikan sediaan weak opioid

D. memberikan paracetamol intravena dan NSAIDs

intravena

WHO Analgesic

LADDER

Comparative Onset of Opioid Drug Effect

Minutes since bolus injection

0 5 10 15 20

Perc

ent

of

peak e

ffect

site c

oncentr

ation

0

20

40

60

80

100Methadone

Remifentanil

Fentanyl

Sufentanil

Alfentanil

Hydromorphone

Morphine

Meperidine

Morphine Sustained Release to Transdermal Fentanyl

Waktu

Ko

ns

en

tra

si o

pio

id

-

-

Analgesic window

Kondisi stabil (dalam 12 jam)

IV

ER: sustained release opioid

IV : intravena opioid

TD : transdermal opioid

ER

TD

Lanjutan Cancer Pain

Setelah mendapatkann strong opioid kerja cepat berupa

Fentanyl intravena 1 mcg/kgBB, pasien tetap tidak

membaik setelah 15 menit. Pasien tetap sadar ( tanpa

sedasi ) dengan nyeri 8/10 . Apa anjuran saudara ?

A. memberitahukan pasien bahwa dosis intervalnya adalah 4

jam dan pasien sebaiknya menunggu

B. Memberikan dosis IV berikutnya setelah sejam

C. segera memberikan dosis berikutnya dengan meningkatkan

dosis sekitar 50-100% dari dosis sebelumnya

D. Menghubungi konsultan nyeri atau paliatif

Opioid Dose EscalationAlways increase by a percentage of the present dose based upon patient’s pain

rating and current assessment

Mild pain

1-3/10

25% increase

Moderate pain

4-6/10

25-50% increase Severe pain

7-10/10

50-100% increase

STEP-3 LADDER

SEVERE PAIN : VAS, NRS : > 7

NON-OPIOID

ASETOMINOPHEN

NSAID

STRONG OPIOID

MORPHINE

FENTANYL

PETHIDINE , Etc

ADJUVANT ( same in other step )

ANALGESIC EFFECT IN CERTAIN PAIN CONDITION

DUE TO SIDE EFFECT

DUE TO THE COMPLAIN

Thank you very much for your kind attention

Together against PAIN