This document discusses the history and treatment of pain management. It begins with a description of pain treatment in ancient times, which involved crude methods like partial strangulation. It then outlines major developments in pain relief, including the discovery of morphine in 1806, the introduction of nitrous oxide and ether for anesthesia, and the development of newer opioids and local anesthetics. The document also discusses the physiology of pain pathways in the body and classifications of pain. It emphasizes the anesthesiologist's role in acute and chronic pain management, including the use of various pharmacological therapies and procedures.

1. Pain!!!!!

2. Dr. Mridul M. Panditrao
CONSULTANT
DEPARTMENT OF ANESTHESIOLOGY AND INTENSIVE CARE
RAND MEMORIAL HOSPITAL
FREEPORT, GRAND BAHAMA
THE COMMONWEALTH OF BAHAMAS

3. Pain
A universal problem!
For eternity, it has plagued mankind
Till 18th century there was nothing!
Remedies like
Opium, Alcohol, Mandragora, soporific sponges
and Magical potions were tried, but the dark
ages of “Pain and suffering” continued

4. AGE OF DARKNESS
NO ANALGESIA
NO ANAESTHESIA
NO DEFINED SURGERY
“AGONY GALORE!!!”

5. BARBARIC PRACTICES
WOODEN BOWL & WOODEN HAMMER”
PARTIAL STRANGULATION
“WHISKY BOTTLE: ½ YOU & ½ ME”
MAGIC & WITCH-CRAFT
MANDRAGORA / HASHISH / HERBS
„ DECREE OF CHURCH‟

8. METHODS OF PAIN RELIEF

9. “ DAWN OF ANALGESIA ”
FREDERICH SERTURNER:1806 MORPHINE
“LAUGHING GAS ” PARTIES & HORACE WELLS : Dec. 10, 1844, N2O IN
DENTISTRY
DEBACLE OF N2O DEMONSTRATION & SETBACK
GQC COLTON : RE-INTRODUCES N2O AS A CARRIER GAS

10. SWEET OIL OF VITRIOL
(“WHIFF OF ETHER”)
16TH OCTOBER 1846
William Thomas Greene MORTON
USHERING IN OF “ ERA OF ANAESTHESIA”
“INVENTOR AND REVEALER OF ANESTHETIC INHALATION
BEFORE WHOM IN ALL TIME, SURGERY WAS AGONY
BY WHOM PAIN IN SURGERY WAS AVERTED AND ANNULLED
SINCE WHOM SCIENCE HAS CONTROL OF PAIN”
WORLD ANAESTHESIA DAY

12. “GOOD OUT OF BAD”
LEAF CHEWING NATIVES OF ANDIES
(PERU & BOLIVIA): “NUMBNESS OF
MOUTH”
COCAINE
ADVENT OF LOCAL ANALGESICS
REGIONAL: SPINAL, EPIDURAL, FIELD
“POST-OPERATIVE ANALGESIA”

13. “MORPHINE & COMPANY”
• NEWER OPIOIDS: FENTANYL….
• “NEURO-LEPT ANAESTHESIA”
• ENDOGENOUS OPIOIDS:
ENDORPHINES, ENCEPHALINS
• OPIOID RECEPTORS: μ, κ, ζ, δ, ε
• “CUSTOM OPIOIDS” : REMIFENTANIL

14. INTRODUCTION
For All The Happiness
Mankind can gain.
Is not in pleasure
But in rest from “pain”
JOHN DRYDEN

15. INTRODUCTION (Contd.)
MAGNITUDE Of PROBLEM
 Millions of Post-op pts : 48-53% unrelieved
 Moderate pain in hospitalized pts: ~ 40%
 Child- bearing age group females : 35-43%
 Ch. Non-oncogenic pain; Ch. Arthritis : 25-30%
 Cancer Patients suffering from pain: 80%+
Panditrao MM, Pain and it’s Physiological considerations, eds, Deshpande S et al. Principles of Anaesthesia,
Paras, Hyderabad, 1st edition. 2007 : 180

16. INTRODUCTION (Contd.)
Nociception: Transduction
Transmission
Modulation
Perception
“Gate Control Theory of Melzac & Wall” : 1965

17. INTRODUCTION (Contd.)
“Reynolds Theory of ‘Supra-Spinal Descending
Control in Modulation in Dorsal Horn’ ”: 1969
“Woolf C.J - Supra spinal inhibition of
nociception” : 1989

18. INTRODUCTION (Contd.)
Definition
The International Association for the Study of Pain
“Unpleasant sensory & emotional
experience associated with actual or
potential tissue damage or described in
term of such damage.”

19. CLASSIFICATION OF PAIN
• Origin
• Pathology
• Onset & Duration

20. Classification of Pain by Origin
 Somato-sensory Pain
 Deep Visceral Pain
 Referred Pain
 Psychogenic Pain

21. Classification of Pain by Pathology
 Nociceptive pain
 Neuropathic Pain

22. Classification of Pain by Onset & Duration
1. Acute- a) Surgical- (i) Pre-operative
(ii) Intra-operative
(iii) Post-operative
b) Non-surgical- (i) Traumatic
(ii) Organic- Physiological
Pathological
(iii) Psychosomatic

23. Classification of Pain by Onset & Duration
2. Chronic- a) Oncogenic
b) Non-oncogenic
(i) Organic
(ii) Neuropathic

24. Terms Used In Pain Management
• Hyperesthesia
• Hyperpathia
• Hypesthesia
• Neuralgia
• Paresthesia
• Radiculopathy

25. Terms Used In Pain Management
• Allodynia
• Analgesia
• Anesthesia
• Anesthesia dolorosa
• Dysesthesia
• Hypalgesia
• Hyperalgesia

26. Psychological and behavioural response to acute pain
 fear
 general sense of unpleasantness or unease
Anxiety
Negative emotions: depression
Sleep deprivation
Existential suffering: may lead to
patients seeking actively end of life.

27. Psychological response to chronic pain
Intermittent pain produces a physiologic response similar to acute
pain.
Persistent pain allows for adaptation (functions of the body are
normal but the pain is not relieved)
Chronic pain produces significant behavioural and psychological changes
The main changes are:
- depression
- an attempt to keep pain - related behaviour to a minimum
- sleeping disorders
- preoccupation with the pain
- tendency to deny pain

28. Psychological response to chronic pain
• often is associated with a sense of
hopelessness and helplessness
• abnormal temperature regulation, tactile
dysfunction
Alteration in sensory function  dysfunctions of the
general or special
senses  chronic
pain

29. Immunological effects of Pain
• Decrease natural killer cell counts
• Effects on other lymphocytes not yet defined.

30. Nociception
Transduction
Transmission
Modulation
Perception

31. Panditrao MM, Pain and it’s Physiological considerations, eds, Deshpande S et al. Principles of Anaesthesia, Paras, Hyderabad, 1st
edition. 2007 : 180

32. Nociception
• “Gate Control Theory of Melzac & Wall” : 1965

34. Nociception
“Reynolds Theory of „Supra-Spinal
Descending Control in Modulation in
Dorsal Horn‟ ”: 1969
“Woolf C.J - Supra spinal inhibition of
nociception” : 1989

35. Peripheral and Central Pathways for
Pain
Ascending Tracts Descending Tracts
Cortex
Thalamus
Midbrain
Pons
Medulla
Spinal Cord
(Brookoff, 2000)

37. Pain-Sensing System in the
Malfunction in Chronic Pain
Pain Acute pain:
Sensing Pain-sensing signals are
initiated in response to a
In chronic pain, stimulus
pain signals are • They elicit a pain-
generated without relieving response
physiologic
significance
Chronic pain:
Pain signals are
generated for no reason
and may be intensified
• Pain-relieving
mechanisms may be
defective or
deactivated
(Illustration: Seward Hung, 2000)

38. Pain Pathway:s & Multimodal Analgesia
Opioids
Pain 2 -agonists
Centrally acting analgesics
COX-2 selective inhibitors
Traditional NSAIDs
Ascending
input Descending
modulation Local anesthetics & blocks
Dorsal Opioids ,2-agonists
horn NMDA antagonists
Interventional modalities
Dorsal root
ganglion
Spinothalamic
tract Local anesthetics
Peripheral
Peripheral nociceptors
nerve Local anesthetics
COX-2 selective inhibitors
Trauma Traditional NSAIDs
From: Gottschalk et al. Am Fam Physician. 2001;63:1979-1984.

39. Panditrao MM, Pain and it’s Management, eds, Deshpande S et al. Principles of Anaesthesia,
Paras, Hyderabad, 1st edition. 2007 : 845

40. THE ANAESTHESIOLOGIST
NOT JUST IN THE OPERATING ROOM
• Operating room • “CPCR” team
hospital • Respiratory therapy
physician office • Administration
• Labor & delivery suite operating room
hospital
• Other procedural areas
Medical College
• Intensive care unit
• Education
• PACU health professionals
• Pain management public
acute • Research
chronic / cancer

41. The management of pain is a
multidisciplinary team effort
involving
physicians, psychologists, nurses, and
physical therapists.
Anesthesiologists are ‘physicians and
experts’ in the diagnosis and
treatment of acute and chronic pain
disorders.
American Society of Anesthesiologists. 2003

42. ANAESTHESIA
FOR “PAIN MANAGEMENT”:
ACUTE : OPERATIVE
PHARMACOTHERAPY & SPECIAL PROCEDURES
REGIONAL & LOCAL BLOCKS
NEURAXIAL PROCEDURES

43. Pharmacological
Depending upon site of Action
CNS: GAAs, N2O, Opioids
Peripherally :-------- NSAIDS
LAAs
Neuraxially : -------- ADJUVANTS

44. Panditrao MM, Pain and it’s Physiological considerations, eds, Deshpande S et al. Principles of Anaesthesia, Paras, Hyderabad, 1st edition. 2007 : 180

45. Panditrao MM, Pain and it’s Management, eds, Deshpande S et al. Principles of Anaesthesia,
Paras, Hyderabad, 1st edition. 2007 : 845

46. Adjuvants to Neuraxial Blockade: Why needed?
Problems of LAAS
• If duration of action to be prolonged?
• Motor blockade causing interference with the
mobility of the patient
• Sympathetic blockade leading to bradycardia
and hypotension.
• So alternatives to LAAs were tried

47. ALTERNATIVES TO LAAs:
Problems:
• Side effects of Opioids
• Difficulty in procuring
• Minimal muscle relaxation
• Other agents viz.
Clonidine, Neostigmine, Ketamine, Midazolam
and their side effects

48. LAAs & ADJUVANTS
COMBINATION!!!!

49. Advantages of Adjuvants
• Improvement of quality of block
• Onset of analgesic effect of LAAs is enhanced
• Duration of action of LAAs is prolonged
• Dose requirement of each drug is reduced
• Lower incidence of side effects

50. Routes of Administration
• In sub-arachnoid space when only SA
is given
• In epidural space through epidural
catheter when Combined Spinal
Epidural (CSE) Analgesia is given

51. Various drugs used as Adjuvants
• Opioids agonists: Morphine, Fentanyl etc.
Agonist /antagonist:
Butorphanol, Buprenorphine
• Clonidine
• Neostigmine
• Ketamine
• Midazolam
• Tramadol

52. SUB-ARACHNOID BLOCK

54. Combined Spinal Epidural
(CSE)
in the Same Intervertebral Space
Using Combipack

69. Combined Spinal &
Epidural (CSE) in two
different Intervertebral
Spaces

76. CONTINUOUS
SUPRA-CLAVICULAR
BRACHIAL-PLEXUS
BLOCK

83. CHRONIC PAIN
Prevalence of chronic pain
• - 35% in the society
• - 40% in females, 31% in males
• - 25% ≤ 18 years, 55% ≥ 65 years
• 20% of the chronic pain population
= postsurgical chronic pain
23rd International Winter Symposium in Leuven, Dr. Jan Maeyaert, 11-12 january 2008

84. CHRONIC PAIN
Prevalence of chronic pain
• - 35% in the society
• - 40% in females, 31% in males
• - 25% ≤ 18 years, 55% ≥ 65 years
• 20% of the chronic pain population
= postsurgical chronic pain
23rd International Winter Symposium in Leuven, Dr. Jan Maeyaert, 11-12 january 2008

85. Prevalence and Impact
of Chronic Pain on Society
• Chronic pain is one of the most common conditions for
which people seek medical treatment
• 35% of Americans suffer from chronic pain
• >50 million Americans are partially or totally disabled by
chronic pain
• 50 million workdays are lost per year
• $100 billion is the estimated annual cost in lost
productivity, medical costs, and lost income
(American Pain Society, 2001; Gitlin, 1999; Glajchen 2001; Loesser et al, 2001)

86. Undertreatment of Chronic Pain
>40% to 50% of patients in routine practice
settings fail to achieve adequate pain relief
In a recent study of 805 chronic pain
sufferers, >50% had to change physicians to
achieve relief because the physician:
was unwilling to treat pain aggressively
did not take the patient’s pain seriously
had inadequate knowledge about pain treatment
(American Pain Society, 2001; Glajchen, 2001; Lister, 1996; Portenoy, 1996)

87. The story of chronic pain
WHY?
-Such a high incidence
-Increasing incidence by aging
- Higher in females

88. The story of chronic pain
The answer: a CUMULATIVE STATE of
CENTRAL SENSITIZATION
over time

89. ACUTE
SOMATIC
nociceptive
ACUTE
NEUROGENIC Ideal cocktail for
VISCERAL
DAMAGE SENSITIZATION nociception
Psychogenic
factors
(stress, anxiety)

90. Somatic Nociceptive
pain
(Trauma & Surgery)
NEUROPATHIC PAIN VISCERAL
CENTRAL
(nerve dysfunction, NOCICEPTIVE PAIN
nerve injury) SENSITIZATION (renal/biliary colic,
dysmenorhea)
PSYCHOGENIC PAIN
(anxiety, depresseion,
prolonged stress)

91. INTRACTABLE
CHRONIC PAIN
UNRESPONSIVE
TO ANALGESICS

92. CHRONIC PAIN is
a provoked irreversible
progressive or stable
dysfunctional or neurodegenerative disease
of the CNS
• Whatever is the initial pain mechanism
• All types of unrelieved pain end as
CENTRAL NEUROPATHIC PAIN

93. Role of the Anesthesiologist
Define the patients at risk
Development of preventive strategies
Early and prompt diagnosis and treatment
Information of the public and medical
community
23rd International Winter Symposium in Leuven, Dr. Jan Maeyaert, 11-12 Januari 2008

94. Role of the Anaesthesiologist
Define the patients at risk
• Unrelieved acute pain
• Anxiety
• Depression
• Prolonged stress
• Nerve damage CNS/PNS
• Recurrent surgery
• Female sex/genetic predisposition

95. Role of the Anaesthesiologist
Develop preventive strategies
• Neuraxial or regional nerve blocks
• Multimodal pain treatment protocols
• Early use of antidepressants and anti-epileptics
in patients with nerve damage
• Use of COX-II inhibitors
• Opiate sparing strategies

96. Role of the Anaesthesiologist
Start early diagnosis and treatment when pain persists
• 50% reduction of chronic pain in CVA and postherpetic
neuralgia pain patients by starting amitryptiline in the
acute phase
• 8 fold decrease of chronic low back pain by starting
multimodal therapy in the acute phase
• Patients with acute neuropathic pain after surgery do
better when amitryptiline and gabapentin are started
early after surgery

97. Role of the Anaesthesiologist
Inform the patients / medical community
• Negative consequences of unrelieved pain
• Possibilities to manage the pain
• Inform the surgeons
- to use minimal invasive techniques
- To take care of neurogenic structures
- Repeat surgery for chronic pain is not an option
- Surgery in a patient with a chronic pain condition is less successful
- To infiltrate the site of incision with long acting local anesthetics

98. Chronic Pain : Oncogenic
• “Pain is what the patient says hurts!”
• “Accept the pain as what the patient says it is and
not what you think it should be”
• “ Your pain is your’s and is real!”
• “Addiction/Dependance has lost it’s significance
in these patients”

99. Chronic Pain : Oncogenic
Treatment Modalities:
1. Treatment of Disease (cancer) itself
2. Analgesics and Adjuvants (WHO ladder)
3. Custom Opioids
4. Computerized drug Delivery : ‘pumps’..
PCA, CCIP(Computerized controlled infusion
pumps’
5. Non-Invasive drug Delivery Devices (NIDDS): TTS-
fentanyl, EMLA, TMDS, intra-nasal, Pulm
6. Implantable Neuraxial Delivery Devices (INDDS):

100. If pain occurs, there should be prompt oral administration of drugs in the following order:
nonopioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong
opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additional
drugs – “adjuvants” – should be used. To maintain freedom from pain, drugs should be given “by
the clock”, that is every 3-6 hours, rather than “on demand” This three-step approach of
administering the right drug in the right dose at the right time is inexpensive and 80-90%
effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are

101. Modified WHO Analgesic Ladder
Quality of Life
Invasive treatments
Proposed 4th Step Opioid Delivery
Pain persisting or increasing
Step 3
Opioid for moderate to severe pain
Nonopioid Adjuvant
Pain persisting or increasing
Step 2
Opioid for mild to moderate pain
Nonopioid Adjuvant
Pain persisting or increasing
Step 1
Nonopioid
Adjuvant
Pain
Deer, et al., 1999

102. Chronic Pain : Oncogenic
Treatment Modalities:
7. Neuro-stimulation-Lysis-Surgical/Anaesthesia/: tri-
cyclics, anti-convulsants, TENS, Ketamine
8. Psycho Therapy & Counselling
9. Physio and Occupational Therapy
10. Miscellaneous: N/V, infections, Patho-
fractures, constipation.....
CONCEPT OF PAIN CLINIC

103. PAIN CLINIC
Definition
The Care provided to the patients for the relief of
Acute or Chronic pain of oncogenic as well as non-
oncogenic origin on comprehensive, inter
disciplinary and multi-dimensional basis by a team
of experts with broad base of knowledge, and skills
under one roof is called “multi-disciplinary
approach to management of Pain” and such an
establishment is called as pain Clinic.

104. PAIN CLINIC (CONTD.)
TEAM
 Physicians : Anaesthesiologists
Oncologists medical
surgical
radiation
 Psychologist/Behavioural Therapist
 Physio/Occupational Therapist
 Nursing staff
 Social Worker

105. CONCLUSION
PAIN
• Is all encompassing, everlasting & complex
• Quest for MANAGEMENT is unending
• Journey from non- existent /barbarism to
PCAs, CCIPs, TTSs, NIIDs or INDDs
• From Opium, Hashish, alcohol, Mandragora &
herbs to Remifentanil, ropivacane.
Must go on & on & on.........never-ending search.

106. ..... For that avails
Valour or strength though matchless, quelled with pain
Which all subdues and makes remiss the hands
of mightiest? Sense of pleasure we may well
Spare out of life perhaps, and not repine
But live content – which is calmest life ;
But pain is the perfect misery, the worst
Of evils and excessive over turns
All patience.
John Milton - Paradise Lost
Book VI

108. Nociception
Transduction
Transmission
Modulation
Perception