Cancer Pain Concept
A. HUSNI TANRA
Department of Anesthesiology & ICU and Pain
Management
Faculty of Medicine
HASANUDDIN U...
Palliative CarePalliative Care
Palliative Care is comprehensive, interdisciplinary
care for patients whose disease is chro...
CurativeCurative vs. Palliativevs. Palliative
Model of CareModel of Care
Disease Progression
D
E
A
T
H
Curative Palliative...
The Continuum of Palliative CareThe Continuum of Palliative Care
PersonPerson
FamilyFamily
DD
II
SS
EE
AA
SS
EE
DD
II
SS
C...
Cancer Pain?
Pain
 Unpleasant sensory and
emotional experience
-Associated with actual or
potential tissue damage
-or described in ter...
What the textbooks
would have you believe
about pain
Noxious (painfull)
stimulus to the body
What PAIN is?What PAIN is?
Pain has two dimensions
1. Unpleasant sensory
(Physical dimension)
2. Emotional experience
(Psychological dimension)
J. Loeser
(1980)
Concept of nociception, pain, suffering and pain behavior
PERILAKU NYERI
(PAIN BEHAVIOUR)
PENDERITAAN
(SUFFERING)
NYERI
(PAIN)
BIOPSIKOSOSIAL
(BIOPSYCHOSOCIAL)
NOSISEPSI
(NOCICEPTI...
Cancer Pain Concept
by Dr. Cicely Saunders 1967, founder of first Hospice in
London.
‘TOTAL PAIN’ is the sum of 4 componen...
4 Components of “total pain” by Cicely Saundres using concept Da Vinci’s
Vitruvian Man representing person.
Physical PainP...
Aspects of “total pain”.
TOTAL PAINTOTAL PAIN
Interpersonal Interactions
 Individual
 Fear of isolation from others
 Fe...
TOTAL
PAIN
ORGANIC PAIN
ANXIETY
ANGERDEPRESSION
Non-cancer pathology
Cancer
Symptoms of debility
Side-effects of theraphy
...
Pain
Somatic or
Visceral
pain
Neuropathic
Pain
Psychologica
l
Disturbances
SufferingPsychologica
l State and
Traits
Loss o...
Magnitude of Cancer Pain
 WHO 1986
4,5 million people suffering from cancer pain with or
without satisfactory treatment e...
For many patients pain is the first sign of cancer.
30 – 50 % of all cancer patients will
experience moderate to severe
p...
Pain is extremely a major problem in cancer patients
Pain is the most disruptive on Q of L of cancer patients
Pain is o...
As a doctor, our task is:
*To cure is sometime
*To treat is often, but …
*To comfort is always
A. Pare (1598)
The “Total” Pain Concept
Spiritua
l
Emotional
Financial
Physical
•Guilt
•Why me?
•Life closure
issues
•From disease
•From ...
Types of pain based on
neurophysiologic mechanism.
Physical PainPhysical Pain
Neurophysiologic MechanismsNeurophysiologic ...
CAUSE OF CANCER PAIN
Can be classified into 3 categories:
1. Pain associated with direct tumor
(tumour infiltration, bone ...
Types of Cancer Pain
 1. Somatic Pain
 2. Visceral Pain
 3. Neurophatic Pain
Mostly in combine form
Somatic Pain
• Constant pain
• May be dull or sharp
• Well localized
• Often worse with movement
Eg/
– Bone & soft tissue
...
Visceral Pain
• Constant or crampy
• Poorly localized
• Usually with Nausea & Vomit
• Often referred
Eg/
– CA pancreas
– L...
Neuropathic Pain
Damage to the nerve pathways
There can be an abnormal response to a
normal stimulus
May be peripheral ...
COMPONENT DESCRIPTORS EXAMPLES
Steady,
Dysesthetic
• Burning, Freezing
• Constant-aching
• Squeezing, Itching
• Allodynia
...
Burning, feeling like the feet are on fire
Stabbing, like sharp knives Lancinating, like electric shocks
Freezing, like th...
Breakthrough PainBreakthrough Pain
An intermittent increase in pain that occurs
spontaneously and is usually associated
wi...
Chronic Cancer PainChronic Cancer Pain
Effectively treating chronic pain poses a great
challenge for physicians. This type...
Breakthrough PainBreakthrough Pain
BTP is a brief flare-up of severe pain that
occurs even while the patient is regularly
...
Breakthrough PainBreakthrough Pain
Breakthrough cancer pain can result from the
cancer or cancer treatmen, or it may occur...
Causes of Cancer pain
DIRECT TUMOR ITSELF
Causes of Cancer pain
Causes of Cancer pain
Cancer pain
FROM CHEMOTHERAPY
Causes of Cancer pain
RELATED TO THERAPY
COBALT RADIATION BURN
Cancer pain
Other Factors
Acute Herpes Zoster
Cancer pain
 OTHER FACTORS-
Immunocompromised state
Cancer pain
Mucositis
 Nociceptor is stimulated by the tumor
 Peripheral sensitization  Enzyme Cox-2
Inflammation.
 Tumor induced acidosis...
Cancer cells + macrophage + inflammation
cells produce high level of Cox-2 enzyme
 high level of prostaglandins.
 Cancer...
Three Step Ladder WHO, 1986
5 essential concepts
 By mouth
 By the clock
 By the ladder
 By individual
 With attentio...
Gold Standard of
Pain Management
Is constant pain assessment.
Pain is whatever the patient says it is.
Pain in cancer n...
Assessment of Pain
using VAS is !
0 3 421 5 6 7 8 9 10
No distress Unbearable
distress
a 10-cm baseline is recommended for...
Assessment of Pain Intensity
No Mild Moderate Severe Very Worst
pain pain pain pain severe possible
pain pain
Verbal Pain ...
Types of Cancer Pain
 1. Nociceptive Pain
Somatic Pain
Visceral Pain
 2. Neurophatic Pain
(Mostly in combine form)
 3. ...
Somatic Pain
• Constant pain
• May be dull or sharp
• Well localized
• Often worse with movement
Eg/
– Bone & soft tissue
...
Visceral Pain
• Constant or crampy
• Poorly localized
• Usually with Nausea & Vomit
• Often referred
Eg/
– CA pancreas
– L...
Neuropathic Pain
Damage to the nerve pathways
There can be an abnormal response to a
normal stimulus
May be peripheral ...
COMPONENT DESCRIPTORS EXAMPLES
Steady,
Dysesthetic
• Burning, Freezing
• Constant-aching
• Squeezing, Itching
• Allodynia
...
Burning, feeling like the feet are on fire
Stabbing, like sharp knives Lancinating, like electric shocks
Freezing, like th...
Chronic Cancer PainChronic Cancer Pain
Effectively treating chronic pain poses a great
challenge for physicians. This type...
Breakthrough PainBreakthrough Pain
BTP is a brief flare-up of severe pain that
occurs even while the patient is regularly
...
Breakthrough PainBreakthrough Pain
Breakthrough cancer pain can result from the
cancer or cancer treatmen, or it may occur...
CAUSE OF CANCER PAIN
Can be classified into 3 categories:
1. Pain associated with direct tumor
(tumour infiltration, bone ...
Causes of Cancer pain
DIRECT TUMOR ITSELF
Causes of Cancer pain
Causes of Cancer pain
Cancer pain
FROM CHEMOTHERAPY
Causes of Cancer pain
RELATED TO THERAPY
COBALT RADIATION BURN
Cancer pain
Other Factors
Acute Herpes Zoster
Cancer pain
 OTHER FACTORS-
Immunocompromised state
Cancer pain
Mucositis
WHO 3-step AnalgesicWHO 3-step Analgesic
LadderLadder
11 MildMild
22 ModerateModerate
33 SevereSevere
Morphine
Hydromorpho...
Gold Standard of
Pain Management
Is constant pain assessment.
Pain is whatever the patient says it is.
Pain in cancer n...
The Phenomenon of CANCER PAIN
COMPLEXand COMPLICATED
is the cumulative among :
• PHYSICAL PAIN
• PSYCHOLOGICAL PAIN
• soci...
Paracetamol
± adjuvants
Weak Opioid for
mild to moderate
pain
± Paracetamol
± adjuvants
Strong Opioid for
severe pain
(Mor...
It’s important to more understanding PAIN,
type and characteristic of pain..
Because…
In many parts of Indonesia :
Many pe...
San Diego, 2002
Total Pain – Osteopathic MedicalTotal Pain – Osteopathic Medical
Care.Care.
Osteopathic Medical Care is based on
osteopath...
Structure andStructure and
FuntionFuntion
ReciprocallyReciprocally
InterrelatedInterrelated
Self-RegulatorySelf-Regulatory...
Elisabeth K.Ross (1969)  “on death
and deying”.
BEHAVIOR CHARES IN CANCER PATIENT
1. DENY
2. ANGER
3. BARGENING
4. DEPRES...
A Patient’s perspective
“ One of the worst aspect of cancer pain is that
it`s a constant reminder of the disease and of
de...
Role of COXIB in cancer painRole of COXIB in cancer pain
Celecoxib is the rational use for the cancer
pain management, pa...
Non-opioid
± adjuvants
Weak Opioid for
mild to moderate
pain
± non-opioid
± adjuvants
Strong Opioid for
severe pain
± non-...
84
WHO ANALGESIC LADDER CANCER PAINWHO ANALGESIC LADDER CANCER PAIN
Aspirin
&
NSAID
+
Adjuvants
Add weak
Opioid
(if pain
unre...
Nociceptive painNociceptive pain
A NOCICEPTION has at least 4
components
1. TRANSDUCTION
2. CONDUCTION/
TRANSMISSION
3. MO...
88
Poisons
Mechanical, thermal, chemical, electrical
Tissue damage
Release of mediators
Hydrogen and potassium ions,
neuro...
A NOCICEPTION has at least 4 components
1. TRANSDUCTION
2. CONDUCTION/
TRANSMISSION
3. MODULATION
4. PERCEPTION
ACUTE (NOC...
Figure 10-13: Referred pain
Allodynia: Nerve Injury Leads to Central
Reorganization in the Spinal Dorsal Horn
Normal terminations of primary
afferents...
Dorsal Horn
Dorsal root
ganglion
Peripheral sensory
Nerve fibers
Aβ
Aδ
C
Large
fibers
Small
fibers
Two sensory afferent ne...
Although in normal condition AAlthough in normal condition Aββ fiber does notfiber does not
response to noxious stimuli, b...
Aβ
Aδ
CLateral
Nucleus
proprius
Marginal layer
Substantia
gelatinosa
Medial
Afferent Synaptic in DHN
Ascending spinomesencephalic
and spinothalamic axons
Dorsal
Root
Ganglion
C
Fiber
A delta Fiber
Second Order
Sensory Neuro...
Pain
Somatic or
Visceral
Pain
Neuropathic
Pain
Psychologica
l Pain
SufferingPsychologica
l State and
Traits
Loss of
Work
P...
Three Step Ladder WHO, 1986
5 essential concepts
 By mouth
 By the clock
 By the ladder
 By individual
 With attentio...
Three Step Ladder WHO, 1986
5 essential concepts
 By mouth
 By the clock
 By the ladder
 By individual
 With attentio...
Step I for MILD PAIN
 NSAIDs may delay the need of opioid.
 About 20% of patients were taking NSAIDs
in the last week of...
Step Il for MODERATE PAIN
 Combine Paracetamol, NSAIDs + Codein
 Formula
 Constipation is the most common side effect o...
– It is a new multimodal analgesic tablet.
– Contains
• 325 mg Acetominophen
• 37.5 mg Tramadol
– Doses were selected base...
TRAMADOL
peak = 2-3 hrs
T1/2 = 6 hrs
TIME
DrugEffect
APAP
peak = 30 min
T1/2 = 2 hrs
In combination, T1/2 extends to 7-9 h...
Step lll for SEVERE PAIN
 Oral morphine is the mainstay of severe cancer
pain.
 Strong pain needs strong analgesic.
 It...
Why Cancer Pain Undertreated
 For Step 1 & 2
- doses are too low
- intervals are too long
- not individualized, by titrat...
Why Morphine is Underused?
Morphin is underused due to:
The Myths and prejudice or
Insufficient knowledge
Which is in ...
MYTHS & PREJUDICE of OPOID
When mention about opioids  negative side
Our textbooks are filled with a side effects.
– Mo...
Myth and Prejudice of Morphine
2. Fear of addiction
 Addiction is the most feared side effects.
 When we say morphine ad...
Opiophobia
“failure to administer
morphin analgesics because
of a fear of these drugs to
produce addiction”
Consequence
Due to those myth and prejudice,
most cancer pain patients do not
get inappropriate treatment, and
failure to ...
Underused of opioid in
Indonesia it might be due that?
 PAIN MANAGEMENT IN
INDONESIA IS NOT THE
PRIORITY.
 Where Univers...
Adjuvant Drugs
 Corticosteroids : Dexamethasone, Prednison
 Anticonvulsant : Carbamazepine, Gabapentin, etc
 Antidepres...
New and Alternative Pain
Treatment Options
 Tramadol
 Ultracet
 Clonidine
 Calcitonin
 Accupuncture
 Magnetic-field ...
Some Invasive Modalities For
Cancer Pain Relief
1. Neurolitic Block
- Alcohol 100 %
- Phenol glycerin 15 %
1. Epidural / S...
Conclusion
About 90% of cancer pain patients can be
relieved by three step ladder of WHO
Morphine such is very safe drug...
In many parts of Indonesia
*Many people may die due to pain
*Many more people dying with pain
* Even many more people livi...
MAGNITUDE OF CANCERMAGNITUDE OF CANCER
PAINPAIN Bonica 1985
– 50 % of patient of all stage reported pain
– > 70 % with ad...
CANCER PAIN
FACTS ABOUT CANCER
PAIN
90% of patients with advanced cancer
experience severe pain;
Pain occurs in 30% of all cancer pa...
FACTS ABOUT CANCER
PAIN
More than 50% of cancer patients may be
undertreated for their pain
Pain usually increases as ca...
Pain Assessment
Treat patient’s pain and regularly reassess
response to therapy.
Discuss care plan with patient and fami...
Causes of Cancer Pain
Pain secondary to the tumor itself
Pain secondary to cancer therapy
Other factors
Nociceptive Pain
SOMATIC PAIN
Nociceptive Pain
VISCERAL PAIN
Barriers to Cancer Pain Management
1. Inadequate knowledge of pain management.
2. Low priority given to cancer pain treatm...
+/- adjuvant
Non-opioid
Weak opioid
Strong opioid
Pain persists or increases
By the
Clock
W.H.O. ANALGESIC LADDER
+/- adju...
COMBINE DRUGS MAY HAVE
3 EFFECTS
1. Synergetic ............. 2+2>4
2. Additive ................ 2+2=4
3. Subadditive ........
Statistical Test for a Range of Synergy
ACETAMINOPHEN
TRAMADOL
Line of
Additivity
• Tramodal &
Acetaminophen
has different...
Ultracet
 Is not an NSAID (not Cox1 or Cox2 inhibitor )
 Not associated with
 prostaglandin-mediated side effects
 Car...
Myth and Prejudice of Morphine
3. Sedation
• Drowsiness may occur at the beginning
but this usually disappears after a few...
WHO ANALGESIC
LADDER
Physical
dimention
ORGANIC PAIN
• Motivational affective
• Cognitive evaluation
• The meaning of pain
• unpleasant sensory...
Definition of Pain
“An unpleasant sensory and emotional experience
associated with actual or potential tissue damage,
or d...
Byock’s five key points:
 “I forgive you.”
 “Forgive me.”
 “Thank you.”
 “I love you.”
 “Goodbye.”
Structure andStructure and
FuntionFuntion
ReciprocallyReciprocally
InterrelatedInterrelated
Self-RegulatorySelf-Regulatory...
TYPES OF PAIN
NEUROPATHICNOCICEPTIVE
Deafferentation Sympathetic
Maintained
Peripheral
Somatic
• bones, joints
• connectiv...
J.Loeser (1980)
Concept of nociception, pain, suffering and pain behaviour
Pain behaviour
Suffering
Pain
Nociception
A-Alpha Motor
Efferent
Sympathetic
Efferent
Delta Sensory
Afferent
C-Fiber Sensory
Afferent
Peripheral
Nociceptor
Spinal C...
 Visceral pain
 Poorly localized, constant, aching and commonly
referred to cutaneous sites
 Results from injury to the...
 constant
 sharp aching
 well localized
 constant
 dull aching
 poorly localized
 usually with nausea and
vomit
 o...
Cancer Pain
Cancer Pain
Cancer Pain
Cancer Pain
Cancer Pain
Cancer Pain
Cancer Pain
Cancer Pain
Cancer Pain
Cancer Pain
Cancer Pain
Cancer Pain
Cancer Pain
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  • Addressing analgesia, the first of the “Four A’s of Pain,” requires an assessment of pain intensity to determine whether existing treatment is providing adequate relief. This slide depicts four of the pain scales that are used to assess a patient’s pain. The scales are considered simple for patients to use as well as being validated methods for measuring the severity of pain.1-3 These scales can be used at the patient’s bedside, and patients can be asked to respond to either a spoken or written question. The 0-10 numeric scale can be administered over the phone.
    With some scales, especially the visual analog scale, the patient marks the line at the point that best indicates the pain’s intensity. Older patients may have difficulty using visual analog scales and it might be more appropriate to use a 0-10 numeric pain intensity scale.4
    The Wong-Baker FACES Pain Rating Scale is validated and recommended for patients aged 3 years or older. On this scale, Face 0 indicates no pain at all, Face 1 feels mild pain, Face 2 feels moderate pain, Face 3 feels severe pain, Face 4 feels very severe pain, and Face 5 feels the worst possible pain. The original appears above, and can be used as is or with the brief word descriptions under each number. In a study of 148 children aged 4 to 5 years, there were no differences in pain scores when children used the original or brief word instructions.2
    People with cognitive impairments and limited ability to communicate (eg, stroke patients) may have difficulty with the use of any self-report pain assessment scales. For these patients it will be necessary for the physician to rely on behavioral observation of patients' facial expressions, movement patterns (eg, bracing, guarding, distorted postures, avoidance of activity), and nonverbal sounds (eg, moans, winces) and reports of significant others (eg, partner, spouse, child) to make judgment of pain intensity.5
    However, remember that patient pain is multidimensional and involves more than just assessment of pain intensity.
    1.Portenoy RK, Kanner RM. Definition and Assessment of Pain. In: Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice. Philadelphia, Pa: F.A. Davis Company; 1996:8-10.
    2. Wong DL. Waley and Wong’s Essentials of Pediatric Nursing. 5th ed. St. Louis, Missouri: Mosby, Inc.; 1997:1215-1216.
    3. McCaffery M, Pasero C. Pain: Clinical Manual. St. Louis, Missouri: Mosby, Inc.;1999:16.
    4. Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986;27:117-126.
    5. Hadjistavropoulos T, von Baeyer C, Craig KD. Pain assessment in persons with limited ability to communicate. In: Turk DC, Melzack R, eds. Handbook of Pain Assessment. 2nd ed. New York, NY: Guilford; 2001:134-152.
  • ULTRACET is not an NSAID or a COX-2 NSAID and hence is not associated with prostaglandin-mediated side effects of NSAIDs such as gastrointestinal (GI) complications, GI bleeding, ulcer formation, adverse effects on platelet function resulting in bleeding disorders, or adverse effects on renal function. ULTRACET can be prescribed for sulfa-sensitive patients.
  • Cancer Pain

    1. 1. Cancer Pain Concept A. HUSNI TANRA Department of Anesthesiology & ICU and Pain Management Faculty of Medicine HASANUDDIN UNIVERSITY MAKASSAR
    2. 2. Palliative CarePalliative Care Palliative Care is comprehensive, interdisciplinary care for patients whose disease is chronic and progressive, or unresponsive to curative treatment. It includes pain and symptom management as well as psychological, emotional and spiritual care. The goal of palliative care is to achieve the best quality of life for patients and their families, regardless of life expectancy Center for Health Workforce Studies School of Public Health, University of Albany September 2002
    3. 3. CurativeCurative vs. Palliativevs. Palliative Model of CareModel of Care Disease Progression D E A T H Curative Palliative B E R E A V E M E N T
    4. 4. The Continuum of Palliative CareThe Continuum of Palliative Care PersonPerson FamilyFamily DD II SS EE AA SS EE DD II SS CC OO MM FF OO RR TT DD YY II NN GG ILLNESS TRAJECTORYILLNESS TRAJECTORY BEREAVEMENTBEREAVEMENT SS YY MM PP TT OO MM SS DD XX DD EE AA TT HH Disease Specific RxDisease Specific Rx Comfort, Supportive RxComfort, Supportive Rx (Palliative Care)(Palliative Care) BereavementBereavement SupportSupport (Palliative Care)(Palliative Care) DD II SS TT RR EE SS SS DD YY SS FF UU NN CC TT II OO NN Caregivers and Service providersCaregivers and Service providers
    5. 5. Cancer Pain?
    6. 6. 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 (1979)
    7. 7. What the textbooks would have you believe about pain Noxious (painfull) stimulus to the body What PAIN is?What PAIN is?
    8. 8. Pain has two dimensions 1. Unpleasant sensory (Physical dimension) 2. Emotional experience (Psychological dimension)
    9. 9. J. Loeser (1980) Concept of nociception, pain, suffering and pain behavior
    10. 10. PERILAKU NYERI (PAIN BEHAVIOUR) PENDERITAAN (SUFFERING) NYERI (PAIN) BIOPSIKOSOSIAL (BIOPSYCHOSOCIAL) NOSISEPSI (NOCICEPTION) PENGERTIAN MODEL NYERI BYERS AND BONICA, 2001 MODIFIKASI PENULIS •Terapi kognitif •Restorasi fungsional •Opioid •Tramadol •Oxcarbazepine •Gabapentin •Eperisone HCL •Paracetamol •OAINS •Antidepresan •Psikotropika •Relaksasi •Spiritual •Blok Lokal •Diklofenak •Etodolac •Dexketoprofen •Celecoxib •Modalitas fisik •steroid
    11. 11. Cancer Pain Concept by Dr. Cicely Saunders 1967, founder of first Hospice in London. ‘TOTAL PAIN’ is the sum of 4 components: 1. Physical noxious stimuli 2. Emotional discomfort 3. Interpersonal conflicts 4. Nonacceptance
    12. 12. 4 Components of “total pain” by Cicely Saundres using concept Da Vinci’s Vitruvian Man representing person. Physical PainPhysical Pain NonacceptanceNonacceptance InterpersonalInterpersonal ConflictsConflicts EmotionalEmotional discomfortdiscomfort
    13. 13. Aspects of “total pain”. TOTAL PAINTOTAL PAIN Interpersonal Interactions  Individual  Fear of isolation from others  Fear of loss of career or job status  Fear of substance abuse  Interpersonal Interactions  Marital discord  Estrangement from family  Isolation from spouse and children  Conflicts with coworkers  Mounting financial stress  Inadequate Pain Control  Verification patient is receiving pain medication.  Assessment for new physical cause of pain  Altered Metabolic States  Medical conditions such, hypocalcaemia, hypoglycemia, hypoxia, delirium and sepsis  Hormone-Secreting Tumors  Pheochromocytoma  ACTH-producing tumors  Thyroid tumors  Anxiety From Medications  Rapid tapering of prednisone.  Alcohol withdrawal  Akathisia associated with metoclopramide hydrochloride  Preexisting Anxiety  Supportive therapy or medication (or both) helpful  Spirituality  Personal values of life, what death mean for him/her.  Fear of dying alaone.  Three-Stage Model  A guide to anticipate difficulties with greater sensitivity: ̶ Initial stage: the patient faces the threat of death; ̶ Middle stage: a universal depression that the patient now knows the disease will cause death; ̶ Third stage: the patient’s acceptance of imminence of own death Anxiety Nonacceptance
    14. 14. TOTAL PAIN ORGANIC PAIN ANXIETY ANGERDEPRESSION Non-cancer pathology Cancer Symptoms of debility Side-effects of theraphy Loss of social position Loss of job prestige and income Loss of role in family Chronic fatigue and insomnia Sense of helpessness Disfigurement Bureaucratic prosedure Friends do not visit Delay in diagnosis Unavailable doctors Irritability Therapeutic failure Fear of hospital or nursing home Worry about family Fear of death Spiritual unrest Fear of pain Family finances Loss of dignity and bodily control Uncertainty about future WHO 1986
    15. 15. Pain Somatic or Visceral pain Neuropathic Pain Psychologica l Disturbances SufferingPsychologica l State and Traits Loss of Work Physical Disability Fear Of Death Financial Concerns Social/ Familial Functioning AMERICAN CANCER SOCIETY 1988
    16. 16. Magnitude of Cancer Pain  WHO 1986 4,5 million people suffering from cancer pain with or without satisfactory treatment every day  More than 9 million cancer deaths will occur in 2015  70 – 80 % of these patients will experience moderate to severe pain  Most of them will die in pain
    17. 17. For many patients pain is the first sign of cancer. 30 – 50 % of all cancer patients will experience moderate to severe pain. 75 – 95 % of patients with advanced stages will experience severe pain. 45 % of cancer patients have inadequate pain control. 25 % Will die in pain. Nature Reviews Cancer March 2002
    18. 18. Pain is extremely a major problem in cancer patients Pain is the most disruptive on Q of L of cancer patients Pain is one of the most feared aspect in cancer patients Unrelieved severe pain may associated with • Disturbed sleep • Reduced appetite • Unrepaired concentration • Irritability and depression, etc.  69 % of severe cancer pain patient to cause consideration of suicide. (Wisconsin 1985) Problem of Pain in Cancer Patient
    19. 19. As a doctor, our task is: *To cure is sometime *To treat is often, but … *To comfort is always A. Pare (1598)
    20. 20. The “Total” Pain Concept Spiritua l Emotional Financial Physical •Guilt •Why me? •Life closure issues •From disease •From treatment •Direct costs •Indirect costs •Loss of function •Coping abilities PAIN
    21. 21. Types of pain based on neurophysiologic mechanism. Physical PainPhysical Pain Neurophysiologic MechanismsNeurophysiologic Mechanisms Visceral Pain  Difficult to localize.  Felt as “deep pressure,” “spasms” associated with nausea, diaphoresis, and emesis. Somatic Pain  Nociceptor stimulation of skin and deep musculoskeletal tissues.  Well localized as “deep, aching feeling,” tender to palpation. Neuropathic Pain  Damage to the peripheral or the central nervous tissue.  Peripheral nerve described as “sharp,” “electric,” “burning” pain.  Central pain is “throbbing”; the headache is “dull” and “never relenting”
    22. 22. CAUSE OF CANCER PAIN Can be classified into 3 categories: 1. Pain associated with direct tumor (tumour infiltration, bone metastases) 2. Pain associated with cancer therapy (chemotherapy, surgery or radiation) 3. Pain unrelated to cancer (RA, OA, headache or herpes zoster) * Due to cancer debility (decubitus)
    23. 23. Types of Cancer Pain  1. Somatic Pain  2. Visceral Pain  3. Neurophatic Pain Mostly in combine form
    24. 24. Somatic Pain • Constant pain • May be dull or sharp • Well localized • Often worse with movement Eg/ – Bone & soft tissue – chest wall
    25. 25. Visceral Pain • Constant or crampy • Poorly localized • Usually with Nausea & Vomit • Often referred Eg/ – CA pancreas – Liver capsule distension – Bowel obstruction
    26. 26. Neuropathic Pain Damage to the nerve pathways There can be an abnormal response to a normal stimulus May be peripheral or central nerve damage
    27. 27. COMPONENT DESCRIPTORS EXAMPLES Steady, Dysesthetic • Burning, Freezing • Constant-aching • Squeezing, Itching • Allodynia • Hyperalgesia • Diabetic neuropathy • Post-herpetic neuropathy Paroxysmal, Neuralgic • Stabbing • Lancinating • Shock-like, electric • Shooting • trigeminal neuralgia • may be a component of any neuropathic pain FEATURES OF NEUROPATHIC PAIN
    28. 28. Burning, feeling like the feet are on fire Stabbing, like sharp knives Lancinating, like electric shocks Freezing, like the feet are on ice, although they feel warm to touch Modified by Meliala 2006
    29. 29. Breakthrough PainBreakthrough Pain An intermittent increase in pain that occurs spontaneously and is usually associated with an increase in activity or stress. If breakthrough pain becomes continuous, it is usually a sign that opioid dose needs to be increased
    30. 30. Chronic Cancer PainChronic Cancer Pain Effectively treating chronic pain poses a great challenge for physicians. This type of pain often affects a person’s life in many ways. It can change someone’s personality, ability to function, and quality of life. According to the American Cancer Society, chronic cancer pain may involve persistent pain and breakthrough pain. Persistent pain is continuous and may last all day.
    31. 31. Breakthrough PainBreakthrough Pain BTP is a brief flare-up of severe pain that occurs even while the patient is regularly taking pain medication. It usually comes on quickly and may last from a few minutes to an hour. Many patients experience a number of episodes of breakthrough pain each day.
    32. 32. Breakthrough PainBreakthrough Pain Breakthrough cancer pain can result from the cancer or cancer treatmen, or it may occur during a certain activity (e.g., walking, dressing, coughing). It also can occur unexpectedly, without a preceding incident or clear cause. Breakthrough pain usually is treated with strong, short-acting pain medications that work faster than persistent pain medications.
    33. 33. Causes of Cancer pain DIRECT TUMOR ITSELF
    34. 34. Causes of Cancer pain
    35. 35. Causes of Cancer pain
    36. 36. Cancer pain FROM CHEMOTHERAPY
    37. 37. Causes of Cancer pain RELATED TO THERAPY COBALT RADIATION BURN
    38. 38. Cancer pain Other Factors Acute Herpes Zoster
    39. 39. Cancer pain  OTHER FACTORS- Immunocompromised state
    40. 40. Cancer pain Mucositis
    41. 41.  Nociceptor is stimulated by the tumor  Peripheral sensitization  Enzyme Cox-2 Inflammation.  Tumor induced acidosis. ( massive apoptosis)  Tumor induced distension of sensory fibers  neurophatic pain  Centra sensitization  Chronic pain
    42. 42. Cancer cells + macrophage + inflammation cells produce high level of Cox-2 enzyme  high level of prostaglandins.  Cancer cells induced acidosis due to that inflammatory cells invade neoplastic tissue  release H+ and massive apoptosis also contribute release H+  increase acidosis.  Two ascending pathway are activated. ( STT and PSDCT)
    43. 43. Three Step Ladder WHO, 1986 5 essential concepts  By mouth  By the clock  By the ladder  By individual  With attention to detail By this modality ± 90% of cancer pain can be relieved
    44. 44. Gold Standard of Pain Management Is constant pain assessment. Pain is whatever the patient says it is. Pain in cancer never purely physical. Nonphysical pain describe as ‘discomfort’ Take a careful history of the pain complaint Assess characteristics of each pain; site, type pattern of referral, aggravating & relieving factors etc.
    45. 45. Assessment of Pain using VAS is ! 0 3 421 5 6 7 8 9 10 No distress Unbearable distress a 10-cm baseline is recommended for VAS ( Visual Analogue and Numeric Scale )
    46. 46. Assessment of Pain Intensity No Mild Moderate Severe Very Worst pain pain pain pain severe possible pain pain Verbal Pain Intensity Scale No pai n Visual Analog Scale Wong-Baker FACES Pain Scale 0 1 2 3 4 5 0–10 Numeric Pain Intensity Scale No Mild Moderate Worst pain pain pain possible pain 0 1 2 3 4 5 6 7 8 9 10 Worst possible pain 29
    47. 47. Types of Cancer Pain  1. Nociceptive Pain Somatic Pain Visceral Pain  2. Neurophatic Pain (Mostly in combine form)  3. BreakThrough Pain (BTP)
    48. 48. Somatic Pain • Constant pain • May be dull or sharp • Well localized • Often worse with movement Eg/ – Bone & soft tissue – chest wall
    49. 49. Visceral Pain • Constant or crampy • Poorly localized • Usually with Nausea & Vomit • Often referred Eg/ – CA pancreas – Liver capsule distension – Bowel obstruction
    50. 50. Neuropathic Pain Damage to the nerve pathways There can be an abnormal response to a normal stimulus May be peripheral or central nerve damage
    51. 51. COMPONENT DESCRIPTORS EXAMPLES Steady, Dysesthetic • Burning, Freezing • Constant-aching • Squeezing, Itching • Allodynia • Hyperalgesia • Diabetic neuropathy • Post-herpetic neuropathy Paroxysmal, Neuralgic • Stabbing • Lancinating • Shock-like, electric • Shooting • trigeminal neuralgia • may be a component of any neuropathic pain FEATURES OF NEUROPATHIC PAIN
    52. 52. Burning, feeling like the feet are on fire Stabbing, like sharp knives Lancinating, like electric shocks Freezing, like the feet are on ice, although they feel warm to touch Modified by Meliala 2006
    53. 53. Chronic Cancer PainChronic Cancer Pain Effectively treating chronic pain poses a great challenge for physicians. This type of pain often affects a person’s life in many ways. It can change someone’s personality, ability to function, and quality of life. According to the American Cancer Society, chronic cancer pain may involve persistent pain and breakthrough pain. Persistent pain is continuous and may last all day.
    54. 54. Breakthrough PainBreakthrough Pain BTP is a brief flare-up of severe pain that occurs even while the patient is regularly taking pain medication. It usually comes on quickly and may last from a few minutes to an hour. Many patients experience a number of episodes of breakthrough pain each day.
    55. 55. Breakthrough PainBreakthrough Pain Breakthrough cancer pain can result from the cancer or cancer treatmen, or it may occur during a certain activity (e.g., walking, dressing, coughing). It also can occur unexpectedly, without a preceding incident or clear cause. Breakthrough pain usually is treated with strong, short-acting pain medications that work faster than persistent pain medications.
    56. 56. CAUSE OF CANCER PAIN Can be classified into 3 categories: 1. Pain associated with direct tumor (tumour infiltration, bone metastases) 2. Pain associated with cancer therapy (chemotherapy, surgery or radiation) 3. Pain unrelated to cancer (RA, OA, headache or herpes zoster) * Due to cancer debility (decubitus)
    57. 57. Causes of Cancer pain DIRECT TUMOR ITSELF
    58. 58. Causes of Cancer pain
    59. 59. Causes of Cancer pain
    60. 60. Cancer pain FROM CHEMOTHERAPY
    61. 61. Causes of Cancer pain RELATED TO THERAPY COBALT RADIATION BURN
    62. 62. Cancer pain Other Factors Acute Herpes Zoster
    63. 63. Cancer pain  OTHER FACTORS- Immunocompromised state
    64. 64. Cancer pain Mucositis
    65. 65. WHO 3-step AnalgesicWHO 3-step Analgesic LadderLadder 11 MildMild 22 ModerateModerate 33 SevereSevere Morphine Hydromorphone Methadone Fentanyl Oxycodone ± Adjuvants A/Codeine A/Hydrocodone A/Oxycodone Tramadol ± Adjuvants ASA Acetaminophen NSAIDs ± Adjuvants Adapted from the EPEC Project
    66. 66. Gold Standard of Pain Management Is constant pain assessment. Pain is whatever the patient says it is. Pain in cancer never purely physical. Nonphysical pain describe as ‘discomfort’ Take a careful history of the pain complaint Assess characteristics of each pain; site, type pattern of referral, aggravating & relieving factors etc.
    67. 67. The Phenomenon of CANCER PAIN COMPLEXand COMPLICATED is the cumulative among : • PHYSICAL PAIN • PSYCHOLOGICAL PAIN • socioeconomic,cultural and spiritual TOTAL PAIN BIOPSYCHOSOCIOCULTUROSPIRITUAL
    68. 68. Paracetamol ± adjuvants Weak Opioid for mild to moderate pain ± Paracetamol ± adjuvants Strong Opioid for severe pain (Morphine) ± Celecoxib ± adjuvants Increasing painIncreasing pain WHO three step ladderWHO three step ladder
    69. 69. It’s important to more understanding PAIN, type and characteristic of pain.. Because… In many parts of Indonesia : Many people may die in pain, but Many more people dying with pain, Even many more people living in pain This is our task to help them as a Doctor Take Home Message
    70. 70. San Diego, 2002
    71. 71. Total Pain – Osteopathic MedicalTotal Pain – Osteopathic Medical Care.Care. Osteopathic Medical Care is based on osteopathic philosophy; the four components being: 1.The body is a unit. 2.The body has self-regulatory mechanisms. 3.Structure and functions are reciprocally interrelated. 4.Rational therapy is based on these principles.
    72. 72. Structure andStructure and FuntionFuntion ReciprocallyReciprocally InterrelatedInterrelated Self-RegulatorySelf-Regulatory MechanismMechanism
    73. 73. Elisabeth K.Ross (1969)  “on death and deying”. BEHAVIOR CHARES IN CANCER PATIENT 1. DENY 2. ANGER 3. BARGENING 4. DEPRESSION 5. ACCEPTANCE
    74. 74. A Patient’s perspective “ One of the worst aspect of cancer pain is that it`s a constant reminder of the disease and of death .. My dreams is for a medication that can relieve my pain while leaving me alert and with no side effects “ Jeanne Stover, 1992
    75. 75. Role of COXIB in cancer painRole of COXIB in cancer pain Celecoxib is the rational use for the cancer pain management, particularly in advance stage, because celecoxib is: * Strong antiinflammation * Analgesic * Antipyretic * Carcinoprotective (prevent angiogenesis, tumor growth and metastasis) * simple administeration
    76. 76. Non-opioid ± adjuvants Weak Opioid for mild to moderate pain ± non-opioid ± adjuvants Strong Opioid for severe pain ± non-opioid ± adjuvants Increasing painIncreasing pain WHO three step ladderWHO three step ladder
    77. 77. 84
    78. 78. WHO ANALGESIC LADDER CANCER PAINWHO ANALGESIC LADDER CANCER PAIN Aspirin & NSAID + Adjuvants Add weak Opioid (if pain unrelived) + Adjuvants Add strong Opioids + Adjuvants PSYCHOLOGICAL & SOCIAL SUPPORT
    79. 79. Nociceptive painNociceptive pain A NOCICEPTION has at least 4 components 1. TRANSDUCTION 2. CONDUCTION/ TRANSMISSION 3. MODULATION 4. PERCEPTION SpinothalamicSpinothalamic tracttract PeripheralPeripheral nervenerve Dorsal HornDorsal Horn Dorsal rootDorsal root ganglionganglion PainPain MedulationMedulation TransductionTransduction AscendingAscending inputinput DescendingDescending modulationmodulation PeripheralPeripheral nociceptorsnociceptors TraumaTrauma Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049. PerceptionPerception transmissiontransmission ConductionConductionConduction/Conduction/ TransmissionTransmission Modified by AHT
    80. 80. 88 Poisons Mechanical, thermal, chemical, electrical Tissue damage Release of mediators Hydrogen and potassium ions, neurotransmitters, kinins, prostaglandins Stimulation of nociceptors Transmission to CNS via afferent pathways What is pain?
    81. 81. A NOCICEPTION has at least 4 components 1. TRANSDUCTION 2. CONDUCTION/ TRANSMISSION 3. MODULATION 4. PERCEPTION ACUTE (NOCICEPTIVE) PAIN PATHWAY
    82. 82. Figure 10-13: Referred pain
    83. 83. Allodynia: Nerve Injury Leads to Central Reorganization in the Spinal Dorsal Horn Normal terminations of primary afferents in the dorsal horn After Nerve Injury
    84. 84. Dorsal Horn Dorsal root ganglion Peripheral sensory Nerve fibers Aβ Aδ C Large fibers Small fibers Two sensory afferent neurons 1. Large myelinated Aβ fibers, very fast conduction velocity. Respond to innocuous stimuli 2. Small myelinated Aδ & C unmyelinated fibers, have slow conduction velocity. Respond to noxious stimuli Modified by AHT
    85. 85. Although in normal condition AAlthough in normal condition Aββ fiber does notfiber does not response to noxious stimuli, but it plays a bigresponse to noxious stimuli, but it plays a big role inrole in NORMAL SENSATION.NORMAL SENSATION. The Role of AThe Role of Aββ fiberfiber Without Aββ fiberfiber, any noxious stimuli will perceive as BURNING PAIN (TN, HZ) A ββ
    86. 86. Aβ Aδ CLateral Nucleus proprius Marginal layer Substantia gelatinosa Medial Afferent Synaptic in DHN
    87. 87. Ascending spinomesencephalic and spinothalamic axons Dorsal Root Ganglion C Fiber A delta Fiber Second Order Sensory Neuron Lateral horn cell and sympathetic axon Ventra horn motor neuron Anterior Lateral Spinal Thalamic Tract Modified by AHT
    88. 88. Pain Somatic or Visceral Pain Neuropathic Pain Psychologica l Pain SufferingPsychologica l State and Traits Loss of Work Physical Disability Fear Of Death Financial Concerns Social/ Familial Functioning Nature of Cancer Pain
    89. 89. Three Step Ladder WHO, 1986 5 essential concepts  By mouth  By the clock  By the ladder  By individual  With attention to detail By this modality ± 90% of cancer pain can be relieved
    90. 90. Three Step Ladder WHO, 1986 5 essential concepts  By mouth  By the clock  By the ladder  By individual  With attention to detail By this modality ± 90% of cancer pain can be relieved
    91. 91. Step I for MILD PAIN  NSAIDs may delay the need of opioid.  About 20% of patients were taking NSAIDs in the last week of life.  Caution is needed when using NSAIDs for long periods  GI bleeding and renal failure are the most common.  It has ceiling effect. Use paracetamol, aspirin or NSAID
    92. 92. Step Il for MODERATE PAIN  Combine Paracetamol, NSAIDs + Codein  Formula  Constipation is the most common side effect of codein Acetominophen 500 mg Codein 10 mg Dulcolax ¼ tab mf pulv dtd XXX 6 dd I cap + adjuvant 06.00 18.00 10.00 22.00 14.00 02.00 prn
    93. 93. – It is a new multimodal analgesic tablet. – Contains • 325 mg Acetominophen • 37.5 mg Tramadol – Doses were selected based on golden ratio  synergic effect. – Decreased side effect, while maintaining efficacy – Approved in over 25 countries including US, Europe, for moderate to severe pain
    94. 94. TRAMADOL peak = 2-3 hrs T1/2 = 6 hrs TIME DrugEffect APAP peak = 30 min T1/2 = 2 hrs In combination, T1/2 extends to 7-9 hours Result of combination: –Fast onset of action –Prolonged action
    95. 95. Step lll for SEVERE PAIN  Oral morphine is the mainstay of severe cancer pain.  Strong pain needs strong analgesic.  It is a very safe drugs as long as given properly  Morphine immediate release is not available  MS contin is one of choice – Sustained release – Long acting
    96. 96. Why Cancer Pain Undertreated  For Step 1 & 2 - doses are too low - intervals are too long - not individualized, by titration  For step 3 (strong opioid = morphine) - morphine is underused STEP 1 Nonopioid STEP 2 Weak opioid + nonopioid STEP 3 Strong opioid + nonopioid + adjuvant
    97. 97. Why Morphine is Underused? Morphin is underused due to: The Myths and prejudice or Insufficient knowledge Which is in clinical experience do not show to be true.
    98. 98. MYTHS & PREJUDICE of OPOID When mention about opioids  negative side Our textbooks are filled with a side effects. – Mostly respiratory depression , addiction, tolerance , physical dependence, sedation, nausea/vomiting; etc.  Not the benefit of potential analgesic In clinical experience those myths & prejudice, do not show to be true.
    99. 99. Myth and Prejudice of Morphine 2. Fear of addiction  Addiction is the most feared side effects.  When we say morphine addiction is the first answer, not the analgesic  Large survey, 12.000 patients only 4 patients (0.03%) were considered addict (Boston Collaborative Drug Surveillance Program)  All studies chronic opioid treatment demonstrate a lack of addiction  No evidence of addiction as long as given properly
    100. 100. Opiophobia “failure to administer morphin analgesics because of a fear of these drugs to produce addiction”
    101. 101. Consequence Due to those myth and prejudice, most cancer pain patients do not get inappropriate treatment, and failure to get the benefit of opioid. Tragedy of Needless PainTragedy of Needless Pain
    102. 102. Underused of opioid in Indonesia it might be due that?  PAIN MANAGEMENT IN INDONESIA IS NOT THE PRIORITY.  Where University also should play a big role.
    103. 103. Adjuvant Drugs  Corticosteroids : Dexamethasone, Prednison  Anticonvulsant : Carbamazepine, Gabapentin, etc  Antidepressant : Amytriptiline, Doxepine  Neuroleptics : Methotrimeprazine  Antihistamines : Hydroxyzine  Local anesthetic/antiarrhytmics : Lidocaine  Psycho-stimulans : Dextroamphetamine  Laxatives : Bisacodyl, Lactulose, etc  Antiemetics : Droperidol, Metoclopropamide, etc
    104. 104. New and Alternative Pain Treatment Options  Tramadol  Ultracet  Clonidine  Calcitonin  Accupuncture  Magnetic-field therapy  Duragesic ( transdermal fentanyl)  TENS  DepoMorphine  etc
    105. 105. Some Invasive Modalities For Cancer Pain Relief 1. Neurolitic Block - Alcohol 100 % - Phenol glycerin 15 % 1. Epidural / Spinal opioid 2. Celiac Ganglion Block 3. Neural blockade 4. SC Morphine / Pethidine continuous infusion 5. Etc.
    106. 106. Conclusion About 90% of cancer pain patients can be relieved by three step ladder of WHO Morphine such is very safe drug when use properly Underuse morphine due to the myths and which cannot be verified in clinical practice Many cancer patients could die free from pain and with dignity if a few of those myths died
    107. 107. In many parts of Indonesia *Many people may die due to pain *Many more people dying with pain * Even many more people living in pain, particularly cancer patients. This is our task as a doctor NATURE OF INDONESIA
    108. 108. MAGNITUDE OF CANCERMAGNITUDE OF CANCER PAINPAIN Bonica 1985 – 50 % of patient of all stage reported pain – > 70 % with advanced cancer  Faley 1985 – 50 % of patient with non metastatic cancer had significant pain – 60-90 % of patient with advanced cancer reported debilitating pain  WHO 1986 – 70 % of patient with advanced cancer has pain – 3,5 million people suffering from cancer pain with or without satisfactory treatment every day  Paice, 2006 – 20-75% have pain at first diagnosis – 23- 100% report pain in advance stage
    109. 109. CANCER PAIN
    110. 110. FACTS ABOUT CANCER PAIN 90% of patients with advanced cancer experience severe pain; Pain occurs in 30% of all cancer patients, regardless of the stage of the disease.
    111. 111. FACTS ABOUT CANCER PAIN More than 50% of cancer patients may be undertreated for their pain Pain usually increases as cancer progresses.
    112. 112. Pain Assessment Treat patient’s pain and regularly reassess response to therapy. Discuss care plan with patient and family.
    113. 113. Causes of Cancer Pain Pain secondary to the tumor itself Pain secondary to cancer therapy Other factors
    114. 114. Nociceptive Pain SOMATIC PAIN
    115. 115. Nociceptive Pain VISCERAL PAIN
    116. 116. Barriers to Cancer Pain Management 1. Inadequate knowledge of pain management. 2. Low priority given to cancer pain treatment. 3. Restrictive regulations, availability of nonopioid and opioid analgesic. 4. Inadequate reimbursement. 5. Fear of patient’s addiction, tolerance, and side effects of opioids; patient’s reluctance to take pain medication. Mercadante S. WHO Guidelines – Problem Areas in Cancer Pain Management
    117. 117. +/- adjuvant Non-opioid Weak opioid Strong opioid Pain persists or increases By the Clock W.H.O. ANALGESIC LADDER +/- adjuvant +/- adjuvant 1 2 3
    118. 118. COMBINE DRUGS MAY HAVE 3 EFFECTS 1. Synergetic ............. 2+2>4 2. Additive ................ 2+2=4 3. Subadditive ........... 2+2=3
    119. 119. Statistical Test for a Range of Synergy ACETAMINOPHEN TRAMADOL Line of Additivity • Tramodal & Acetaminophen has different action • Synergistic analghesia • Reduced adverse effect • Faster onset longer action ‘‘Isobologram’ for analgesic interaction between acetaminophen and tramadolIsobologram’ for analgesic interaction between acetaminophen and tramadol
    120. 120. Ultracet  Is not an NSAID (not Cox1 or Cox2 inhibitor )  Not associated with  prostaglandin-mediated side effects  Cardiovascular side effects  Not associated with GI bleeding or ulcer formation in clinical trials  No effect on platelet aggregation  No risk for NSAID-induced nephrotoxicity
    121. 121. Myth and Prejudice of Morphine 3. Sedation • Drowsiness may occur at the beginning but this usually disappears after a few days • Drowsiness due to the fact that the patient has first good sleep. • No patient would accept pain free with sedation.
    122. 122. WHO ANALGESIC LADDER
    123. 123. Physical dimention ORGANIC PAIN • Motivational affective • Cognitive evaluation • The meaning of pain • unpleasant sensory • emotional experienced “ an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in term of such damage” PAIN is defined (by IASP1979) as : PAIN Psycological dimention
    124. 124. Definition of Pain “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” “Suatu perasaan dan pengalaman emosional yang tidak menyenangkan akibat kerusakan jaringan yang nyata atau yang berpotensi rusak, atau sesuatu yang tergambarkan seperti itu” IASP, 1979
    125. 125. Byock’s five key points:  “I forgive you.”  “Forgive me.”  “Thank you.”  “I love you.”  “Goodbye.”
    126. 126. Structure andStructure and FuntionFuntion ReciprocallyReciprocally InterrelatedInterrelated Self-RegulatorySelf-Regulatory MechanismMechanism
    127. 127. TYPES OF PAIN NEUROPATHICNOCICEPTIVE Deafferentation Sympathetic Maintained Peripheral Somatic • bones, joints • connective tissues • muscles Visceral • Organs – heart, liver, pancreas, gut, etc.
    128. 128. J.Loeser (1980) Concept of nociception, pain, suffering and pain behaviour Pain behaviour Suffering Pain Nociception
    129. 129. A-Alpha Motor Efferent Sympathetic Efferent Delta Sensory Afferent C-Fiber Sensory Afferent Peripheral Nociceptor Spinal Cord NSST PSST NRMBrainstem Midbrain Hypothalamus and Pituitary Cortex and Thalamus LC PAG MTVPL SSC FLC Ascending Pathaways Descending Pathaways Sympathetic Outflow Hypothalamic- Pituitary Outflow
    130. 130.  Visceral pain  Poorly localized, constant, aching and commonly referred to cutaneous sites  Results from injury to the organs that are sympathetically innervated  Referred pain  Pain and hyperalgesia localized to deep or superficial tissues and often found distant from the source  One proposed mechanism to explain this occurrence is central convergence of afferent impulses Acute Pain
    131. 131.  constant  sharp aching  well localized  constant  dull aching  poorly localized  usually with nausea and vomit  occasional colicky or cramp  often referred to cutaneous sites Somatic pain Visceral pain Somatic Pain vs Visceral Pain

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