It is not only about alleviated the Pain It is also about modulating the Body System to a better quality of ( end) life care

1. THE NEED OF PAIN
RELIEF IN CANCER PAIN
N Margarita Rehatta

2.  Human`s Right
 The Ethical Principles
to provide pain management
and comfort all patients including
those – unable to speak for themselves
 To cure some times
To relieve often
but .. To comfort always

3.  Basic`s of Pain Management

4. Pain is the net effect of many simultaneously
interacting
Biochemical, Physiologic, Psychological, that involve
activity of nervous system concerned with sensory,
motivational, cognitive processes and psychodynamic
mechanism.
John J Bonica, The Management of
Pain, 1990
Biopsychosociocultural Model

5. Nyeri Total – pada nyeri kanker
Nyeri fisik
Nyeri psikologis
Nyeri kultural
Nyeri sosial
Nyeri spiritual
Nyeri finansial
Nyeri
total
• Segi nyeri mana yang paling penting berbeda untuk setiap
pasien
Karjadi Wirjoatmodjo, IPS 2005

6. Influence
perception of
pain intensity
Bio - Pain Pathway & Integrated Response

7.  Why Pain need to be alleviated

8. The body
response to
stress
ACTH -Endorphin
CS
NE
EPI
ENK
Pain

9. Neurotransmitter
release
Electrophysiological
response
Intracellular
stress
response
Structural
response
Neuropsychological
response
Glutamate, aspartate
Substance P, calcitonin
gene-related peptide
Excitatory
postsynaptic
potential
Calcium
Nitric oxide
synthase
Protein
kinase C
Enkephalin
Dynorphin
Sensitisation
Wind-up
c-fos
c-jun
Cholecystokinin,
Neuropeptide Y
Vasoactive
Intestinal peptide
Galanin
?Bcl-2
?Bax
Sprouting
Remodelling
? Apoptosis / cell death
Perception
Aversion
Avoidance
Stimulation-produced
analgesia
Allodynia,
Chronic pain syndrom
Disability
Quality of life
Suffering
-3 -2 -1 0 1 2 3 4 5 6 7 8
Pain Sttmulus
(s) (min) (h) (days) (moths) (years))
Time in seconds (logarithmic scale)
CASCADES OF SYSTEM RESPONSES
Adapted form Jones, 1996

10. Pathophysiology and mechanisms
of cancer pain
 Nociceptive (somatic and visceral)
 Neuropathic
 Psychogenic
 Idiopathic / unrelated to cancer
Fundamental in assessment
&
determine therapy

11. - Abolish tumor directed pain
(chemotherapy, hormonal, radiation)
- Altering the pain response
(psychological approach)
- Interfering the pain pathway
(nerve block, neurolytic destruction)
- Mechanism based
• Management of cancer pain
Multimodality

12. Goal of Cancer Pain management
ACUTE (NEW OR BREAKTHROUGH)
PAIN MANAGEMENT
To relieve pain
CHRONIC PAIN MANAGEMENT
To enhance function
To improve quality of life

13. Global Improvement Ratings
Physical functioning
Emotional functioning
Adverse symptom
(Drug) Efficacy issues.

14. Chronic Pain
Cancer pain
ACUTE PAIN
SHORT TERM POOR SLEEP
LONG TERM POOR SLEEP
STRSS & ANXIETY
ACTIVATION HP AXIS
RISE IN IL – 6 RELEASE
NOVEL PAIN
MORE
INTENSE
PAIN
Pain and sleep ,Lavigne Gilles .
53 – 89 % patients

15. Key barriers to good Cancer Pain
control Patients and carers
 reluctant to complain about symptoms
 fear pain and don’t know how to get help
 lack knowledge about strong opioid analgesia
 fear adverse effects leading to poor adherence.
 Healthcare professionals
 fail to assess pain adequately
 reluctant to prescribe and monitor effective analgesia
 provide insufficient education to promote self-
management
 Healthcare systems
 fail to recognise patients with cancer pain
 communicate data on pain ineffectively
Wendy etal,European Journal of Can
2009

16. WHO Analgesic Ladder for treating cancer pain,since 1986

17. Step up –Step Down adaptation Ladder

18. The Analgesia Balance
ACUTE PAIN vs CANCER PAIN

19. Cancer
Pain

21.  It is not only about alleviated the Pain
 It is also about modulating the Body System
to a better quality of ( end) life care

22. Semoga bermanfaat

23. Anesthesiology
and
Reanimation
Critical
care
Safestress
&painfree
anesthesia
Management
ofstress&pain
Basic science
Interpersonal
Communication skill
Team building and teamwork skill
Model yang disederhanakan Karjadi Wirjoatmodjo, IPS 2005

24. Expectation is involved in the therapeutic outcome
Hidden analgesic therapy (no expectation) analgesic >
Open analgesic therapy (expectation +) analgesic <
 Specific treatment effect and placebo response – additive
True treatment effect
True placebo effect
Natural course
Regression towards mean
Other time effects
Unidentified parallel interventions
Perceived treatment effect
minus
Other non-specific effect
= True treatment effect
Levine, J.D. & Gordon, N.C., Nature, 1984

25. Luana Colloca and Fabrizio Benedetti, Neuroscience, 2005
As the drug has analgesic
effect only in association
with placebo procedure it’s
action is not directed to
pain pathway but to
expectation pathway