Pain management

1. PAIN MANAGEMENT A. M. Takdir Musba Department of Anesthesiology, Intensive Care and Pain Management Faculty of Medicine, Hasanuddin University MAKASSAR, INDONESIA

2. 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

3. Protective Function : Withdrawal Reflex Defensive Function : Immobilitation Diagnostic Function : Acute Abdomen PAIN Functional Body System

4. 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

5. 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

6. 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

7. 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

8. POINT OF VIEW  THEORY OF PAIN  PRINCIPLE OF PAIN MANAGEMENT  ANALGESIC CHOICE IN PAIN MANAGEMENT  CLINICAL CASE LEARNING

9. “ 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

10. Beecher Pain perception depend on the meaning of injury

11. NO BRAIN, NO PAIN

12. Pain knowledge progress  Specificity Theory , Descartes, 17th century  Gate Controlled Theory , Melzack and Wall, 1965  Sensitization Theory, Woolf, 1992

13. Pain was faithfully transmitted from periphery to brain 1. Specificity theory Descartes (17th Century)

14. 2.GATE CONTROL THEORY by MELZACK and WALL Ascending Action System Large fibers Central Control Descending Modulation Small fibers Dorsal Horn “Gate” The Gate control theory of pain processing. T = Second-order transmission cell; SG = substantia gelatinosa cell.

15. 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

16. Spinothalamic tract Peripheral 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

17. Good Drug in a Right Doctor

18. AS A DOCTOR WE HAVE TO USE “ LOGICAL APPROACH TO PAIN CONTROL “

19. Principle of Pain Management : A Mechanism-based DRG •Opioids •Gabapentinoids •Clonidine Modify by AHT Ketamin Paracetamol Transduction TransductionModulation Perception Transmission Modulation

20. 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

21. 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

22. 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

23. 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

24. 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

25. cyclooxygenase inhibitor Ibuprofen Nabumetone Etodolac Dexketoprofen Diclofenac Meloxicam Nimesulide Celecoxib Rofecoxib Valdecoxib Acetosal Indomethacin Piroxicam Dual COX inhibitor preferentially COX-2 selective inhibitor COX-2 selective inhibitor COX-1 selective inhibitor preferentially COX-1 selective inhibitor COXIB GIT Incidence CV Incidence

26. PCT, NSAIDs, COXIBs J Can Dent Assoc 2002; 68(8):476-82

27. 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 ….

28. Opioid in Indonesia  Morphine  considered to be the standard opioid analgesic, oral sustained 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

29. 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

30. Potentiation Opioid Paracetamol NSAIDs Coxibs Nerve blocks Gabapentinoids 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

31. Rationale of Multimodal Analgesia Synergy Antagonism Additive

32. Farmakokinetik parasetamol dan tramadol Paracetamol Paracetamol/Tramadol Tramadol 0 1 2 3 4 0 2 4 6 8 10 Waktu (jam) Parasetamol/ tramadol Para- setamol Tramadol Bebasnyeri • Onset kerja parasetamol cepat • Efek tramadol yang bertahan lama Medve RA, Wang Julia, Karim . Anesth prog 48:79-81. 2001

33. 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

34. Interventional procedures for chronic non-cancer pain

35. WHO Analgesic LADDER for Cancer Pain

36. PAINASSESSMENT INDONESIA TIDAK NYERI NYERI RINGAN NYERI SEDANG NYERI SEDANG NYERI HEBAT NYERI TAK TERTAHANKAN

37. kortikosteroid NSAID COXIB Ketamine Gabapentanoid (Gabapentin,Pregabalin) PARACETAMOL OPIOID (Morphine, Fentanyl, Tramadol, Codein )

38. 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

39. Thank you very much for your kind attention Together against PAIN

40. 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

41. 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

42. Pilihan Analgesia  Parasetamol  NSAIDs ( non-specific or Specific inhibitor )  Opioid  Anti neuropatik  Multimodal Analgesia  Evidence-based  Karakteristik pasien :  Comorbid pasien  Usia  Jenis Kelamin  dll

43. IPM Evidence,2012

44. IPM in Low Back pain

45. 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.

46. Apa yang kita lakukan ?  Anamnesis  Intensitas nyeri  Jenis nyeri  Faktor yang memperparah dan mengurangi  Analgesia sebelumnya  dll  Pemeriksaan fisik  Pemeriksaan Penunjang  Diagnosis  Terapi

47. 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)

48. 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

49. Decision making in pain management ; Ramamurthy, James N, Alamnou. 2006

50. 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)

51. IPM in KNEE OA

52. 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

53. WHO Analgesic LADDER

54. 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

55. 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

56. WHO Analgesic LADDER

57. Comparative Onset of Opioid Drug Effect Minutes since bolus injection 0 5 10 15 20 Percentofpeakeffect siteconcentration 0 20 40 60 80 100 Methadone Remifentanil Fentanyl Sufentanil Alfentanil Hydromorphone Morphine Meperidine

58. Morphine Sustained Release to Transdermal Fentanyl Waktu Konsentrasiopioid - - Analgesic window Kondisi stabil (dalam 12 jam) IV ER: sustained release opioid IV : intravena opioid TD : transdermal opioid ER TD

59. 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

60. Opioid Dose Escalation Always 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

61. 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

62. Thank you very much for your kind attention Together against PAIN