Chronic non cancer Pain   Rachmat Gunadi Wachjudi   Departement of Internal Medicine      Dr Hasan Sadikin Hospital       ...
Pain as the 5th Vital Sign•     Consider pain the fifth vital sign and assess patients for pain every        time you chec...
Pain is a significant issue•   #1 Admitting diagnosis in US•   #1 Reason for missed work in US•   Chronic pain costs the U...
Prompt Pain Management is Vital•   The sooner pain is                             Lengt h of Tim e Of f    managed  the m...
Types of Pain1. Acute2. Cancer, acute or chronic3. Chronic non-cancer
Chronic Pain Treatment Continuum                                                   Advanced Pain                          ...
Targeting your ApproachNOCICEPTIVE PAIN        arthropathies        ischemic disorders        visceral painNEUROPATHIC PAI...
Principles of Treatment              Reduction of Pain:Behavioral, Meds, Blocks, Surgery, Complementary     There is no ma...
Treatment ObjectivesDecrease the frequency and / or severity of the pain          General sense of feeling better         ...
Modified WHO Analgesic                    Ladder Quality of Life                         Pain Severit                     ...
Using Pharmacological Options           Safely         Pharmacokinetics        Pharmacodynamics           Compliance      ...
Despite all the advances in medical           technology…. Complete relief of symptoms (pain) often an unrealistic        ...
Chronic pain often accompanied by other problems that interact                    REDUCED                    ACTIVITY     ...
Pain - current viewPain is an end-product of many interacting processes in  the nervous system (including the brain).The r...
Treatment principles     Pain as a symptom     Find the cause and fix it        Pathology oriented      Works well in acut...
Treatment principles   Pain as a symptom   Find the cause and fix it       Works well here
Treatment principles      Pain as a symptom      Find the cause and fix itDoes all headaches have a pathology?
Treatment principles       Pain as a symptom         Control the symptom               Passive  Long term effects and side...
Symptom control         Medications   Antipyretics (paracetamol)             NSAID            Opioids        Antidepressan...
Symptom control               Paracetamol            Effective in OA knees                     Amadio Curr. Ther. Res. 198...
Symptom control         Paracetamol       Evidence in OA onlyHepatic and renal toxicity do occur  Medication induced heada...
Symptom control             Medications     Antipyretics (paracetamol)               NSAID              Opioids          A...
Symptom control                     NSAID      Best evidence from rheumatoid arthritis             Also good for cancer pa...
NSAIDS-> not approved by FDA for the whole range of     rheumatic diseases but all are probably     effective in:     ¤ rh...
Chemical Class           Prototype      Analgesia   Antipyresis   AntiinflammatorySalicylates           Aspirin           ...
Treatment of chronic inflammation requires use of these   agents at doses well above those used for analgesia             ...
Common Adverse Effects               Platelet Dysfunction  Gastritis and peptic ulceration with bleeding          (inhibit...
Symptom control           Medications     Antipyretics (paracetamol)               NSAID              Opioids          Ant...
Symptom control               OpioidsGold standard for cancer pain management   (mostly) cheap and readily available      ...
Efficacy of opioids in chronic non-cancer                 pain: systematic review        Reduction in Pain Intensity Follo...
Symptom control                Opioids   Controversial for non-cancer painLimited (but positive) evidence of efficacy     ...
Symptom control                   Opioids       Controversial for non-cancer pain  “Physicians should make every effort to...
Symptom control                       Opioids          Controversial for non-cancer pain“Opioids are our most powerful ana...
2006 Guideline in Treatment Moderate to Severe Pain in OA patients with Risk Factors                                      ...
Symptom control                 Opioids Practical guidelines for non-cancer pain           Exhaust other methods       Aim...
Symptom control            Medications     Antipyretics (paracetamol)               NSAID              Opioids          An...
Symptom control         AntidepressantsAnalgesic at below mood altering doses  NNT for diabetic neuropathy ~ 3.4        Co...
Symptom control         AntidepressantsAnalgesic at below mood altering doses NNT for post-herpetic neuralgia ~ 2.1       ...
Symptom control     AntidepressantsHow good is NNT of 2.1 to 3.4?     It is not good for this
Symptom control     AntidepressantsHow good is NNT of 2.1 to 3.4?   It is really good for pain
Symptom control       Antidepressants    Major problem: side effects        NNH (minor) ~ 2.7  No consensus which one is b...
Symptom control           Medications     Antipyretics (paracetamol)               NSAID              Opioids          Ant...
Symptom control         AnticonvulsantsCarbamazepime for trigeminal neuralgia              NNT ~ 2.6              NNH ~ 3.4
Symptom control           Anticonvulsants  NNT for diabetic neuropathy (red) ~ 2.7NNT for post-herpetic neuralgia (white) ...
Symptom control  Anticonvulsants     Gabapentin  Less organ damage  No drug interaction
Symptom control    Intervention        Nerve  Counter-stimulation
Symptom control    Nerve block     Where to cut      How to cut   What is left behind
Symptom control    Nerve block     Where to cut      How to cut   What is left behind
Symptom controlTranscutaneous Electrical Nerve Stimulation                    (TENS)             Product of Gate theory   ...
Symptom controlSpinal cord stimulation    Patient controlled     No medication   Permanent (almost)
Symptom controlSpinal cord stimulation   Failed back surgery   Isolated neuropathy  Ischemic heart diseasePeripheral vascu...
Treatment principles     Pain as a symptom   Find the cause and fix it     Symptomatic control    Pain as a disease   How ...
Pain as a disease                 Insomnia  Depression                         Socially deprived                  Pain    ...
Pain as a disease    Our contribution     “Degenerative”      “Bone spurs”    “Nothing wrong”   “It is in your mind”
Pain as a diseaseNeed a multi-disciplinary approach       Clinical psychology          Physiotherapy      Occupational the...
Pain as a disease           Alleviate their depression     Motivate them to mobilise despite pain           Encourage acti...
Pain as a disease     Cognitive behavioral therapy        Pain intensity (VAS)98765                                   Pre4...
Pain as a disease       Cognitive behavioral therapy      Analgesic consumption (types) 32.5 2                            ...
Pain as a disease Cognitive behavioral therapy    Pain is the same, but         More active       Less depressed         L...
Pain as a specialty            Getting established      IASP and its 65 global chaptersOver 300000 members of multiple spe...
Pain as a specialty     Anaesthesiology    Orthopediac surgery       Neurosurgery  Oncology / palliative care         Neur...
Pain as a specialty … is to specialize in everthing!
Pain as a specialtyOpportunity to work with other doctors
SummaryChronic pain is common (1 in 5 people)It is a risk factor for disabilityThe presence of mental disorders increases ...
Treatment of Pain           Options:           • Non-pharmacologic           • Medications                • Acetaminophen ...
Opioids - Key messagesPain is prevalent, underestimated, debilitatingWe have effective analgesics   need careful pain asse...
Thank You   Dr. John J. Bonica“Father of pain medicine”
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Chronic noncancer pain management R Gunadi Bandung

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an overview of pain management

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  • Kalso analysed available randomised, placebo-controlled trials of WHO step 3 opioids for efficacy and safety in chronic non-cancer pain. The Oxford Pain Relief Database (1950-1994) and Medline, EMBASE and the Cochrane Library were searched until September 2003. The short-term efficacy of opioids was good in both neuropathic and musculoskeletal pain conditions. However, only a minority of patients in these studies went on to long-term management with opioids.  
  • This slide indicates the guidelines published in 2006 on the management in patients with moderate to severe pain and with risk factors.   繼 FDA ( 美國 ) 及 EMEA ( 英國 ) 在 2005 二月的公告後 , 世界疼痛小組在 六月的維也納 EULAR ( 歐洲免疫風濕學會 ) 中召開第二次會議並提出以下建議 : APAP- Acetaminophen 的安全性值得肯定 , 仍建議為關節炎 , 下背痛的首選用藥 根據目前大量完整的臨床實證分析 , NSAIDs 及 COX-2 的 CV risk 是 cross effect, 非常不建議長期使用 , 針對有心血管 腎臟疾病的病人 , 需長期疼痛控制者建議以改以 tramadol/APAP ( ULTRACET ) 為首選用藥之一…… . 因此 Tramadol/APAP 在未來關節炎的疼痛控制將伴演越來越重要的角色
  • Use of chronic opioid therapy for chronic pain has increased substantially. We should assess pain and patients with pain carefully to achieve optimal pain control. Chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. Management of chronic pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion.
  • Chronic noncancer pain management R Gunadi Bandung

    1. 1. Chronic non cancer Pain Rachmat Gunadi Wachjudi Departement of Internal Medicine Dr Hasan Sadikin Hospital Bandung
    2. 2. Pain as the 5th Vital Sign• Consider pain the fifth vital sign and assess patients for pain every time you check for pulse, blood pressure, core temperature, and respiration. • Urge your colleagues to take their patients complaints of pain seriously. Remind them not to put patients in the position of asking for a favor when they want pain relief. • Inform patients that they deserve to have their pain evaluated and treated. • Work to implement the APS Quality Improvement Guidelines for the Treatement of Acute Pain and Can in your own practice setting. (JAMA, 274, 1874-1880) • Wear your Fifth Vital SignTM button and make opportunities to explain the importance of pain evaluation and treatment to other healthcare professionals and to the public. http://www.ampainsoc.org/
    3. 3. Pain is a significant issue• #1 Admitting diagnosis in US• #1 Reason for missed work in US• Chronic pain costs the US $100B / year in direct medical costs, lost income and productivity• Pain is the 5th vital sign (JCAHO)• Patients have a right to adequate pain control (JCAHO) Stewart et al, Work-related cost of pain in the US, IASP/10 th World Congress on Pain 2002, as cited by Dr. John Stamatos, Medscape.com.
    4. 4. Prompt Pain Management is Vital• The sooner pain is Lengt h of Tim e Of f managed  the more 2% likely patients are to Work 19% return to normal daily 94% living activities 0% 50% 100% Percent age Ret ur ning t o Work < 90 days > 90 days < 2 yrs J. McGill, J. Occupational Medicine, 1968
    5. 5. Types of Pain1. Acute2. Cancer, acute or chronic3. Chronic non-cancer
    6. 6. Chronic Pain Treatment Continuum Advanced Pain Second-Tier Therapies Pain Therapies First -Tier Pain Therapies Neurostimulation Implantable Diagnosis Drug Pumps Surgical Intervention Opioids Neuromodulation Neurolysis Thermal NSAIDs Procedures TENS Psychological Rx Nerve Blocks Physical Rx OTC pain meds Chronic Pain Treat ment Cont inuum Source: Implantable Technologies: Spinal Cord Stimulation and Implantable Drug Delivery Systems, Elliot Krames, MD, Pacific Pain Treatment Center, SF, www.painconnection.org
    7. 7. Targeting your ApproachNOCICEPTIVE PAIN arthropathies ischemic disorders visceral painNEUROPATHIC PAIN neuropathy PHN post-stroke pain (central)
    8. 8. Principles of Treatment Reduction of Pain:Behavioral, Meds, Blocks, Surgery, Complementary There is no magic bullet, no single cure Rehabilitation: Reconditioning & Prevention Coping: Management of Residual Pain
    9. 9. Treatment ObjectivesDecrease the frequency and / or severity of the pain General sense of feeling better Increased level of activity Return to work Decreased health care utilization Elimination or reduction in medication usage
    10. 10. Modified WHO Analgesic Ladder Quality of Life Pain Severit Invasive treatments Proposed 4 th Opioid Delivery Step Pain persisting or increasing Step 3 8 -10 Opioid for moderate to severe pain ±Nonopioid±Adjuvant Pain persisting or increasing Step 2 Opioid for mild to moderate pain 4-7 The WHO ±Nonopioid± Adjuvant Ladder Pain persisting or increasing Step 1 ± Nonopioid 1-3 ± Adjuvant PainDeer, et al., 1999
    11. 11. Using Pharmacological Options Safely Pharmacokinetics Pharmacodynamics Compliance Cost Polypharmacy
    12. 12. Despite all the advances in medical technology…. Complete relief of symptoms (pain) often an unrealistic goal once pain becomes chronic More realistic to seek ways to limit disability despite pain That is, manage pain to limit its impact Goucke CR. The management of persistent pain. Med J Aust 2003; 178(9): 444-447. Loeser JD. Mitigating the dangers of pursuing cure. In: Cohen MJM, Campbell JN, eds. Pain Treatment Centers at a Crossroads: A Practical and Conceptual Reappraisal. Seattle, IASP Press, 1996:101-108.
    13. 13. Chronic pain often accompanied by other problems that interact REDUCED ACTIVITY PHYSICAL DETERIORATION (eg. muscle wasting, joint stiffness) UNHELPFUL BELIEFS & THOUGHTSPAIN FEELINGS OF EXCESSIVEPERSISTING DEPRESSION, SUFFERING REPEATED HELPLESSNESS, TREATMENT IRRITABILITY & DISABILITY FAILURES LONG-TERM USE OF ANALGESIC, SEDATIVE DRUGS SIDE EFFECTS (eg. stomach problems lethargy, constipation) LOSS OF JOB, FINANCIAL DIFFICULTIES, FAMILY STRESS © M K Nicholas PhD Pain Management & Research Centre Influence of workplace, A BIOPSYCHOSOCIAL PERSPECTIVE Royal North Shore Hospital St Leonards NSW 2065 AUSTRALIA home, treatment providers
    14. 14. Pain - current viewPain is an end-product of many interacting processes in the nervous system (including the brain).The relationship between injury and pain is quite variable.Knowledge of cause of pain is not sufficient to tell us how much pain a person will have or its impact.Diagnosis (eg. “Lumbar Discogenic Pain”) is a poor guide to prediction of disability (Caragee et al, Spine Journal, 2005)
    15. 15. Treatment principles Pain as a symptom Find the cause and fix it Pathology oriented Works well in acute painWell accepted by patient and doctor
    16. 16. Treatment principles Pain as a symptom Find the cause and fix it Works well here
    17. 17. Treatment principles Pain as a symptom Find the cause and fix itDoes all headaches have a pathology?
    18. 18. Treatment principles Pain as a symptom Control the symptom Passive Long term effects and side effects Case specific What are the options?There is no magic bullet, no single cure
    19. 19. Symptom control Medications Antipyretics (paracetamol) NSAID Opioids Antidepressants AnticonvulsantsSteroids, muscle relaxants, etc.
    20. 20. Symptom control Paracetamol Effective in OA knees Amadio Curr. Ther. Res. 1983 Effectiveness ~ Ibuprofen Bradley N. Eng. J. Med. 1991Safe and economical, NSAID sparing for elderly Nikles Am. J. Ther. 2005
    21. 21. Symptom control Paracetamol Evidence in OA onlyHepatic and renal toxicity do occur Medication induced headache
    22. 22. Symptom control Medications Antipyretics (paracetamol) NSAID Opioids AntidepressantsMembrane stabilisers (anticonvulsants) Steroids, muscle relaxants, etc.
    23. 23. Symptom control NSAID Best evidence from rheumatoid arthritis Also good for cancer pain Effective in 5 out of 10 placebo-trials for LBP Effective in 4 out of 9 Panadol-trials for LBPDoubtful value for non-specific musculoskeletal pain Koes Ann. Rheum. Dis. 1997 Eisenberg J. Clin. Onco. 1994
    24. 24. NSAIDS-> not approved by FDA for the whole range of rheumatic diseases but all are probably effective in: ¤ rheumatoid arthritis ¤ seronegative spondyloarthropathies e.g.> psoriatic arthritis > arthritis associated w/ inflammatory bowel disease ¤ osteoarthritis ¤ localized musculoskeletal syndromes e.g. sprains and strains, low back pain ¤ gout – except tolmetin -->ineffective for gout 24
    25. 25. Chemical Class Prototype Analgesia Antipyresis AntiinflammatorySalicylates Aspirin +++ +++ +++Para-aminophenols Acetaminophen +++ +++ MarginalIndoles Indomethacin +++ ++++ ++++Pyrrol acetic acids Tolmentin, +++ +++ +++ mefenamic acidPropionic acids Ibuprofen, ++++ +++ ++++ naproxenEnolic acids Phenylbutazone, +++ +++ ++++ piroxicamAlkanones Nabumetone ++ ++ +++Sulfonamide Celecoxib ++++ +++ ++++
    26. 26. Treatment of chronic inflammation requires use of these agents at doses well above those used for analgesia and antipyresis the incidence of adverse drug effects is increased.
    27. 27. Common Adverse Effects Platelet Dysfunction Gastritis and peptic ulceration with bleeding (inhibition of PG + other effects) Acute Renal Failure in susceptible Sodium+ water retention and edema Analgesic nephropathyProlongation of gestation and inhibition of labor.Hypersenstivity (not immunologic but due to PG inhibition) GIT bleeding and perforation
    28. 28. Symptom control Medications Antipyretics (paracetamol) NSAID Opioids AntidepressantsMembrane stabilisers (anticonvulsants) Steroids, muscle relaxants, etc.
    29. 29. Symptom control OpioidsGold standard for cancer pain management (mostly) cheap and readily available Administered at every route
    30. 30. Efficacy of opioids in chronic non-cancer pain: systematic review Reduction in Pain Intensity Following Oral Opioid Treatment * 30% is the suggested clinically relevantKalso et al. Pain 2004;112:372-80 decrease in pain intensity in chronic pain
    31. 31. Symptom control Opioids Controversial for non-cancer painLimited (but positive) evidence of efficacy Extensive side effects Tolerance Dependence Divergence
    32. 32. Symptom control Opioids Controversial for non-cancer pain “Physicians should make every effort to controlindiscriminate prescribing, even under pressure from patients…” Ballantyne N. Eng. J. Med. 2003
    33. 33. Symptom control Opioids Controversial for non-cancer pain“Opioids are our most powerful analgesics, but politics, prejudice, and our continuing ignorance still impede optimum prescribing” McQuay Lancet 1999
    34. 34. 2006 Guideline in Treatment Moderate to Severe Pain in OA patients with Risk Factors Paracetamol up to 4g/day Cardiovascular Renal Gastrolintestinal risk risk risk Avoid NSAIDs/ Flares Long term COX-2 inhibitors • Paracetamol / tramadol COX-2 NSAIDs Paracetamal / weak opioid compinations* inhibitor +PPI Tramadol • Tramadol •Tramadol • Strong opioid •Strong opioids * 2nd choiceClinical Rheumatol (2006) 25 (Suppl 1): S22-S29 WGPM ( The Working Group on Pain Management ) Recommendation at the 2nd meeting in EULAR 2005
    35. 35. Symptom control Opioids Practical guidelines for non-cancer pain Exhaust other methods Aim at functional improvementLimit prescription authority, monitor behavior Slow release, avoid injectables Opioid contract
    36. 36. Symptom control Medications Antipyretics (paracetamol) NSAID Opioids AntidepressantsMembrane stabilisers (anticonvulsants) Steroids, muscle relaxants, etc.
    37. 37. Symptom control AntidepressantsAnalgesic at below mood altering doses NNT for diabetic neuropathy ~ 3.4 Collins J. Pain & Sym. Manag. 2000
    38. 38. Symptom control AntidepressantsAnalgesic at below mood altering doses NNT for post-herpetic neuralgia ~ 2.1 Collins J. Pain & Sym. Manag. 2000
    39. 39. Symptom control AntidepressantsHow good is NNT of 2.1 to 3.4? It is not good for this
    40. 40. Symptom control AntidepressantsHow good is NNT of 2.1 to 3.4? It is really good for pain
    41. 41. Symptom control Antidepressants Major problem: side effects NNH (minor) ~ 2.7 No consensus which one is best Classically TCASSRI: seemed more specific on mood
    42. 42. Symptom control Medications Antipyretics (paracetamol) NSAID Opioids AntidepressantsMembrane stabilisers (anticonvulsants) Steroids, muscle relaxants, etc.
    43. 43. Symptom control AnticonvulsantsCarbamazepime for trigeminal neuralgia NNT ~ 2.6 NNH ~ 3.4
    44. 44. Symptom control Anticonvulsants NNT for diabetic neuropathy (red) ~ 2.7NNT for post-herpetic neuralgia (white) ~ 3.2 Collins J. Pain & Sym. Manag. 2000
    45. 45. Symptom control Anticonvulsants Gabapentin Less organ damage No drug interaction
    46. 46. Symptom control Intervention Nerve Counter-stimulation
    47. 47. Symptom control Nerve block Where to cut How to cut What is left behind
    48. 48. Symptom control Nerve block Where to cut How to cut What is left behind
    49. 49. Symptom controlTranscutaneous Electrical Nerve Stimulation (TENS) Product of Gate theory Better than placebo in short term Minimal side effects No long term benefit
    50. 50. Symptom controlSpinal cord stimulation Patient controlled No medication Permanent (almost)
    51. 51. Symptom controlSpinal cord stimulation Failed back surgery Isolated neuropathy Ischemic heart diseasePeripheral vascular disease Pain relief as a therapy
    52. 52. Treatment principles Pain as a symptom Find the cause and fix it Symptomatic control Pain as a disease How is this disease like?
    53. 53. Pain as a disease Insomnia Depression Socially deprived Pain Medical DependenceThink negative In-activity
    54. 54. Pain as a disease Our contribution “Degenerative” “Bone spurs” “Nothing wrong” “It is in your mind”
    55. 55. Pain as a diseaseNeed a multi-disciplinary approach Clinical psychology Physiotherapy Occupational therapy Nursing Social work / vocational training
    56. 56. Pain as a disease Alleviate their depression Motivate them to mobilise despite pain Encourage active coping Reduce dependency on medical input Stop searching for a causeStop giving analgesics together with side effects Cognitive behavioral therapy
    57. 57. Pain as a disease Cognitive behavioral therapy Pain intensity (VAS)98765 Pre4 Post3210
    58. 58. Pain as a disease Cognitive behavioral therapy Analgesic consumption (types) 32.5 2 Pre1.5 Post 10.5 0
    59. 59. Pain as a disease Cognitive behavioral therapy Pain is the same, but More active Less depressed Less doped
    60. 60. Pain as a specialty Getting established IASP and its 65 global chaptersOver 300000 members of multiple specialties
    61. 61. Pain as a specialty Anaesthesiology Orthopediac surgery Neurosurgery Oncology / palliative care Neurology Rheumatology Rehabilitative medicine Psychiatry Radiology
    62. 62. Pain as a specialty … is to specialize in everthing!
    63. 63. Pain as a specialtyOpportunity to work with other doctors
    64. 64. SummaryChronic pain is common (1 in 5 people)It is a risk factor for disabilityThe presence of mental disorders increases risk of disability in those with chronic painCurative treatment is unlikely (no magic bullet)Interventions need to be targeted against identified risk factors (bio – psycho – social)Challenge: Collaborative approach offers best chance of success
    65. 65. Treatment of Pain Options: • Non-pharmacologic • Medications • Acetaminophen • Nonsteroidal anti-inflammatory drugs • Opioids • Antidepressants & anticonvulsants • Adjuvants Invasive proceduresCopyright © 2003 American Society of Anesthesiologists. All rights reserved
    66. 66. Opioids - Key messagesPain is prevalent, underestimated, debilitatingWe have effective analgesics need careful pain assessment and drug titration to achieve optimal balance: safety + tolerability + efficacyStrong opioids play a pivotal role in non-cancer and cancer pain treatment Opiophobia education and example understanding addiction, abuse, dependence addiction uncommon in pain patients Level 1 evidence based Guidelines Rich BA. Ethics of opioid analgesia for chronic noncancer pain. Pain Clinical Updates. Dec 2007
    67. 67. Thank You Dr. John J. Bonica“Father of pain medicine”

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