PAIN

MANAGEMENT
dr. Yuddi Gumara, SpAn KMN

DEPT. PALLIATIVE CARE

DHARMAIS HOSPITAL
NATIONAL CANCER CENTER
Lecture Plan
• What is pain?
• Why should we treat pain?
• Classification of pain
• Physiology and pathology
• Overview Pain treatment
• Evaluation of Pain treatment
Pendahuluan
▪ Alasan tersering pasien mencari pertolongan medis
adalah nyeri.
▪ Terkendalinya rasa nyeri yang merupakan hak pasien
▪ Mendukung hak pasien untuk mendapatkan
penilaian dan tatalaksana nyeri yang adekuat
merupakan bagian dari standar JCI.
▪ Rasa nyeri sudah dianggap sebagai "tanda vital
kelima"
 Deklarasi IASP Montreal 2010
Manajemen Nyeri Adalah Hak Asasi Manusia Yang Mendasar

Manajemen nyeri tidak memadai di sebagian besar dunia

What is Pain?
 What is Pain?
Scientific An unpleasant sensory and emotional
experience associated with, or
resembling that associated with, actual or
potential tissue damage.
July 2020, the International Association for the Study of Pain (IASP)

Clinical Pain is whatever the experiencing

person says.
“Pain is what ever the patient says”
(Mc Caffery, 1999)
Is this man feeling pain?
Classification of Pain
Not all pain is the same!

• Three main questions:

1. How long has the patient had pain?
2. What is the cause?
3. What is the pain mechanism?
Classification of Pain
Duration Acute
Chronic
Acute on chronic
Cause Cancer
Non-cancer
Mechanism Nociceptive (physiological)
- Somatic
- Visceral
Neuropathic (pathological)
Acute versus Chronic
• Acute
• Pain of recent onset and probable limited duration
• Chronic
• Pain persisting beyond healing of injury
• Often no identifiable cause
• (Pain lasting for more than 3 months)
Cancer versus Non-Cancer
• Cancer pain
• Progressive
• May be mixture of acute and chronic
• Non-cancer pain
• Many different causes
• Acute or chronic
Nociceptive Pain
• Obvious tissue injury or illness
• “Physiological pain”
• Description
• Sharp ± dull
• Well localised
Neuropathic Pain
• Nervous system damage or abnormality
• “Pathological pain”
• Tissue injury may not be obvious
• Description
• Burning, shooting ± numbness, pins and needles
• Not well localised
Examples of Pain Types
Acute Non-Cancer Pain
• Examples
• Fracture, appendicitis
• Symptom of tissue injury or illness
• Useful
• Usually nociceptive
• Occasionally neuropathic (e.g. sciatica)
Chronic Non-Cancer Pain
• Examples
• Headache, back pain
• Usually no obvious injury
• Not useful
• Complex, may be mixed nociceptive and neuropathic
• Does not respond to usual drug treatment
Cancer Pain
• Examples
• Oral cancer, breast cancer, uterine cervical cancer
• Features of acute and chronic pain
• May be acute on chronic
• Often mixed nociceptive and neuropathic pain
• Usually gets worse over time if untreated
Pain Physiology and
Pathology
Why is pain physiology important?

• Many factors affect how we “feel” pain.

• Psychological factors are very important.
• Different treatments work on different parts of the pathway.
• More than one treatment may be needed.
Physiology

• 4 steps:
• Transduction (Periphery)
• Transmision (Periphery-Spinal
cord-Brain)
• Modulation (Spinal cord-Brain)
• Perception (Brain)
Periphery
• Tissue injury
• Transduction → Release of
chemicals (Histamine,
Subtance P, Cytokines,
Bradykinin, Prostaglandins)
• Transduction→Stimulation of
pain receptors (nociceptors)
• Transmision → Signal travels in
Aδ or C nerve to spinal cord.
• Peripheral sensitization
Spinal Cord
• Dorsal horn is the “first relay
station”
• Aδ or C nerve synapses
(connects) with second nerve
• Second nerve travels up opposite
side of spinal cord
• Modulation → wind up
phenomenon (central
sensitization)
Brain
• Thalamus is the
“second relay station”
• Connections to many
parts of the brain
• Cortex
• Limbic system
• Brainstem
• Pain perception occurs
in the cortex
Brainstem

• Descending pathway
from brain to dorsal
horn
• Usually decreases pain
signal
Neuropathic Pain
• “Pathological” pain
• Abnormality of:
• Peripheral nerves
• Spinal cord or brain
• Needs to be treated differently
Neuropathic Pain
• Peripheral
• Damaged nerves (e.g. trauma, diabetes)
• Abnormal firing of nerves
• Central
• Changes in “wiring”
• Abnormal firing
• Loss of modulation
Pain Treatment Overview

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Treatments - Periphery

• Non-drug treatments
• Rest, ice, compression,
elevation
• Anti-inflammatory
medicines
• Local anaesthetics
Treatments - Spinal Cord

• Non-drug treatments
• Acupuncture, massage
• Local anaesthetics
• Opioids
• Ketamine
Treatments - Brain
• Non-drug treatments
• Psychological
• Drug treatments
• Paracetamol
• Opioids
• Amitriptyline
• Clonidine
Non-Pharmacology Treatments
• Physical
• Rest, ice, compression, elevation
• Surgery
• Acupuncture, massage, physiotherapy
• Psychological
• Explanation
• Reassurance
• Counseling
Drug Classification
• Simple analgesics
–Paracetamol (acetaminophen)
–Anti-inflammatory medicines
– Aspirin, ibuprofen, mefenamic acid, natrium diclofenac, ketoprofen,
ketorolac
• Opioids
–Mild
– Codeine, tramadol
–Strong
– Morphine, pethidine, oxycodone, hidromorfon, fentanyl
Drug Classification
• Other analgesics
• Amitriptyline
• Gabapentin/pregabalin
• Carbamazepine
• Local anaesthetics
• Ketamine
• Clonidine
Post-operative Pain Relief
• Post operative pain
starts at its peak
intensity and
improves over time
• Analgesia may be
started at higher
steps and then
stepped down
accordingly as pain
improves.
WFSA Analgesic Ladder
1. Charlton E. World Federation of Societies of Anaesthesiologists. The management of post operative pain. Update in anaesthesia1997;7:1–7.
Cancer Pain Management

The three-step analgesic ladder