Anjoman Pain

8/11/2019 Anjoman Pain

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Pain

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MYTHS

Anesthetics mask symptoms

Patient will harm itself iftheres no pain

Pain is difficult to assess


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The Truth!

Pain is BAD: Decreased cardiovascular function Decresed appetite Slows wound healing Decreased immune function

Greater chance of infection

Increased fear and anxiety


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STIMULATION () TRANSMISSION ()

PERCEPTION () MODULATION ( )

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Mechanism

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Process #2 Transmission

Impulse spinal cord brain stemthalamus central structures of brain painis processed.

Neurotransmitters are needed to continue the pain impulse from the spinal cord to the brain opioids (narcotics) are effectiveanalgesics because they block the release ofneurotransmitters


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Process #4 Modulation of Pain Changing or inhibiting pain impulses in thedescending tract ( brain spinal cord )

Descending fibers also release substances such as

norepinephrine and serotonin (referred to asendogenous opioids or endorphins) which have thecapability of inhibiting the transmission of noxiousstimuli. Helps explain wide variations of pain among

people.

Cancer pain responds to antidepressants whichinterfere with the reuptake of serotonin andnorepinephrine which increases their availability to

inhibit noxious stimuli.


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Process #3 Perception of Pain

The end result of the neural activity of paintransmission

It is believed pain perception occurs in the corticalstructures behavioral strategies and therapy can beapplied to reduce pain. Brain can accommodate alimited number of signals distraction , imagery ,relaxation signals may get through the gate, leavinglimited signals (such as pain) to be transmitted to thehigher structures.


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Nociceptive Neuropathic

-soft tissue

-bone-skeletal muscle

-smooth muscle

NerveCompression

NerveInjury

Classification of Chronic Pain


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Nociceptive (

)

( )

NSAID


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Classification of Pain

Acute Chronic

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Postoperative pain can be divided into:

Acute pain is experienced immediately aftersurgery (up to 7 days)

Pain which lasts more than 3 months after the

injury is considered to be chronic pain


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Describing pain only in terms of its

intensity is like describing music only

in terms of its loudness

von Baeyer CL; Pain Research and Management 11(3) 2006; p.157-162


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PAIN HISTORY

Description : severity, quality, location,frequency,aggravating & alleviating factors

Previous history

Context : social, cultural, emotional, spiritualfactors


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PatientAssessment

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Treatment

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Treatment

Non-pharmacologic Pharmacologic

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Non-Pharmacologic

Stimulation Therapy: electrical nerve stimulation

Psychological Intervention relaxation training, and hypnosis, have proven

effective in the management of postprocedure painand in cancer-related pain

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Pharmacologic Therapy

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General Treatment Principles

In general, common causes of treatment failureis Under-dosing

When treating chronic pain, elimination and prevention of pain is best accomplished byusing analgesics at fixed time intervals ratherthan on an as-needed basis

Effective analgesic therapy begins with anaccurate assessment of the patient

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+/- adjuvantNon-opioid

Weak opioid

Strong opioidBy the

Clock

W.H .O . ANALGESIC LADDER

+/- adjuvant

+/- adjuvant

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2

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Guidelines for Cancer painThe WHO 3-step Analgesic Ladder

Strong opioid+non opioids+ adjuvants

Weak opioid+non opioid+ adjuvants

Non opioid(antipyretic)+ adjuvants

Pain

Pain persisting orincreasing

Pain persisting orincreasing

Step 1.

Step 2.

Step 3.

90% respond well to oral medicines


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Adjuvant Analgesics

first developed for non-analgesic indications

subsequently found to have analgesic activity in specific pain scenarios

Common uses: pain poorly-responsive to opioids (eg. neuropathic

pain), or with intentions of lowering the total opioid dose and

thereby mitigate opioid side effects.


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Adjuvants Used In Palliative Care

General / Non-specific corticosteroids cannabinoids (not yet commonly used for pain)

Neuropathic Pain gabapentin antidepressants ketamine topiramate Clonidine

Pregabaline Bone Pain

bisphosphonates (calcitonin)


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inflammation

edemaspontaneous nerve depolarization

tumor mass

effects

CORTICOSTEROIDS AS ADJUVANTS

}


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Pain Level Description

Numerical Rating (0 to

10 Scale)

WHO Therapeutic Recommendations

Example Medicines for Initial Therapy

Mild pain 1 3 Nonopioid analgesic: takenon a regular schedule, not as

needed (prn)

Acetaminophen 650 mgevery 4 hrAcetaminophen 1,000 mgevery 6 hrIbuprofen 600 mg every 6hr

Moderate pain 4 6dd opioid for moderate pain

(e.g., moderate potencyanalgesic). Use on a

schedule, not prn

Acetaminophen 325

mg/codeine 60 mg every 4 hrAcetaminophen 325mg/Oxycodone 5 mg every 4hrTramadol 50 mg every 6 hr

Severe pain 7 10Switch to a high potency

(strong) opioid ; administeron a regular schedule

Morphine 15 mg every 4 hrHydromorphone 4 mg every4 hrMorphine controlled release60 mg every 8 hr

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Dosing

The management of chronic pain is also bestaccomplished by around-the-clockadministration

As-needed schedules are to be used inconjunction with around-the-clock regimensand are used when patients experiencebreakthrough pain

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TOLERANCE

physiological phenomenonnormal A

in which increasing doses are requiredto produce the same effect

3.2.4: Chapter1993Oxford Textbook of Palliative MedicineInturrisi C, Hanks G.


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PHYSICAL DEPENDENCE

physiological phenomenon innormal A

which a withdrawal syndrome occurs

when an opioid is abruptly discontinued

or an opioid antagonist is administered


PSYCHOLOGICAL DEPENDENCE


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PSYCHOLOGICAL DEPENDENCEand ADDICTION

A pattern of drug use characterized by a

continued craving for an opioid which is

manifest as compulsive drug-seekingbehaviour leading to an overwhelming

involvement in the use and procurementof the drug



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h


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Type of Pain Nonopioids OpioidsOther

MedicationsComments

Chronic low back pain Acetaminophen, NSAIDs

Short-term use formild-to-moderate

flare-upsTCAs, AEDs

Acetaminophen and NSAIDS first; opioids inselected patients; AEDs or

TCAs if neuropathicsymptoms

Fibromyalgia Acetaminophen, NSAIDs Long-term use notrecommended Tramadol,TCAs; AEDs

Acetaminophen and

NSAIDs considered first;tramadol may be betteralternative than opioids

Neuropathic pain

Acetaminophenor NSAIDs arerarely effective

Considered first-line therapy butusually are tried

after AEDs and/ orTCAs, tramadol,

lidocaine 5% patch

TCAs, AEDs,SNRIs, trama

dol, topical(e.g., 5% lidocaine patch,capsaicin)

Gabapentin, 5% lidocaine

patch, tramadol, nortriptyline, desipramine, allconsidered first-line agents;opioids considered first-lineagents but usually are tried

after above


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AcetaminophenTynelolPanadol

325 6504 5001000 6 4000

Mefenamic acid

Ponstan 500 250 6 1000

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Naproxen

Aleve 500 50012 2506

8 1000

IbuprofenAdvil

200400 68 OTC400 8

510 68

32001200

OTC

NSAID

6

CelecoxibCelebrex

Cobix100 200 200

200

DiclofenacVoltaren

2550 68100

200

IndomethacinIndocin

2523 150

2 256

150

NSAID

Tolmetin 200400 8 1800

MeloxicamMobic

7.515 15

COX2

Piroxicamfeldene

10 2 20


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Patient Control Analgesia (PCA)


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Treatment of Neuropathic Pain

Pharmacologic tr eatment Opioids Steroids Anticonvulsants gabapentin, topiramate

TCAs (for dysesthetic pain, esp. if depression) NMDA receptor antagonists: ketamine, methadone Anesthetics

Radiation therapy

I nterventi onal treatment Spinal analgesia Nerve blocks


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