Pain Management in daily

practice for Primary care

dr. Suparto, Sp.An

Department of Anesthesiology
Faculty of Medicine
Christian Krida Wacana University
Jakarta
Learning Objectives

1. Definition of pain
2. Physiology of pain
3. Classification of pain
4. Effects of pain
5. Pain assessment
6. Pain control
Hippocratic precepts:

“ the first duty of medicine is to cure sometimes,

to relieve often, to comfort always”
 Pain
- unpleasant sensory and emotional experience
associated with actual or potential tissue damage,
or described in terms of such damage.’’
“Suatu pengalaman sensorik dan
emosional yang tidak menyenangkan
berkaitan dengan kondisi aktual atau
potensial terjadinya kerusakan jaringan”

International Association for the Study of Pain, 1979

• Nosiseptor adalah aferen primer yang berespon
terhadap stimulus.
– Stimulus nyeri mencetuskan aktivitas pada aferen
primer di neuron ganglion sensorik (nosiseptor

• Nosisepsi adalah istilah yang menunjukkan proses

penerimaan informasi nyeri yang dibawa dari
reseptor perifer di kulit dan visera ke korteks serebri
melalui penyiaran neuron-neuron

• Akson sensorik (nosiseptif) tersebar luas diseluruh

tubuh (kulit, otot, persendian, visera, meninges)
Sensation
• Noxious (Pain)
– High threshold receptors, conducted by smaller,
lightly myelinated (Aδ) and unmyelinated (C) nerve
fibers
• Non-noxious (light touch, pressure,
temperature)
– Low threshold receptors,
conducted by large myelinated
(Aβ) nerve fibers
 Peripheral sensitization
Painful stimulus
o Prostaglandins produced in
response to tissue injury;
Pain-sensitive tissue increase sensitivity of
Prostaglandin
nociceptor (pain)
1 Blood
Substance P
Mast cell vessel o Nociceptor then releases
Histamine substance P, which dilates
Bradykinin blood vessels and increases
Substance P
2 release of inflammatory
3
mediators, such as
Nociceptor Bradykinin (redness & heat)
o Substance P also proses
degranulation of mast
cells, which release
histamine (swelling)
 PERCEPTION

TRANSDUCTION

TRANSMISSION

MODULATION
 SENSATION
Spinal Cord

I
Dorsal root
C II
III
Peripheral  IV
nerve
A V

INPUT VI X

VII
IX

REFLEKS VIII
LAMINA REXED
Categorizing Pain
Nociceptive pain
Caused by activation or
sensitization of peripheral
nociceptors initiated by
tissue injury;
it can be secondary to an
incision, inflammation, or
disease.
ex: Acute osteoarthritis,
Post operative pain,
exercise injuries
Neuropathic pain
Pain related to disease or
injury of the peripheral or
central nervous system
(extending to the spinal
cord)
Described as: burning,
shooting, tingling,
stabbing, or like a vise or
electric shock.
ex: Neuropathic low back
pain, Post herpetic
neuralgia, Diabetic
polyneuropathy
Two types of Nociceptive Pain
• Somatic Pain
• Visceral Pain
Somatic Pain
• Superficial described as sharp, stabbing, well
localized
– Typically arises from the skin, subcutaneous tissues,
and mucous membranes.
• Deep described as dull, aching quality, less well
localized
– Typically arises from skeletal muscles, tendons, joint
or bones
– Pain from surgical incision, 2nd stage of labor,
peritoneal irritation
Visceral Pain
• Due to a disease process or abnormal function
of an internal organ or its covering (eg parietal
pleura, pericardium or peritoneum)
• Dull, Difuse, Poorly localized
• Associated with either abnormal sympathetic or
parasympathetic activity causing nausea,
vomiting, sweating and changes in blood
pressure and heart rate.
• Parietal pain is typically sharp
• Described as a stabbing sensation either
localized to the area around the organ or
referred to a distant site.
• Typically radiates with the same dermatome
origin as the diseased viscus
• Occurs as rhythmic contractions of smooth
muscles
• A cramping type accompanies
gastroenteritis, gallbladder disease, ureteral
obstruction, menstruation, distension of
uterus during 1st stage of labor
Acute and Chronic pain:
• Acute pain
– Trauma or surgery
– Easier to manage than chronic pain
– Related to a form of tissue damage resulting in
excitation of nociceptor nerve ending
• Chronic pain
– may be due to nociception but in which
psychological and behavioral factors often play
a major role
– Lasting ≥ 3 months
 Effects of Pain
Components of the Surgical Stress Response
a) Neuro-endocrine
b) Cardiovascular
c) Respiratory catecholamines: vasoconstriction,
d) Gastrointestinal Dec FRC work  myocardial contractility
myocardial
↑platelet
↑sphincteric adhesiveness
tone heart rate
Impaired -diaphragmatic
dysrhythmias
e) Genitourinary ↓↑sphincteric
fibrinolysis tone
Immobility
Hipersecretion
Function(reflex
- angina
gastric acid
inhibition
Activation
Insomnia
↓↓smooth of coagulation
f) Immunologic/ ofsmooth
glucagon:
phrenic-
muscle
muscle tone
tone
hyperglycemia
nerve)
MI
cascade
Anxiety
↓Insulin, ↓= protein anabolism
- Atelectasis
CHF
Coagulation Helplessness
═ urinary
═ retention
Ileus
= Pneumonia
═ incidence of thromboembolic
═ Fear
g) General Well Being phenomena
 Assessing Pain
“Tell me about any pain you have”
For each pain, consider the following:
• Palliative factors: “What makes it better?”
• Provocative factors: “What makes it worse?”
• Quality: “What is it like?”
• Radiation: “Where does it spread to?”
• Severity: “How bad is it?”
• Temporal factors: “Is it constant? Does it come
and go?”
Analgesic history:
• “What has helped in the past?”
• “What has not helped in the past?”
• “Show me exactly what you are taking now”
• “How much and how often?”
• Does it help the pain? Does it relieve the pain or
only reduce it?”
• Does your medicine do anything that you don’t
like?”
 Pain Assessment
Self-Report:

Visual Analog Scale

Numeric Rating Scale
Faces Pain Scale
 Numeric Rating Scale

0 1 2 3 4 5 6 7 8 9 10
No pain Worst pain
 Principal of pain management
• Pain as the Fifth Vital Sign
• Multimodal analgesic approach
• “It is easier to keep pain at bay rather than
trying to control it after it has resurfaced”
 MULTIMODAL TREATMENT
Multimodal or multipharmacological treatment
has been recognized as a mainstay treatment of
many diseases.
• Hypertension  Asthma
• Congestive heart  Sepsis
• Diabetes  Chemotherapy, ect.

Multimodal Analgesia for pain management has

been recomended by:
 WHO (World Health Organization)
 APS (American Pain Society)
 ACR (American Collage of Rhematology)
 • REDUCED DOSES
of each analgesic
• IMPROVED PAIN RELIEF
due to synergistic or
additive effects
• REDUCE SIDE EFFECTS
of each drug

1Kehlet H et al. Anesth Analog. 1993;77:1048-1056.

No single analgesic agent is perfect and no
single analgesic can treat all types of pain.

Each agent has advantage and

disadvantage compered to others.

Clinical outcomes will be improved with the

use of combination of analgesic, rather then
a single agent.
3 step ladder for pain relief
Tramadol+
APAP
 Multimodal Pain Control
• Inflammation
– NSAID, Selective COX-2 Inhibitors
• Analgesia
– Paracetamol
– Opioid
– NMDA Antagonist
– Anticonvulsant
• Non-pharmacologic therapy
– Psychological support
– TENS (Transcutaneous Electric Nerve Stimulation)
– Acupunture
– Physiotherapy
– Complementary therapies
Adjuvant drugs:
• Antidepressant
• Alpha 2 Agonist
• Steroids
• Antiemetic

Management of drug related side effects

• Antacids
• Laxatives/stool softeners
NSAID mechanism of Action
– Inhibition of PG-mediated amplification of chemical
and mechanical irritants on the sensory pathway.
– Inhibits COX (prostaglandin synthetase)
– Blocks response to inflammatory substances,
bradykinins, acetylcholine, serotonin
═ mediation of peripheral inflammatory
response
 Opioid Receptors
RECEPTOR RESPONSE ON ACTIVATION

m (mu) Analgesia, respiratory depression, miosis

euphoria, reduced GI motility

k (kappa) Analgesia, dysphoria, miosis,

psychotommetic effects

 (delta) Analgesia, facilitation of Mu receptor

m1 k3 2 located supraspinally
m2 k1 1 located at spinal level
Undesirable Effects of Opioids

Respiratory depression
Sedation
Nausea and Vomiting
Suppression of cough reflex
Psychic and Physical dependence
Tolerance
Constipation
Agonists: Mu receptor
– Morphine: oral, IV, IM, intrathecal, epidural
– Meperidine: IV, IM, epidural
– Fentanyl: transdermal, transmucosal, IV
– Tramadol: oral, IV, transmucosal
Agonist-antagonists: kappa, sigma/ no activity on
Mu; potential to reverse effect of agonist
– Nalbuphine: IM, IV
– Butorphanol: IM, IV
 Ethical Consideration
• Give regular analgesics of sufficient strength for
continuous pain
• Ensure pain control by titrating analgesic doses
without overdosing
• Recognize that analgesics are for pain control
and aren’t to be used as sedatives
• Recognize our own limitations and request
advice from specialist pain relief services
“Pain management is more of an art
than a science”

Thank you