CURRICULUM VITAE

Nama : dr. Andi M. Takdir Musba, Sp.AnTTL : Pare-Pare, 31 Oktober 1974Alamat rumah : JL. Datuk Ditiro II No. 15 Makassar 90214, IndonesiaTelp / Hp : 0411-452113 / 0811463304Email : takdir1974@yahoo.comAlamat kantor : Bagian Ilmu Anestesi, Perawatan Intensif & Manajemen

Nyeri Fakultas Kedokteran UNHAS / RS. Dr. Wahidin Sudirohusodo Jl. Perintis Kemerdekaan Km.11 Tamalanrea Makassar-90245

Telp/HP/Fax/Email: 0411-582583-589777 /Fax. 0411-590290 / anestesiologi_unhas@yahoo.co.id

CURRICULUM VITAE

Riwayat Pendidikan :- Dokter Umum tahun 1999 Fakultas Kedokteran Universitas Hasanuddin- Spesialis Ilmu Anestesi tahun 2007 Fakultas Kedokteran Universitas

HasanuddinPelatihan / Kursus :- Tahun 2003 : Kursus Perioperative, Surabaya, Indonesia- April 2006 : Pain Management Workshop and Refresher Course,

Makassar- November 2006 : Acupuncture and TCM Workshop, Makassar oleh Fakultas

Kedokteran Universitas Hasanuddin dan Xiamen University, China

- Februari - April 2008 : Course on Clinical Pain Management Program, Siriraj Hospital, Mahidol University, Bangkok, Thailand

- Maret 2008 : Interventional Pain Management Workshop, Bangkok

OPTIMALIZATION OF THE 3-STEPLADDER WHO

A.M.TAKDIR MUSBA

DEPARTMENT OF ANESTHESIOLOGY ,INTENSIVE CARE AND PAIN MANAGEMENT FACULTY OF MEDICINE , HASANUDDIN UNIVERSITY

TOTALPAIN

SOMATIC SOURCE

ANXIETY

ANGERDEPRESSION

Non-cancer pathologyCancer

Symptoms of debility Side-effects of theraphy

Loss of social position Loss of job prestige and incomeLoss of role in family Chronic fatigue and insomnia Sense of helpessness Disfigurement

Bureaucratic bungling Friends who do not visit Delay in diagnosis Unavailable doctorsIrritabilityTherapeutic failure

Fear of hospital or nursing homeWorry about familyFear of deathSpiritual unrest

Fear of painFamily financesLoss of dignity and bodily controlUncertainty about future

WHO 1986

J.Loeser (1980)

Concept of nociception, pain, suffering and pain behaviour

Pain behaviourSuffering

Pain

Nociception

HISTORY OF 3-STEP LADDER WHO 1980 – WHO establishes Cancer Control Programme

Cancer prevention Early diagnosis with curative treatment Pain relief and palliative care

1986 – ” Cancer Pain Relief “ published by WHO Step Ladder WHO

Updated on 1996

Worldwide acceptance protocol Today, worldwide consensus favouring its used for

management of all pain associated with serious illness

Dr. Kathleen M. FoleyPain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center in New York City

Former Chair WHO Expert Committee on Cancer Pain Relief and Active Supportive Care (1982-1998) group that drafted the WHO guidelines

Early evidence support the Ladder

Observational studies 3220 patients studied, retrospective Reported proportion of patients achieved

adequate control 2361 (71%) achieved control

Ventafridda et al 1987 Prospective 10 year study, 1995

2118 patients with cancer pain Opioids given

orally (83%), parenterally (9%), spinally (2%) Pain relief

Good 76% Satisfactory 12% Inadequate 12%

Zech et al 1995

Systematic reviews for the Ladder

1995, Jadad et al 8 studies (1982-1995) adequate pain management in 69-100%’

2006, Ferriera et al 17 studies (8 overlap with earlier review) adequate pain management in 45-100 %

WHO study , 2007 Most expert in developing and developed countries

follow the WHO analgesic ladder for cancer related pain relief.

“LOGICAL APPROACH TO CANCER PAIN CONTROL“

WHO Analgesic LADDER

WHO Analgesic LADDER

Step ladder represent

SPECIFIC DRUG CLASS SPECIFIC TYPE OF PAIN BASED ON INTENSITY OF PAIN COMBINED WITH ADJUVANT

5 phrases of 3-step ladder1. By the mouth 2. By the clock 3. By the ladder4. Individualized for the patient5. Attention to detail

WHO Cancer pain relief principles

Assessment pain severity is essential Started in appropriate level Analgesia given regularly Prescription for breakthrough pain Consider adjuvant drugs PCT and /or NSAIDs should be used

at all step Morphine is the strong opioid choice Opioid rotation

Who ladder in practice Analgesics are the cornerstone of

good cancer pain management Most experts in developing and

developed countries follow the WHO analgesic ladder and WHO guidelines for cancer related pain relief.

Barriers to pain management educating patients and caretakers access to medicines DOCTOR knowledge

Doctor’s problem

Opiophobia Pk/Pd

e.g. Drugs doses and interval Regular assessment Limited time Mis-interpretation of the ladder

Common ladder mis-nterpretations

starting at step 1 for moderate to severe pain

the ladder is restricted to opioids Weak and strong opioid combined rotating around analgesics at steps 1

or 2 despite inadequate pain relief

Criticism to WHO ladder Usefulness of weak opioids in step 2

Weak opioids no better than NSAIDs alone ( Eisenberg et al , 1994, McNicol, 2006 ) High doses weak opioid Vs Low doses strong opioid

( Gronds et 1999 )

Moving directly from step 1 to step 3 was possible ( Maltoni et al, 2005, Mercadante et al 2006 )

Strong opioids for first-line treatment of pain in patients with terminal cancer. ( Marinangeli, 2004 )

New formulations of opioid ( Davis MP, 2006 )

Strong Opioid Availability in Indonesia

Long acting opioid preparations : Fentanyl patch, morphine sustained release

Short acting opioid preparations : ?

INTRAVENOUS OPIOID

Opioid – principles of using Opioid titration Opioid rescue dose Opioid rotation Opioid side-effect management Opioid sparing strategies

Opioid Titration Guidelines Titrate with short–acting hydrophilic

opioid; can be given at interval based on the time to peak serum level as needed; oral ~ 1 hour , sc ~ 30 min, iv ~ 10 min.

Calculate 24 hrs requirements and convert to long-acting opioid

Opioid Dose EscalationAlways increase by a percentage of the present dose based upon patient’s pain rating and current assessment

Mild pain 1-3/10

Moderate pain4-6/10

25-50% increase Severe pain7-10/10

50-100% increase

Opioid Rescue Dose

Used for breakthrough pain. Dose:

Approximately 10% of daily dose equivalent.

Frequency : Oral every 1 - 2 hours Parenteral every 15 - 30 minutes

Opioid Rotation

Oral dose ( mg )

Opioid Parenteral iv/sc/im( mg )

150 Meperidine 50150 Tramadol 100150 Codeine 5015 Morphine 5- Fentanyl 0.050

Morphine 50 mg PO in 24 hrs = fentanyl patch 25 mcg/hr

Equianalgesic doses Opioids

Example : Opioid converting to Fentanyl patch

Determine consistent daily opioid use and fentanyl patch equianalgesic

Convert from PCA opioid : reduce basal rate 50% for first 12

hr, discontinued after 12 hr and keep PCA bolus dose in first 24 hr

Parenteral opioid : reduce infusion 50% for first 12 hr, discontinue after 12 hr, continue breakthrough dose

Oral long acting : apply patch with long acting dose equianalgesic , discontinue long-acting preparation, continue breakthrough dose

Opioid-sparing strategiesAnalgesic adjuvants

e.g. Antiemetics, Laxatives, Antidepressant, Anticonvulsant, Corticosteroid, Anxiolytics, NMDA antagonist

Alternate route (e.g. intraspinal)Anaesthetic/Neurolytic proceduresPM&R approachesCognitive therapyComplementary therapies

e.g., acupuncture, massage, music therapy

A. The 3-step analgesic ladder developed by the World Health Organization. WHO. Cancer Pain Relief. Geneva: WHO; 1986. B. The proposed 4th step. Miguel R. Interventional Treatment of Cancer Pain: The Fourth Step in

the World Health Organization Analgesic Ladder? Cancer Control 2000, 7 (2): 149-56.

Interventional pain management

INTERVENTION PAIN TECHNIQUE CAN BE USED AT EACH STEP DEPENDING ON THE PATIENT’S NEED

Foley K., WHO Cancer Pain Release, 2006, Vol.19

CONCLUSION

Although simple, appropriate use of the WHO Pain Ladder give marked efficacy and low risk complication

Still many barrier to optimalize the ladder such doctor knowledge and drug availability in our country.

“ Total pain “

G. T. Linklater and M. E. F. Leng Recent advances in pain management in palliative careCurrent Anaesthesia & Critical Care (2001) 12, 296-301

Please keep in mind ………

"relief of psychological, social and spiritual problems is paramount. Attempting to relieve pain without addressing the patient's non-physical concerns is likely to lead to frustration and failure.“

WHO Guideline , 1986

Thank you