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Pain and Pain Relief- a Brief Introduction
Dr. Reino Pöyhiä, MD, PhDConsultant in AnaesthesiologySpecial Competence in Pain Medicine, Cardiac Anaesthesia and Palliative Medicine, FinlandAssociate Professor of Anaesthesiology and Palliative Medicine, Helsinki and Turku University, FinlandHead of the Dept of Anaesthesia, Helsinki Univ Central Hosp
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What is pain?
• PAIN is an unpleasant sensory AND emotional experience associated with actual or potential tissue damage OR described in terms of such damage
• IASP = International Association for the Study of Pain 1979
→ physiological sensation→ emotional experience
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Physiology
Descartes 1677, Tractus de homini
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INHIBITORY DESCENDING TRACT
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Different types of pain – different treatmentsTypes of pain Examples Treatments
Somatic (nociceptive) pain Rheumatoid arthritisVisceral painAcute postoperative pain
NSAID, paracetamol, steroids, opioids
Nerve (neuropatic) pain Postherpetic neuralgia Antidepressants (AMITR), antiepileptics (CARBAMAZ)
Psychogenic pain (?) Psychological problems Psychological support
Non-cancer chr pain Ischaemic heart pain Nitrates, NSAID, neuropathic pain drugs, (opioids)
Cancer pain Bone metasthases NSAID, opioids, adjuvants
Pain in advanced and progressive disease
AIDS NSAID, opioids, adjuvants- Think mechanisms!
Acute Pain Labour pain, postop pain Mechanism based!
Chronic Pain (> 6 months) Cancer pain, arthrosis Mechanism based!
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Visceral pain
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Assess and record pain• What´s causing the pain?• Intensity of pain
– when resting/moving– before and after treatment
• What pain prevents• Observation of “pain-related behaviour”• Surrogates of acute pain
– HR ↑– BP ↑– RR ↑
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Set a goal
• Intensity of pain ALWAYS < 3/10- if not, something must be done …
• In cancer pain / palliative care– pain-free night– improvement in functionality
• Assess and follow
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Transduction- nociceptive stimulus in peripheral nerve endings
-action potential in Aδ/C fibers
Transmission- Nociceptive signal ”goes” in sensory nerves to the dorsal column in spinal cord → projection neuron → spinothalamic tract → brain
Modulation- spinal cord
- brain stem, brain
- Inhibitory descending tracts
Perception- brain: ACC, SSC
Effect site of analgesics
opioids
α2-agonists
paracetamol
Psychotherapy (CBP)
Antidepressants, antiepileptics
- serotonin ja noradrenalin ↑ in the inhibitory descending tracts
TNS, DCS
α2-agonists
opioids
local anaesthetics
local anaesthetics
NSAID
physical therapy
ointments, gel
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Acute postoperative pain
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What can acute pain cause?
– respiratory depression– cardiovascular stress– endocrine stress– abdominal irritation (ulcus)– muscle spasms– immobilisation, thrombosis– psychologic distress– genetic changes in the body ?
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Poor postoperative pain relief
• Ethically wrong!• Prolongs recovery from surgery• May lead to chronic pain!• An international problem
– which could be (easily?) solved (!)
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Chronic postoperative painKehlet et al. Lancet 2006; 367: 1618-25
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How well are we doing?Wu & Raja, Lancet 2011
• the number of the patients with moderate to severe postoperative pain ↓ about 2%/y 1973–1999
• but still 15-40 % patients have moderate to severe pain after surgery
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Postoperative pain relief
• good surgery• preoperative planning• multimodal approach• possibilities:
– opioids– NSAIDs, paracetamol– antiepileptics, antidepressants– blocks
• choiche depends on– procedure – patient– resources
www.ebandolier.com, Feb 2003
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How to improve postop pain relief?1. Assessment of pain2. Protocols
- must be composed locally – by an expert group- each patient should get NSAID/paracetamol at fixed intervals- tramadol PRN after minor surgery- pethidin or oral morphine PRN
3. Individual tailoring- if preoperative pain, consider carbamazepine preoperatively- if protocols fail, ketamine im or orally in small doses- intercostal block with bupivacaine for cholecystectomy- wound injection of bupivacaine
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Chronic pain
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What can chronic pain cause?
– depression– insomnia– mental irritation– helplesness– loss of apetite– loss of social contacts↓– libido ↓– human value ↓– genetic changes in the body ?
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Pain in HIV/AIDSOral/skin Visceral Somatic Neuropathy/Headache
Kaposi´sSarcomaOral cavity Herpes zostercandidiasis
TumorsGastritisPancreatitisInfectionBiliary tract problems
Rheumatological diseaseBack painmyopathies
HIV related headaches:- encephalitis, meningitisIatrogenic-AZT-DDI, D4T toxic neuropathyPeripheral neuropathyHerpes zosterAlcohol, malnutritionHIV unrelated:- tension headache, migraine etc
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What is causing pain in cancer patients?Cancer with different mechanisms!
– Distension of visceral organs– Arterial/venous embolisms– Bone methastases → algesic substances from the bone– Nerve compression or infiltration
Side-effects of the oncological therapies– Nerve damage due to radiation therapy/ chemotherapy– Postsurgical syndromes
Non-malignant pain– Muscular pain– Angina pectoris
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Cancerpain prevalencevan den Beuken-van Everdingen et al. Oncology 2007; 18: 1437-49
• Prevalence – at all stages: 53%– at the end-of-life (methastatic cancer): 64%
• Moderate to severe pain in> 1/3 of patients during active treatments
> 2/3 of patients at the end-of-life
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Undertreatment of cancer pain- an international problem
• Japani: 75 % Okayama -04
• Hollanti: 65 % Enting -07
• Saksa: 61 % Felleiter -05
• Italia: 10-55 % Apolone -09
• Kanada: 40-48 % Krou-Mauro -09
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Undertreatment - why?
• patient does not tell about the pain/ask for relief • doctor does not listen/alleviate
– lack of basic knowledge– lack of pain specialists
• both – society: fear of opioids– dependency– tolerans– side-effects
• shortage of analgesics• lack of other resources
NIH Cancer Institute, British Pain Society
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WHO cancer pain relief with analgesics
– By the mouth
– By the clock
– By the ladder← concomitant use of different drugs with different mechanisms
1986 Geneve
+ breakthrough pain relief
75-80 % can achieve excellent pain relief with the WHO guide
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WHO analgesics ladder
■ Morphine
■ ± Adjuvants
■ ± NSAIDS
3 severe
2 moderate
■ Tramadol
■ (A/Codeine)
■ ± Adjuvant
■ ± NSAIDs
1 mild
■ ASA
■ Acetaminophen
■ NSAIDs
■ ± Adjuvants (amitriptyline, carbamzepine, ketamine)
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IBUPROFEN + DICLOFENAC
TRAMAL + MORPHIN
BUT YES:IBUPROFEN + (PARACETAMOL) + (AMITRIPTYLINE) + TRAMADOLIBUPROFEN + (PARACETAMOL) + AMITRIPTYLINE + MORPHINE
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How to use morphine for cancer/AIDS pain?
– individual tailoring– by the clock + PRN!– dose ↑ → effect ↑– treat side-effects: start always a laxative– when pain increases increase the dosing
• by 30-50 % of the previous daily dose OR • by adding the PRN doses to the maintenance dose
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Side-effects of opioidsAddiction?
– Psychological: NEVER!– Physiological: ALWAYS! → don´t stop opioids immediatedly but
slowly, if neededTolerans?
– Vaihtelevasti, valmisteen vaihto voi auttaa! Other:
– Constipation → laxatives, stool softeners, stimulants– Nausea, vomiting → antiemetics; haloperidol, metoclopramide,
5HT-inhibitors– Itching– Respiratory depression: only in acute use– Dizziness, sleepiness, hallucinations
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Side-effects vs analgesia at E-o-L
• PAIN RELIEF >> SIDE-EFFECTS (unless untolerable)
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Summary• pain analysis is important• record the intensity and influence of pain before and
after treatments• treatments of pain should be based on pain
mechanisms – multimodal analgesia• undertreatment of pain is common
– may severe effects on recovery• defined protocols may improve postop pain relief• WHO cancer pain relief programme is highly effective• don´t be afraid of opioids• pain relief can be increased with supportive methods