The Essentials of Pain Management

Curriculum Vitae:
Staf pengajar Departemen Ilmu Penyakit Dalam FK UNPAD/ RS Hasan Sadikin Bandung
dr. Laniyati Hamijoyo SpPDKR. M.Kes

Pendidikan: 1994 : FK Universitas Atma Jaya, Jakarta 1996 : Internship di CWZ Nijmegen-Netherland 2005 : Spesialis Penyakit Dalam FK.UNPAD, Bandung 2005 : Magister kesehatan FK. UNPAD, Bandung 2007 : Subspesialisasi Reumatologi di Univ.Santo Tomas Manila 2008 : Adaptasi Konsultan Reumatologi FKUI,Jakarta Organisasi: Anggota: IRA, PAPDI, PRA, IDI, APLAR Penghargaan: JCR, APLAR, EULAR, TIR, PRA
Lanny
The Essentials of Pain Management

Laniyati Hamijoyo
Divisi Reumatologi Departemen Ilmu Penyakit Dalam FK Universitas Padjadjaran/ RS Hasan Sadikin Bandung
Lanny
Case # 1
Mr B 23/M Acute pain 2 hours ago On his right ankle History of falling during play basketball 2 hour ago
What is the diagnosis? What will you suggest?
Lanny
Case # 1
Ms. D 35/F Pain on both hands Since 2 months Swollen
What is the diagnosis? What medicine will you start on her?
Lanny
Case # 2
Mrs. L 55/F Sharp and burned like pain on her fingers especially right hand Since 3 months Worse in the morning History of type 2 DM What is her diagnosis? Therapy?
Lanny
Pain
Lanny
Pain
How to diagnose? Therapy?
Which medicine?
Lanny
Barriers to effective pain management

Problems related to healthcare professionals
Inadequate knowledge Poor assessment Concern about regulation of controlled substances Fear of patient addiction Concerns of side effects of analgesics Concerns about patients tolerant to analgesics
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Problems related to patients
Reluctance to report Fear that pain means disease is worse Reluctance about taking pain medicines Concerns of being tolerant to medicines Poor adherence Worries about unmanageable side effects
Lanny

Problems related to healthcare system Cost Reimbursement Restrictive regulation Availability
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Outline the essentials of pain management

Definition of pain Assessment and diagnosis of pain Management and monitoring of pain
1 2 3
Lanny
Definition of pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage IASP
In reality, its what the patient says it is.

Lanny
Merskey H, Bogduk N. 2nd ed Seattle, WA: IASP Press; 1994.
Physiology of Pain Perception

Injury Brain
Descending Pathway Dorsal Root Ganglion Ascending Pathways
Peripheral Nerve C-Fiber A-beta Fiber A-delta Fiber
Dorsal Horn
Lanny Adapted
with permission from WebMD Scientific American Medicine.
Spinal Cord
Injury-induced Pain: Patient Factors

Injury
Individual variation in response to injury: physiological, behavioral, and cultural Individual variation in response to treatment
Complaint of pain
McQuay H. BMJ 1997;314:1531.
Lanny
Outline
1 2 3
Definition of pain Assessment and diagnosis of pain Management and monitoring of pain
Lanny
Assessment of pain
Goals:
Achieve diagnosis of pain and underlying disorder Characterizing and quantifying the pain
Lanny
Achieve diagnosis and underlying disorder

History taking
Pattern : onset, duration, frequency Area Nature : location, topography : description, history of similar episodes, intervention & what helped Intensity: level
Lanny
Question to evaluate pain

P-Q-R-S-T format
Provocation How the injury occurred & what activities the pain, exacerbating and alleviating factors Quality Referral/ Radiation characteristics of pain (tingling, burning, dull) Referred site distant to damaged tissue that does not follow the course of a peripheral nerve. Radiating follows peripheral nerve; diffuse How bad is it? Pain scale When does it occur? p.m., a.m., before, during, after activity, all the time
Severity Timing
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Pain assessment tools
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Pain assessment tools

Brief pain inventory Patients rate pain intensity and its effect on general activity, mood, ability to walk, work, relationships, sleep, and enjoyment of life McGill Pain questionnaire Patients rank pain in words sets that are grouped in 4 main categories: sensory, affect, evaluative, and miscellaneous
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Physical examination
General PE: Vital sign
Regional examination
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Musculoskeletal examination
Inspection: look for redness, swelling, deformity Palpation : Test for warmness Test for deep/ superficial muscle tenderness Range of motion
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Neurological examination
Mental status Cranial nerves Motor function: weakness, ataxia Sensory function Reflexes
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Classify Pain
duration:
Acute Chronic
Recent onset Limited duration The cause is generally known resolution of underlying cause, self limited
Persist for > 3- 6 months Persist at least 1 month beyond the usual course of acute pain Associated with chronic pathologic process Recurs at relatively short interval
Lanny
http://www. medscape.org 2011
Classify the Pain

mechanism:
Neuropathic
Malfunction on peripheral / central nerves
Nociceptive
Irritation/ Tissue injury
Psychogenic
Psychologic factor
Mixed
Nociceptive & neuropathic
Lanny
Type of pain
Pain Nociceptive Neuropathic
Visceral
Somatic
Poorly localized Cramping, dull Pleurisy Appendicitis cholecystitis

Lanny
well localized Variably
Abn neural activity due to injury or disease of the nervous system
Skin, muscle Soft tissue, bone
Thalamic pain Trigeminal neuralgia Diabetic neuropathy
Nociceptive VS neuropathic pain

Nociceptive pain
Caused by activity in neural pathway in response to potentially tissue- damaging stimuli
Mixed pain
Caused by a combination of both primary injury or secondary effects
Neuropathic pain
Initiated or caused by primary lesion or dysfunction in the nervous system
Postoperative pain Mechanical LBP
ARTHRITIS
PHN
CRPS
Sickle cell crisis
Neuropathic LBP Distal polyneuropathy (e.g. diabetic)
Trigeminal neuralgia Central post stroke pain
Sport / exercise injuries
Lanny
International Association for the Study of Pain. IASP Pain Terminology. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57
Pain characteristic
Nociceptive Neuropathic
Focal/ diffuse pain Sharp, dull, ache with sign of inflammation usually acute Often decrease over time
Regional/ dermatomal Burning, tingling, numbness, needle prick pain Often persists / worsen over time
Lanny
Pain characteristic
Nociceptive
Alodinia/ hyperalgesia MS regional pain (arthritis, bursitis, tenosynovitis, etc) Post traumatic pain , fracture Inflammation pain Bone metastases NSAIDs often work, opiods effective, adjuvant and topical analgesics somewhat effective
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Neuropathic
Peripheral neuropathic pain: - post herpetic neuralgia - diabetic neuropathic - radiculapathic pain etc - metastases on plexus Central neuropathic pain NSAIDs not effective, opioid less effective, adjuvant and topical analgesics somewhat effective
Evaluate the functional status

How does it affect physical function and work (ADLs)? How does it affect social and mental functioning?
Lanny
Evaluate the pain

Identify comorbid conditions Identify past medical history Family history
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Additional examination
Imaging Laboratory Psychosocial
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Identify Pain Treatment Options

Non-Drug Therapies Drug Therapies More Invasive Therapies
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Pain Treatment Continuum

Least invasive Most invasive
Continuum not related to efficacy
Psychological/physical approaches Topical medications Systemic medications* Interventional techniques*
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*Consider referral if previous treatments were unsuccessful.
Non-Drug Therapies
Ice/Heat Exercise/Rest Physical Therapy Chiropractic Care Acupuncture TENS Units Behavioral Therapy And Many More.
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Drugs for Pain

Non-Opioid Analgesics
Acetaminophen Salicylates and Non-Selective NSAIDS Selective COX-2 Inhibitors
Adjuvant Analgesics
Antidepressants Anticonvulsants Topicals, Muscle Relaxants, and Others
Opioids
Short- and long-acting formulations
Lanny
WHO (World Health Organization) ThreeStep Analgesic Ladder

Satisfactory Symptom Management
Opioid for moderate to severe pain + Non-opioid + Adjuvant
Pain persisting or increasing

Opioid for mild to moderate pain + Non-opioid + Adjuvant
Pain persisting or increasing

Non-opioid + Adjuvant
Pain
Lanny
WHO 3 -STEP LADDER
3 SEVERE Morphine Hydromorphone Methadone Oxycodone Fentanyl +/- Adjuvants 3 MODERATE A/Codeine A/Hydrocodone A/Oxycodone Tramadol +/- Adjuvants
3 MILD ASA/NSAIDS Acetaminophen Cox-3 +/- Adjuvants

Lanny
Bio-psycho-social in pain management

Cognitive therapies Functional restoration
Pain Behaviors Suffering
Anti-depressants / psychotropics Relaxation Spiritual
Opioid Adjuvants NSAIDs? Acetaminophene Neural augmentation Ablative surgery
Pain Perception
Local block Nociception
NSAIDs
Surgery Physical modalities
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Some More Invasive Therapies

Trigger Point Injections Intra-arthricular Injections Regional Nerve Blocks Epidural Injection Various Surgeries
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Evaluation of pain management

Follow up: - reassessed pain - functional improvement - side effect therapy - adherence to therapy Educate patients: - about the cause of pain - set appropriate expectations of treatment
Lanny
Case # 1
Mr B 23/M Acute pain 2 hours ago On his right ankle History of falling during play basketball 2 hour ago
What is the diagnosis? PE: Warmth, swelling, pain limited range of motion What will you suggest?
Pattern : onset, duration, frequency Area Nature : location, topography : description, history of similar episodes, intervention & what helped Lanny Intensity: level
Case # 1
Ms. D 35/F Pain on both hands Since 2 months Swollen, tender. Warm, morning stiffness Lab: RF (+), ESR What is the diagnosis? What medicine will you start on her?
Pattern : onset, duration, frequency Area Nature Lanny : location, topography : description, history of similar episodes, intervention & what helped Intensity: level
Case # 2
Pattern : onset, duration, frequency Area Nature : location, topography : description, history of similar episodes, intervention & what helped Intensity: level
Mrs. L 55/F Sharp and burned like pain on her fingers especially right hand Since 3 months Worse in the morning History of type 2 DM Test: Tinel (+), Phallen (+) What is her diagnosis? Therapy?
Lanny
Summary of a Practical Approach to Pain Management

1. Evaluate and treat the underlying cause. 2. Evaluate and treat the pain itself. 3. Listen to and trust your patients. 4. Use all the resources at your disposal. 5. Re-evaluate the treatment 6. Refer if you get stuck
Lanny
Lanny

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Curriculum Vitae:

dr. Laniyati Hamijoyo SpPDKR. M.Kes

The Essentials of Pain Management

What is the diagnosis? What will you suggest?

What is the diagnosis? What medicine will you start on her?

Barriers to effective pain management

Barriers to effective pain management

Barriers to effective pain management

Outline the essentials of pain management

In reality, its what the patient says it is.

Merskey H, Bogduk N. 2nd ed Seattle, WA: IASP Press; 1994.

Physiology of Pain Perception

Descending Pathway Dorsal Root Ganglion Ascending Pathways

Peripheral Nerve C-Fiber A-beta Fiber A-delta Fiber

with permission from WebMD Scientific American Medicine.

Injury-induced Pain: Patient Factors

Achieve diagnosis and underlying disorder

Question to evaluate pain

Pain assessment tools

Pain assessment tools

http://www. medscape.org 2011

Classify the Pain

Irritation/ Tissue injury

Nociceptive & neuropathic

Poorly localized Cramping, dull Pleurisy Appendicitis cholecystitis

well localized Variably

Abn neural activity due to injury or disease of the nervous system

Skin, muscle Soft tissue, bone

Thalamic pain Trigeminal neuralgia Diabetic neuropathy

Nociceptive VS neuropathic pain

Postoperative pain Mechanical LBP

Sickle cell crisis

Neuropathic LBP Distal polyneuropathy (e.g. diabetic)

Trigeminal neuralgia Central post stroke pain

Sport / exercise injuries

Evaluate the functional status

Evaluate the pain

Identify Pain Treatment Options

Pain Treatment Continuum

Continuum not related to efficacy

Psychological/physical approaches Topical medications Systemic medications* Interventional techniques*

*Consider referral if previous treatments were unsuccessful.

Drugs for Pain

WHO (World Health Organization) ThreeStep Analgesic Ladder

Pain persisting or increasing

Pain persisting or increasing

WHO 3 -STEP LADDER

3 MILD ASA/NSAIDS Acetaminophen Cox-3 +/- Adjuvants

Bio-psycho-social in pain management

Anti-depressants / psychotropics Relaxation Spiritual

Opioid Adjuvants NSAIDs? Acetaminophene Neural augmentation Ablative surgery

Local block Nociception

Some More Invasive Therapies

Evaluation of pain management

Summary of a Practical Approach to Pain Management

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