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Pain and Pain Relief - a Brief Introduction Dr. Reino Pöyhiä, MD, PhD Consultant in Anaesthesiology Special Competence in Pain Medicine, Cardiac Anaesthesia.

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Presentation on theme: "Pain and Pain Relief - a Brief Introduction Dr. Reino Pöyhiä, MD, PhD Consultant in Anaesthesiology Special Competence in Pain Medicine, Cardiac Anaesthesia."— Presentation transcript:

1 Pain and Pain Relief - a Brief Introduction Dr. Reino Pöyhiä, MD, PhD Consultant in Anaesthesiology Special Competence in Pain Medicine, Cardiac Anaesthesia and Palliative Medicine, Finland Associate Professor of Anaesthesiology and Palliative Medicine, Helsinki and Turku University, Finland Head of the Dept of Anaesthesia, Helsinki Univ Central Hosp

2 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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4 Physiology Descartes 1677, Tractus de homini

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7 INHIBITORY DESCENDING TRACT

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9 Different types of pain – different treatments Types of painExamplesTreatments Somatic (nociceptive) painRheumatoid arthritis Visceral pain Acute postoperative pain NSAID, paracetamol, steroids, opioids Nerve (neuropatic) painPostherpetic neuralgiaAntidepressants (AMITR), antiepileptics (CARBAMAZ) Psychogenic pain (?)Psychological problemsPsychological support Non-cancer chr painIschaemic heart painNitrates, NSAID, neuropathic pain drugs, (opioids) Cancer painBone metasthasesNSAID, opioids, adjuvants Pain in advanced and progressive disease AIDSNSAID, opioids, adjuvants - Think mechanisms! Acute PainLabour pain, postop painMechanism based! Chronic Pain (> 6 months)Cancer pain, arthrosisMechanism based!

10 Visceral pain

11 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 ↑

12 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

13 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 NSAID physical therapy ointments, gel

14 Acute postoperative pain

15 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 ?

16 Poor postoperative pain relief Ethically wrong! Prolongs recovery from surgery May lead to chronic pain! An international problem – which could be (easily?) solved (!)

17 Chronic postoperative pain Kehlet et al. Lancet 2006; 367: 1618-25

18 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

19 Postoperative pain relief good surgery preoperative planning multimodal approach possibilities: – opioids – NSAIDs, paracetamol – antiepileptics, antidepressants – blocks choiche depends on – procedure – patient – resources www.ebandolier.comwww.ebandolier.com, Feb 2003

20 How to improve postop pain relief? 1.Assessment of pain 2.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

21 Chronic pain

22 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 ?

23 Pain in HIV/AIDS Oral/skinVisceralSomaticNeuropathy/Headache Kaposi´s Sarcoma Oral cavity Herpes zoster candidiasis Tumors Gastritis Pancreatitis Infection Biliary tract problems Rheumatological disease Back pain myopathies HIV related headaches: - encephalitis, meningitis Iatrogenic -AZT -DDI, D4T toxic neuropathy Peripheral neuropathy Herpes zoster Alcohol, malnutrition HIV unrelated: - tension headache, migraine etc

24 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

25 Cancerpain prevalence van 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

26 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

27 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

28 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

29 WHO analgesics ladder ■Morphine ■± Adjuvants ■± NSAIDS 3 severe 2 moderate ■Tramadol ■(A/Codeine) ■± Adjuvant ■ ± NSAIDs 1 mild ■ASA ■Acetaminophen ■NSAIDs ■± Adjuvants (amitriptyline, carbamzepine, ketamine)

30 IBUPROFEN + DICLOFENAC TRAMAL + MORPHIN BUT YES: IBUPROFEN + (PARACETAMOL) + (AMITRIPTYLINE) + TRAMADOL IBUPROFEN + (PARACETAMOL) + AMITRIPTYLINE + MORPHINE

31 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

32 Side-effects of opioids Addiction? – Psychological: NEVER! – Physiological: ALWAYS! → don´t stop opioids immediatedly but slowly, if needed Tolerans? – 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

33 Side-effects vs analgesia at E-o-L PAIN RELIEF >> SIDE-EFFECTS (unless untolerable)

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35 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


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