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Pain and Pain Relief - a Brief Introduction

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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
Examples Treatments Somatic (nociceptive) pain Rheumatoid arthritis Visceral pain Acute 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 - Think mechanisms! Acute Pain Labour pain, postop pain Mechanism based! Chronic Pain (> 6 months) Cancer pain, arthrosis

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 Effect site of analgesics
Perception - brain: ACC, SSC Effect site of analgesics opioids α2-agonists paracetamol Psychotherapy (CBP) Antidepressants, antiepileptics - serotonin ja noradrenalin ↑ in the inhibitory descending tracts Modulation - spinal cord - brain stem, brain - Inhibitory descending tracts Transmission - Nociceptive signal ”goes” in sensory nerves to the dorsal column in spinal cord → projection neuron → spinothalamic tract → brain TNS, DCS α2-agonists opioids local anaesthetics Transduction - nociceptive stimulus in peripheral nerve endings -action potential in Aδ/C fibers 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 % patients have moderate to severe pain after surgery

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

20 How to improve postop pain relief?
Assessment of pain 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 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/skin Visceral Somatic Neuropathy/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 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
Cancerpain prevalence van den Beuken-van Everdingen et al. Oncology 2007; 18: 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: % Apolone -09 Kanada: % 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 75-80 % can achieve excellent pain relief with the WHO guide + breakthrough pain relief

29 WHO analgesics ladder 3 severe 2 moderate 1 mild Morphine ± Adjuvants
± NSAIDS 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 % 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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