PAIN
Management
Pharmacological Approaches
dr. Yuddi Gumara, SpAn KMN
DEPT. PALLIATIVE CARE
DHARMAIS HOSPITAL
NATIONAL CANCER CENTER
Lecture Plan
◦What is pain?
◦Physiology and pathology
◦Classification of pain
◦Pain treatment overview
◦Pharmacological options
◦Opioid rationalisation
What is Pain?
What is Pain?
Scientific An unpleasant sensory and emotional experience associated
with, or resembling that associated with, actual or potential
tissue damage.
July 2020, the International Association for the Study of Pain (IASP)
Clinical Pain is whatever the experiencing
person says.
“Pain is what ever the patient says”
(Mc Caffery, 1999)
What is Pain?
▪ Unpleasant
▪ Emotions are important
▪ The cause is not always visible
▪ “Pain is what the patient says hurts.”
Is this man feeling pain?
Classification of Pain
Not all pain is the same!
Three main questions:
1. How long has the patient had pain?
2. What is the cause?
3. What is the pain mechanism?
Classification of Pain
Duration Acute
Chronic
Acute on chronic
Cause Cancer
Non-cancer
Mechanism Nociceptive (physiological)
- Somatic
- Visceral
Neuropathic (pathological)
Acute versus Chronic
Acute
◦Pain of recent onset and probable limited duration
Chronic
◦Pain persisting beyond healing of injury
◦Often no identifiable cause
◦(Pain lasting for more than 3 months)
Cancer versus Non-Cancer
Cancer pain
◦Progressive
◦May be mixture of acute and chronic
Non-cancer pain
◦Many different causes
◦Acute or chronic
Nociceptive Pain
▪ Obvious tissue injury or illness
▪ “Physiological pain”
▪ Description
◦Sharp ± dull
◦Well localised
Neuropathic Pain
▪ Nervous system damage or abnormality
▪ “Pathological pain”
▪ Tissue injury may not be obvious
▪ Description
◦ Burning, shooting ± numbness, pins and needles
◦ Not well localised
Examples of Pain
Types
Acute Non-Cancer Pain
▪ Examples
▪ Fracture, appendicitis
▪ Symptom of tissue injury or illness
▪ Useful
▪ Usually nociceptive
▪ Occasionally neuropathic (e.g. sciatica)
Chronic Non-Cancer Pain
▪Examples
▪Headache, back pain
▪Usually no obvious injury
▪Not useful
▪Complex, may be mixed nociceptive and neuropathic
▪Does not respond to usual drug treatment
Cancer Pain
▪Examples
▪Oral cancer, breast cancer, uterine cervical cancer
▪Features of acute and chronic pain
▪May be acute on chronic
▪Often mixed nociceptive and neuropathic pain
▪Usually gets worse over time if untreated
Neuropathic Pain
Peripheral
◦Damaged nerves (e.g. trauma, diabetes)
◦Abnormal firing of nerves
Central
◦Changes in “wiring”
◦Abnormal firing
◦Loss of modulation
Pain Physiology
and Pathology
Why is pain physiology
important?
Many factors affect how we “feel” pain.
◦ Psychological factors are very important.
Different treatments work on different parts of the
pathway.
◦ More than one treatment may be needed.
Physiology
4 steps pain pathway:
◦ Transduction (Peripheral
sensitization)
◦ Transmision (Periphery-Spinal cord-
Brain)
◦ Modulation (Spinal cord-Brain-
central sensitization)
◦ Perception (Brain)
Difficult to achieve
effective analgesia
by using a single
class of analgesic
drug alone
Multimodal
analgesia
Pain Treatment
Overview
CC BY-NC-SA: THIS WORK IS LICENSED UNDER A CREATIVE COMMONS ATTRIBUTION-NONCOMMERICAL-SHAREALIKE 3.0 LICENSE.
Treatments - Periphery
▪Non-drug treatments
◦ Rest, ice, compression,
elevation
▪Anti-inflammatory medicines
▪Local anaesthetics
Treatments - Spinal Cord
▪Non-drug treatments
◦ Acupuncture, massage
▪Local anaesthetics
▪Opioids
▪Ketamine
Treatments - Brain
▪Non-drug treatments
◦ Psychological
▪Drug treatments
◦ Paracetamol
◦ Opioids
◦ Amitriptyline
◦ Clonidine
Non-Pharmacology Treatments
Physical
◦ Rest, ice, compression, elevation
◦ Surgery
◦ Acupuncture, massage, physiotherapy
Psychological
◦ Explanation
◦ Reassurance
◦ Counseling
Post-operative Pain Relief
Post operative pain starts at its
peak intensity and improves over
time
Analgesia may be started at
higher steps and then stepped
down accordingly as pain
improves.
WFSA Analgesic Ladder
1. Charlton E. World Federation of Societies of Anaesthesiologists. The management of post operative pain. Update in anaesthesia1997;7:1–7.
Cancer Pain Management
The three-step analgesic ladder WHO
Drug Classification
• Simple analgesics
– Paracetamol (acetaminophen)
– Anti-inflammatory medicines
• Aspirin, ibuprofen, mefenamic acid, natrium diclofenac, ketoprofen, ketorolac
• Opioids
– Mild
• Codeine, tramadol
– Strong
• Morphine, pethidine, oxycodone, hidromorfon, fentanyl
Drug Classification
• Other analgesics
• Amitriptyline
• Gabapentin/pregabalin
• Carbamazepine
• Local anaesthetics
• Ketamine
• Clonidine
Paracetamol (Acetaminophen)
Advantages
◦ Cheap, safe
◦ Can be given orally or rectally
◦ Good for:
◦ Mild pain (by itself)
◦ Mod-severe pain (with other drugs)
Disadvantages
◦ Liver damage in overdose
Non Steroid Anti-Inflammatory
▪ Aspirin, ibuprofen, Sodium Diclofenac, ketorolac, celecoxib, etoricoxib
▪ Advantages
▪ Generally safe
▪ Good for nociceptive pain
▪ Best given regularly with paracetamol
▪ Disadvantages
▪ Gastrointestinal and renal side effects
▪ Increased risk cardiovascular events
Codeine
Advantages
◦ Cheap, safe
◦ Good for mild-moderate acute nociceptive pain
◦ Best given regularly with paracetamol
Disadvantages
◦ Constipation
◦ Not good for chronic pain
◦ Myths about addiction
Morphine 1
Advantages
◦ Cheap, generally safe
◦ Can be given orally, IV, IM, SC
◦ Effective if given regularly
◦ Good for:
◦ Mod-severe acute nociceptive pain (e.g. post-op pain)
◦ Cancer pain
Morphine 2
Disadvantages
◦ Constipation
◦ Respiratory depression in high dose
◦ Myths about addiction
◦ Regulations about use
Sustained-release oral formulation of Morphine
▪ For moderate to severe pain when a
continuous, around-the clock opioid
analgesic is needed for an extended
period of time.
▪ Sustained release tablets are NOT
intended for use as a prn analgesic
▪ Tablets are to be swallowed whole
and are not to be broken, chewed,
dissolved, or crushed.
Pethidine
Advantages
◦ Cheap
◦ Can be given orally, IV, IM
◦ Can be good for severe acute nociceptive pain
Disadvantages
◦ Must be given more often than morphine
◦ Breakdown product (norpethidine) can cause convulsions
◦ Not good for chronic pain
Amitriptyline
Increases descending inhibitory signals
Advantages
◦ Cheap, safe in low dose
◦ Good for neuropathic pain
◦ Also treats depression, poor sleep
Disadvantages
◦ Anti-cholinergic side effects (glaucoma, urinary retention)
Fentanyl
Strong opioid agonist
Available in parenteral, transdermal, transbuccal preparation
Synthetic piperidine opioid agonist
80x more potent than morphine
Highly lipophylic
Transdermal Fentanyl
Notes about the Fentanyl patch
▪ Takes 12 hours for onset of analgesia
▪ Need adequate subcutaneous tissue for
absorption
▪ Takes 24 hours to reach maximum effect
▪ Change patch every 72 hours
▪ Suitable for stable pain only
Transdermal Fentanyl
Patch
▪ Transdermal fentanyl
patches are marketed in
dosages graded as 25, 50,
75 and 100 where the
number describes the →
fentanyl-release rate (i.e. 25
corresponds to 25 µg/h )
Anti-Epileptic Drugs
Carbamazepine (Tegretol)
Sodium valproate (Epilim)
“Membrane stabilisers”
◦ Reduce abnormal firing of nerves
Good for neuropathic pain
Opioids and Addiction
◦ Do opioids cause addiction?
◦ Would this stop you giving opioids to a patient who has pain?
Opioids and Addiction
Pain is sometimes poorly treated because of concerns about
addiction.
Addiction is very rare in:
◦ Acute pain
◦ Cancer pain
Addiction is more likely in chronic non-cancer pain.
