PAIN, WHERE IS COME FROM

Ferdiansyah

Dept. Orthopaedi & Traimatology

Dr. Soetomo Hospital – Medical School of Airlangga University
Surabaya
 Pain

Unpleasant sensory and

emotional experience:
 Associated with actual or
potential tissue damage
 or described in terms of such
damage

International Association for the Study of Pain (1986)

Definitions
• Agology : the science and study of pain
• Allodynia : pain caused by a stimulus that is not normally painful
• Analgesia : the absence, or decrease, of pain in the presence of a
stimulus that would normally be painful
• Hyperalgesia : an increased sensitivity to a stimulus that is
normally painful
• Nociception : the reception, conduction, and central nervous
processing of nerve signals resulting in the perception
of pain
• Somatic pain : pain originating from skin, joints, muscles, and other
deep tissues
• Visceral pain : pain originating from the internal organs
Definitions
 Noxious stimulus : a stimulus which is actually or potentially damaging to body
tissues
 Pain threshold : the point at which an individual just begins to feel pain; is
relatively consistent among normal individuals
 Pain tolerance : the greatest amount of pain that a subject will tolerate; varies
greatly among individuals
 Radiculalgia : pain along the distribution of one or more sensory nerve roots
 Radiculitis : an inflammation of one or more nerve roots
 Wind-up : a cascade of events resulting from ongoing stimulation of
nociceptors and activation of NMDA receptors; causes
hyperalgesia and opioid tolerance
Background

 Pain accounts for 80% of all physician visits

 64% of pain sufferers will see a doctor only when they cannot
stand the pain any longer

 42% of patients feel misunderstood by physician

Most Frequently Stated Opinions of the Respondents of the Attitudes of their Friends,
Family-members, Colleagues, and Doctors

My doctor would rather treat my illness than my pain

Breivik H et al. Eur J Pain 2005 in press

 Pain is UNDERTREATED!

 22% of pain patients has been suffered from sustained pain (WHO 1998)

 Satisfaction survey for pain treatment (American Pain Society, 1998)

o 70% of patients who has moderate pain

o 50% of patients who has severe pain

o Only 39% of patients who has more severe pain showed their
satisfaction
 Difference of Pain Concept
Comparison between patients’ ratings of average pain & doctors’

(Moderate pain)
(Mild pain)

(Mild pain) (Moderate pain)

 Difference
Difference of Pain
of Pain concept
concept

Pain
pain Disease
disease
Pain
Disease

Doctor Patient
Physician - Doctors Patient
 Our Situation:
Pain Intensity vs Analgesic Option
- Inadequate Pain Treatment -

100% National Pain Survey in Outpatient Setting

16%
Survey Period: 1 June- 30 November 2011
90% 63% 5100 patients, 174 MDs
80%

70%

60%
60% 22%
50%

40% 8%
1% 6%
30%

20% Ladder 1 Ladder 2 Ladder 3 Adjuvant NA

10% 24%

7-10 (Severe)
0%
Number of Patients 4-6 (Moderate)
0-3 (Mild)
Pain Physiology

11
Stage of Nociception

12
Stage of Nociception

13
 Release and creation of pain
mediators

Tissue damage

Release Formation

Transmitters Ions Kinins Prostaglandins

ACH K+ Bradykinins Prostaglandin E2
Histamines H+

Striebel, W.: Treatment of Chronic Pain Schattauer, 2002 14

Peripheral Chemical Mediators of Pain

15
Stage of Nociception

16
Stage of Nociception

17
 Physiological Pain Processing

Pain transfer
Nociceptor neurons
Spinal cord-Posterior horn Body's
own pain defenses

Dynamic balance of the nociceptive
system

18
Sandkühler, J.: Pain Memory - Origin, Avoidance, and Removal. Deutsches Ärzteblatt 42, 2725-2730, 2001
 Perception

Pain

Modulation
Descending
modulation Dorsal Horn
Ascending Dorsal root
Transmission
input ganglion (peripheral)

Spinothalamic
tract Transduction
Peripheral
nerve

Transmission Trauma:
Peripheral inflammation or
(central)
nociceptors non-inflammation

Adapted from 23 Gottschalk A et al. Am Fam Physician. 2001;63:1981, and 24 Kehlet H et al. Anesth Analg. 1993;77:1049.
 Process of the pain disease

Acute pain + insufficient pain therapy

Collapse of the body's pain defenses
Central sensitization
Pain memory
Pain disease
20
Sandkühler, J.: Preventing Pain Memory. MMW 2002; Special edition 2
 Vicious Circle of Pain Chronification

21
A.M.A.D.E.U.S. Study Group Basic Course in the Therapy of Chronic Pain. Cologne 2003
 Chronification of Pain:
Breaking the Vicious Circle

22
A.M.A.D.E.U.S. Study Group Basic Course in the Therapy of Chronic Pain. Cologne 2003
Pain: The Fifth Vital Sign™

• Pulse
Pain:
• Blood pressure The Fifth
Vital Sign™1*
• Temperature

• Respiratory rate

*Trademarks are the property of their respective owners.

1 American Pain Society Web site.
 Issues to deal with:

 Pain is often viewed as expected and inevitable and

therefore, not routinely assessed, treated and reassessed.

 One third of chronic pain patients report little or no relief

from any past therapies.

 28% believe that there is no solution to their pain.

 Among hospitalized patients, less than half (45%) recall

being asked about their pain by a healthcare professional.
The Complexity of PAIN

Patient-Related Healthcare provider-Related

Barrier Barrier

System-Related Barrier
PATIENT –RELATED BARRIERS:

 Reluctance to report pain

• Patients’ reluctance to request analgesia and/or fear of taking
pain medications.

 Non-adherence to pharmacotherapy

 Fear of addiction or of building tolerance to therapy

 Worries about side effects.

HEALTHCARE PROVIDER-RELATED BARRIERS:

 Inadequate knowledge of pain-management standards

 Suboptimal assessment

 Concern over possible violations of controlled substance laws and

the patient’s development of addiction.

 Belief that pain is not harmful to the patient.

 Belief that pain is a “normal consequence” of surgery and injury.

 SYSTEM-RELATED BARRIERS:

 Inadequate reimbursement – self paid

 Restrictive controlled-substance regulations

Gold-standard of Pain Assessment

Pain is always subjective

Patients
Self-report of pain is the
gold Standard for assessment

IASP 1999; Portenoy RK, Lesage P. lancet, 1999

 Basic Pain Management Principles

• The patient is the authority on his or her own pain

• The health professional should always believe the patient’s
assessment of his own pain
• Pain is best treated before reaching a severe level

1 American Pain Society (APS) 2005

2 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2003
Management
 Pharmacological Treatments
• Nonopioid analgesics :
• acetaminophen
• NSAID
• Opioid analgesics :
• strong opioids
• weak opioids
• Adjuvant analgesics or co-analgesics :
• include antiepileptic drug
• tricyclic antidepressants
• local anesthetics

3 National Pharmaceutical Council. Section III:Types of Treatment

 Visual Analogue Scale (VAS)

G. B. Langley1 and H. Sheppeard1(1)

Medical Research Laboratory, Public Hospital, Palmerston North, New Zealand. Received:
21 May 1984 Accepted: 20 September 1984
. Q
WHO Analgesics Ladder
Nociceptive vs Neuropathic
Pain
Nociceptive Pain Mixed Type Neuropathic
Caused by activity in Caused by a combination
neural pathways in of both primary injury or
Pain
Initiated or caused by
response to potentially secondary effects
primary lesion or
tissue-damaging stimuli
dysfunction in the
nervous system
CRPS*
Postoperative Postherpetic Trigeminal
pain Arthritis neuralgia neuralgia

Sicle cell Neuropathic low

Mechanical Central post-
crisis back pain
low back pain stroke pain
Sports/exercise Distal
injuries polyneuropathy
(eg, diabetic, HIV)

*Complex Regional Pain

Syndrome
 Perception

Pain

Modulation
Descending
modulation Dorsal Horn
Ascending Dorsal root
Transmission
input ganglion (peripheral)

Spinothalamic
tract Transduction
Peripheral
nerve

Transmission Trauma:
Peripheral inflammation or
(central)
nociceptors non-inflammation

Adapted from 23 Gottschalk A et al. Am Fam Physician. 2001;63:1981, and 24 Kehlet H et al. Anesth Analg. 1993;77:1049.
 Multi-modal Analgesia

OPIOID
PERCEPTION

Pain
OPIOID
Antidepresan

Descending
OPIOID
modulation Dorsal Horn Paracetamol
Ascending Dorsal root TRANSMISSION
input ganglion

Local Anesthesi
NSAID/COXIB
Spinothalamic
Peripheral
tract TRANSDUCTION
nerve

Peripheral
nociceptors Trauma:
infalmmation or
No single drug can produce optimal analgesia without adverse effect non-inflammation
37
Adapted from 23 Gottschalk A et al. Am Fam Physician. 2001;63:1981, and 24 Kehlet H et al. Anesth Analg.
1993;77:1049.
 Pain treatment based on severity and
presence of inflammation
Mild Moderate Severe
• NSAID or
• Weak opioid ±
coxib or
NSAID or coxib
Inflammation aspirin
• Fixed combination Strong opioid ±
• Paracetamol
of weak opioid and NSAID or coxib
and (NSAID
paracetamol ±
or coxib or
NSAID or coxib
aspirin)

± Antineuropathic agents (anticonvulsant; antidepressant;

Local anesthetics) if needed

No Fixed combination of
Strong opioid
Inflammation Paracetamol weak opioid and
paracetamol

Developed by Cancer Pain Management Advisory Board member based on WHO ladder
Multimodal Analgesia
Multimodal Analgesia
• Administration of two analgesic agents that act by
different mechanism for providing superior
analgesic efficacy with equivalent or reduced
adverse effects
• Therefore it is facilitating early postoperative recovery

• Most effective approach to postoperative pain

• Combination of agents : nonopioid and opioid

30 Ashburn MA et al. Anesthesiology 2004; 100:1573-81

31 Reuben SS. J Bone Joint Surg Am 2007; 89:1343-58 32Bonnet F, Marret E. Best Practice & Research Clinical Anaesthesiology, 2007; 21: 99-107
 Recommendation for OA patients with cardiovascular, renal
and gastrointestinal risk factors

Paracetamol up to 4g/day

Cardiovascular
Renal risk Gastrointestinal risk
risk

Avoid NSAIDs/ Flares Long term

COX-2 inhibitors

Moderate
•Paracetamol / tramadol COX-2 NSAIDs Paracetamol /
weak opioid compinations* inhibitor +PPI Tramadol
• Tramadol
Strong opioid •Tramadol
Severe •Strong opioids

* 2nd choice

WGPM ( The Working Group on Pain Management ) Recommendation at the 2 nd meeting in EULAR 2005
29 Clinical Rheumatol (2006) 25 (Suppl 1): S22-
 2006 New Guideline in Treatment
Moderator-to-Severe Pain in OA patients
withParacetamol
Risk Factors
up to 4g/day

Cardiovascular Renal Gastrolintestinal

risk risk risk

Avoid NSAIDs/ Flares Long term

COX-2 inhibitors

• Paracetamol / tramadol COX-2 NSAIDs Paracetamol /

Moderate weak opioid compinations* inhibitor +PPI Tramadol

• Tramadol •Tramadol
• Strong opioid •Strong opioids
Severe
* 2nd choice

WGPM ( The Working Group on Pain Management ) Recommendation at the 2 nd meeting in EULAR 2005
29 Clinical Rheumatol (2006) 25 (Suppl 1): S22-S29
 2006 New Guideline in Treatment
Moderate-to-Severe Low Back Pain
Nociceptive +/- neuropathic pain

Long term

Elderly Young / Healthy

• Weak opioid combinations eg. • COX-2 inhibitors /NSAIDs

Moderate Paracetamol / tramadol low dose)
+/or paracetamol/ tramadol
(NSAIDs-sparing)
•Tramadol
•Tramadol*
Severe • Strong opioid
•Strong opioids IR

*Tramadol is efficacious for both nociceptive and neuropathic pain

WGPM ( The Working Group on Pain Management ) Recommendation at the 2 nd meeting in EULAR 2005
29 Clinical Rheumatol (2006) 25 (Suppl 1): S22-S29
THANK YOU