Step Ladder in Pain Management

Yunus A. Bari, dr., Sp.OT

 What is pain ???
Task force on taxonomy of the International Association for the Study of Pain (IASP)
says that pain is “An unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such damage.”

Bell: The subject’s conscious perception of modulated nociceptive impulses that

generate an unpleasant sensory and emotional experiences associated with actual or
potential tissue damage or described in terms of such damage

Burket LW, Greenberg MS, Glick M. Burkett’s Textbook of Oral Medicine. 10th ed. Philadelphia, PA: Lippincott.
Okeson JP. 2013. Bell`s Orofacial Pain. 5th ed. Chicago: Quintessence Publ., Co..
UNDERSTANDING MODELS OF PAIN
•Cognitive
therapies
PERILAKU NYERI
•Functional (PAIN BEHAVIOUR)
restoration •Antidepressan
PENDERITAAN •Psychotropic
(SUFFERING)
•Relaxation
•Opioid NYERI •Spiritual
•Tramadol (PAIN)

•Oxcarbazepine
•Local block
•Gabapentin
•Diclofenac
•Eperisone HCL NOSISEPSI •Etodolac
•Paracetamol (NOCICEPTION)
•Dexketoprofen
•NSAID
•Celecoxib
•Nimesulide
•Physic modalities
BIOPSIKOSOSIAL
(BIOPSYCHOSOCIAL)
WHO 1986
Symptoms of debility Non-cancer pathology
Side-effects of therapy Cancer

ORGANIC PAIN
Loss of social position
Bureaucratic prosedure
Loss of job prestige and
income Friends do not visit
TOTAL
Loss of role in family DEPRESSION ANGER Delay in diagnosis
PAIN
Chronic fatigue and insomnia Unavailable doctors

Sense of helpessness Irritability

Disfigurement ANXIETY Therapeutic failure

Fear of hospital or nursing Fear of pain

home Family finances
Worry about family
Loss of dignity and bodily control
Fear of death
Uncertainty about future
Spiritual unrest
 Classification Of Pain
1. Acute pain
a. Somatic
b. Visceral

2. Chronic pain
a. Malignant, eg; cancer, HIV, end stage organ
b. Nonmalignant, eg: back pain, arthritis, migrain
Acute Pain
• It caused by noxius stimulation due to injury,
a disease process, or the abnormal function of muscle or vicera.
• It is usually nociceptive
• Asssociated with a neuroendocrine stress that is proportional to intensity
• Four physiological processes are involved: transduction, transmission, modulation,
and perception
Pain Pathway
Chronic Pain
• Pain that persists beyond the usual course of an acute disease or after a reasonable
time for healing to occur
• May be nociceptive, neuropathic, or mixed
• Psychological and behavioral factors often play a major role.
• Acute pain is inadequate teraphy
Acute vs Chronic Pain

Characteristic Acute Pain Chronic Pain

Cause Generally know Often unknown

Duration Short, well-characterized Persists after healing,  3 months

Underlying cause and pain

Resolution of underlying cause, usually
Treatment disorder; outcome is often pain
self-limited
control, not cure
Pain Pathway
Tissue Damage  Pain Producing Substance

kortikosteroid

NSAID
 TRANSDUCTION
Activation & Sensitization Nociceptor

BK : Bradykinin SP : Substance P
5HT : Serotonin H : Histamin
PG : Protaglandin
 Transmition

Neuroblockade
Neurolysis
- Cryo Anesthesia Local Blockade
- Chemical
- Physiologic
- Radiofrequency
Descending Inhibition
 Types Of Pain
Types of Pain Patient’s Description Cause

Somatic Well-localized Activation of pain receptors in the skin

Aching and deep tissues
Throbbing
Gnawing

Visceral Deep aching Activation of pain receptors resulting

Crampy from stretching, distention, or
Pressure inflamation of a viscous
Poorly localized
Difficult to describe

Neuropathic Burning Injury to peripheral and/or central

Shooting Nervous system.
Stabbing
Paroxysmal
Shock-like

Spastic Cramping Spasm of smooth or skeletal muscle.

Gripping
Clenching
 Categories of Pain

• Physical
• Emotional
• Financial
• Spiritual or existential

Beng KS. 2004. The last hours and days of life: A biopsychosocial-spiritual model of care. Asia Pacific Family Medicine 4: 1–3.
 Emotional
•Loss of function
•Coping abilities

Spiritual
•Guilt PAIN Financial
•Why me? •Direct costs
•Life closure issues •Indirect costs

Physical
•From disease
•From treatment
 Gold Standart Of Pain Management
• Is constant pain assessment.
• Pain is whatever the patient says it is.
• Pain in cancer never purely physical.
• Nonphysical pain describe as ‘discomfort’
• Take a careful history of the pain complaint
• Assess characteristics of each pain; site, type pattern of referral, aggravating &
relieving factors etc.
 WHO 3-Step Ladder
WORLD HEALTH ORGANIZATION
The WHO Pain Ladder was developed in 1986 as a conceptual model to guide the management of cancer pain. There is
now a worldwide consensus promoting its use for the medical management of all pain associated with serious illness,
including pain from wounds. Step 3, Severe Pain
Morphine
Hydromorphone
Step 2, Moderate Pain
Methadone
Acet or ASA + Fentanyl
Codeine Oxycodone
Step 1, Mild Pain Hydrocodone + Nonopioid analgesics
Aspirin (ASA) Oxycodone + Adjuvants
Acetaminophen (Acet) + Adjuvants
Nonsteroidal anti-
inflammatory drugs
(NSAIDs)
+ Adjuvants
World Health Organization,(2009). WHO’s Pain Relief Ladder. www.who.int/cancer/palliative/painladder/en/
 WHO 3-Step Ladder
WORLD HEALTH ORGANIZATION
3
Strong opioid
+/- adjuvant
2
Weak opioid
+/- adjuvant
1
Non-opioid
+/- adjuvant

World Health Organization, (2009). WHO’s Pain Relief Ladder. www.who.int/cancer/palliative/painladder/en/

 Non-opioid medications

Acetominophen 650mg tid-qid : concern for hepatic toxicity

>3-4grams

NSAIDs including Ibuprofen, Naproxen, COX-2 inhibitors:

concern for gastric / renal toxicity, platelet dysfunction, may
inhibit anti-hypertensive meds
 Opioid combination products
• The following opioids are available as combination products with
acetaminophen, aspirin, or ibuprofen
– Codeine; hydrocodone; oxycodone; propoxyphene
• Typically used for
– Moderate episodic (PRN) pain
– Breakthrough pain in addition to a long-acting opioid.
• Never prescribe more than one combination drug at any one time.
STEP-1 LADDER
• MILD PAIN : VAS,NRS < 3
• NON-OPIOID
– ASETOMINOPHEN
– NSAID
• ADJUVANT
– ANALGESIC EFFECT IN CERTAIN PAIN CONDITION
– DUE TO SIDE EFFECT
– DUE TO THE COMPLAIN
– Antiemetics, laxatives, antidepressant, anticonvulsant, corticosteroid, anxiolyitics
STEP-2 LADDER
• MODERATE PAIN : VAS, NRS 4 - 6
• NON-OPIOID
– ASETOMINOPHEN
– NSAID
• WEAK OPIOID
– CODEINE
– TRAMADOL
• ADJUVANT ( same in step 1 )
– ANALGESIC EFFECT IN CERTAIN PAIN CONDITION
– DUE TO SIDE EFFECT
– DUE TO THE COMPLAIN
STEP-3 LADDER
• SEVERE PAIN : VAS, NRS : > 7
• NON-OPIOID
– ASETOMINOPHEN
– NSAID
• STRONG OPIOID
– MORPHINE
– FENTANYL
– Etc
• ADJUVANT ( same in other step )
– ANALGESIC EFFECT IN CERTAIN PAIN CONDITION
– DUE TO SIDE EFFECT
– DUE TO THE COMPLAIN
STEP-4 LADDER

 Interventional pain management

 Coeliac plexus block
 Superior hypogastric block
 Ganglion impar block
 etc
 Which combination product?
Analgesic potency:
– hydrocodone and oxycodone are more potent than codeine, which
is more potent than propoxyphene, which some studies suggest is
equipotent to aspirin.
– there is little difference between hydrocodone products and
oxycodone products in terms of potency.

Note: propoxyphene products are not recommended for pain in most

national pain guidelines, due to side effects and unclear efficacy
compared to other products
 Adjuvants
• Non-pharmacologic
• Topicals
• Tylenol
• NSAIDS, Celecoxib, steroids
• Anticonvulsants
• Antidepressants
• Antiarrhythmics
 Opioid Pharmacology

• Block the release of neurotransmitters in the spinal cord

• Agonist of Mu, delta, kappa receptors
• Conjugated in liver
• Excreted via kidney (90%–95%)
• Central and peripheral effects of opioids
• This leads to desired effects, as well as side effects
 Equianalgesic Example

40 yr old male, Lung Ca & Bone mets, severe pain

Morphine Equivalent Current: MS Contin 400 mg TID = 1200 mg/24 hrs

Duragesic 2 100 mcg patches = 400 mg/24 hrs
Roxanol 20 mg/ml x10 doses of 1ml = 200 mg/24 hrs
Morphine Equivalent Total (Oral) = 1800 mg/24 hrs
Equianalgesic Dose, one-third for IV use = 600 mg/24 hrs
IV/Subcut Morphine Rate, divide by 24 hrs = 25 mg/hrs
 Principles
• Work with oral morphine equivalents
• Give around the clock
• Limited cross-tolerance
• Opioid rotation
• Begin with low dose
• In elderly begin with ½ the usual dose
• Titrate
• Q 4 hr booster is 10% of 24 hr dose
 Principles

• Avoid meperidine-metabolized to normeperidine with 15-20 hr ½ life

• Avoid pentazocine-inhibits analgesia of morphine
• Avoid IM
• Treat constipation-softening agent and stimulant, avoid bulking agents
 Principles

• Severe liver disease-opioids and benzodiazepines will have delayed

metabolism (avoid methadone and acetominophen)
 Analgesics

Non-opioid Opioid
e.g. aspirin, e.g. codeine,
paracetamol morphine

Adjuvant
e.g. muscle relaxant,
antidepressant,
anti-epileptic
 Pain Problem #1

Mrs. T on 10 mg morphine every 4hrs around the clock for her cancer
pain with good effect. She says she’s tired of taking a pill every 4 hours.
Convert her to long-acting morphine with appropriate prn doses.
 Pain Problem #2

She is admitted to the hospital and unable to take oral medications--

convert Mrs. T to: IV morphine
 Pain Problem #3

Mrs. T has uncontrolled pain of moderate intensity because of progression

of her disease. How would you re-dose her IV morphine?