General View of

Pain Management

Emergency Department PGH

What is pain?
International Association for The Study of Pain
Definition of pain:
An unpleasant sensory and emotional

experience associated with actual or potential

tissue damage and expressed in terms of
such damage

Perception

Nociception

Pain

Descending
modulation
Ascending
input

Modulation
Dorsal Horn
Dorsal root
ganglion

Transmission
Transduction

Spinothalamic
tract

Peripheral
nerve

Peripheral
nociceptors

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

Trauma

Normal Nerve Impulses

Leading to Pain
Perceived pain

Noxious
stimuli
Descending
modulation

Ascending
input

Nociceptive afferent fiber

Spinal cord

.The Pain Response

Tissue Damage

Transmission of the Pain

Signal to the Brain

Activation of the
Peripheral Nervous
System

Activation of the Central

Nervous System
at
the Spinal Cord Level

Pain
Samad TA et al. Nature. 2001;410:471-5.

There are Two Sensory Afferent Neurons

1. Large myelinated A fibers
Very fast conduction velocity
Respond to innocuous stimuli
2. Small myelinated A & C unmyelinated fibers
Slow conduction velocity
Respond to noxious stimuli
Large
A
fibers

Dorsal root
ganglion

A
Small
fibers
C

Peripheral sensory
Nerve fibers

Dorsal Horn

Transduction

KERUSAKAN JARINGAN
INFLAMASI

Si-Na+

SENSITISASI
MI
NOS
Pg
AKTIFASI
B
5HT
Adenosin
KORNU DORSALIS

SSA
ECT. DISC.

R-NE

Activation

Pengalaman
Kognitif
Behaviour
Psikologik

Inhibisi
desenden

OTAK
PAIN NO PAIN

External Heat

VR1
Ca

Mechanical

Stimuli

Pain and auto-sensitization

2+

Na+

mDEG ACTION
ACTION POTENTIAL
POTENTIAL
Voltage gated sodium channels
P2X3

ATP
Chemical

Generator potentials

action potentials
Woolf & Mitchel, 2001
Modifikasi Meliala, 2003

Current Pain Management

Pharmacologic Methods
*Non-opioids (e.g paracetamol, aspirin,

NSAID)

for mild pain

*Non-opioids with weak opioid (e.g codeine)
for mild to moderate pain
*Opioid / morphin
for moderate to severe pain
*Alternative strong opioids
*Adjuvant drugs (e.g corticosteroids,
antidepressants,
anticonvulsant, neuroleptics)

Nonopioid analgesics
Route
Maximum

Analgesic

Time to

peak (hr)
duration (hr) recommended

Half-life
(hr)

Analgesic
onset (hr)

daily dose (mg)

---------------------------------------------------------------------------------------------------------

-------------Salicylates
Aspirin

Oral

0.5-2

2-3

0.5-1

2-4

Oral

1-2

1.8-2.5

0.5

4-6

Oral

0.5-2

4-6

300

3,600
Propionic acids
Ibuprofen
3,200
Ketoprofen
Naproxen
Acetic Acids

Oral
1,500

2-4

2-4
12-15

4-7

Nonopioid analgesics
Route

Time to
peak (hr)

Half-life
(hr)

Analgesic
onset (hr)

Analgesic

Maximum

duration (hr) recommended

daily dose

(mg)
-----------------------------------------------------------------------------------------------------------------------

Fenamates
(anthranilic acids)
Meclofenamate

Oral

0.5-1

Mefenamic acid

Oral

2-4

0.5-1

4-6

400

2-4

4-6

1,000

30-86

48-72

20

Oxicams
Piroxicam

Oral

3-5

Phenylacetic acids
Diclofenac

Oral

2-3

1.6

200

1.4

0.5

2-4

1,200

P-Aminophenols
Acetaminophen

Oral

0.5-1

Phenacetin

Oral

2,400

Selective COX-2 Inhibitors

Celecoxib

Oral

2-3

Rofecoxib

Oral

2-3

0.4

8-12
12-24

400
50

Opioid Analgesics
Dosage (mg)
Onset (hr)
Peak (hr) Duration
(hr) Comment
----------------------------------------------------------------------------------------------------------Morphine
2.5-15 iv
0.125
Rapid onset, peak

Respir depr 10 min

Meperidin
50-100 im
Codeine
15-60 oral
Methadone
2.5-10 oral
Pentazocine
50 oral
30-60 im

0.12-0.5
0.25-1
0.5-1

1
0.5-2
1.5-5

2-4
3-4
4-8
4-7

0.12-0.5

1-3

3-6

Arachidonic Acid Cascade

& COX Hypothesis
Arachidonic Acid
Cyclooxygenase (COX)

COX-1

X
Body Homeostasis
Gastric integrity
Renal function
Platelet function

COX-2
Nonselective
NSAID

X
X

COX-2
selective
Inhibitor

Inflammation
Pain

Needleman P. et al. J Rheumatol 1997;24(suppl 49):6-8

Fitzgerald GA et al. N Engl J Med 2001;345:433-42

COX-1 & COX-2