THE NEED OF PAIN RELIEF IN CANCER PAIN N Margarita Rehatta

Human`s Right

The Ethical Principles to provide pain management and comfort all patients including those – unable to speak for

themselves To cure some times

To relieve often but .. To comfort always

Basic`s of Pain Management

Pain is the net effect of many simultaneously interacting Biochemical, Physiologic, Psychological, that involve activity of nervous system concerned with sensory, motivational, cognitive processes and psychodynamic mechanism.

John J Bonica, The Management of Pain, 1990

Biopsychosociocultural Model

Nyeri Total – pada nyeri kanker Nyeri

fisikNyeri psikologis

Nyeri kultural

Nyeri sosial

Nyeri spiritual

Nyeri finansial

Nyeri total

• Segi nyeri mana yang paling penting berbeda untuk setiap pasien

Karjadi Wirjoatmodjo, IPS 2005

Influenceperception of pain intensity

Bio - Pain Pathway & Integrated Response

Why Pain need to be alleviated

The body response to

stress

ACTH -Endorphin

CS

NEEPIENK

Pain

Neurotransmitterrelease

Electrophysiologicalresponse

Intracellularstressresponse

Structuralresponse

Neuropsychologicalresponse

Glutamate, aspartate

Substance P, calcitoningene-related peptide

Excitatorypostsynapticpotential

CalciumNitric oxidesynthaseProteinkinase C

Enkephalin

Dynorphin

Sensitisation

Wind-up

c-fosc-jun

Cholecystokinin,Neuropeptide YVasoactiveIntestinal peptideGalanin

?Bcl-2

?Bax

Sprouting Remodelling ? Apoptosis / cell death

Perception AversionAvoidance

Stimulation-producedanalgesia

Allodynia, Chronic pain syndrome Disability Quality of life

Suffering

-3 -2 -1 0 1 2 3 4 5 6 7 8

Pain Sttmulus

(s) (min) (h) (days)(moths) (years))

Time in seconds (logarithmic scale)

CASCADES OF SYSTEM RESPONSES

Adapted form Jones, 1996

Pathophysiology and mechanismsof cancer pain

Nociceptive (somatic and visceral) Neuropathic Psychogenic Idiopathic / unrelated to cancer

Fundamental in assessment&

determine therapy

- Abolish tumor directed pain(chemotherapy, hormonal,

radiation)- Altering the pain response

(psychological approach)- Interfering the pain pathway

(nerve block, neurolytic destruction)

- Mechanism based

• Management of cancer painMultimodality

Goal of Cancer Pain management

ACUTE (NEW OR BREAKTHROUGH) PAIN MANAGEMENT

To relieve pain

CHRONIC PAIN MANAGEMENT To enhance function To improve quality of life

Global Improvement Ratings

Physical functioning Emotional

functioning Adverse symptom (Drug) Efficacy

issues.

Chronic PainCancer pain

ACUTE PAIN SHORT TERM POOR SLEEP

LONG TERM POOR SLEEP

STRSS & ANXIETYACTIVATION HP AXIS RISE IN IL – 6 RELEASE

NOVEL PAIN

MORE INTENSE PAIN

Pain and sleep ,Lavigne Gilles .

53 – 89 % patients

Key barriers to good Cancer Pain control

Patients and carers reluctant to complain about symptoms fear pain and don’t know how to get help lack knowledge about strong opioid analgesia fear adverse effects leading to poor adherence.

Healthcare professionals fail to assess pain adequately reluctant to prescribe and monitor effective

analgesia provide insufficient education to promote self-

management

Healthcare systems fail to recognise patients with cancer pain communicate data on pain ineffectively prevent patients receiving timely analgesia

Wendy etal,European Journal of Cancer 2009

WHO Analgesic Ladder for treating cancer pain,since 1986

Step up –Step Down adaptation Ladder

The Analgesia Balance

ANALGESIASIDE-EFFECTSRISKSCOST

ACUTE PAIN vs CANCER PAIN

Cancer Pain

It is not only about alleviated the Pain It is also about modulating the Body

System to a better quality of ( end) life

care

Semoga bermanfaat

Anesthesiologyand

Reanimation

Criti

cal

care

Safe

stre

ss&

pain

free

anes

thes

ia

Man

agem

ent

of st

ress

& p

ain

Basic scienceInterpersonal

Communication skillTeam building and teamwork skill

Model yang disederhanakan Karjadi Wirjoatmodjo, IPS 2005

Expectation is involved in the therapeutic outcome

Hidden analgesic therapy (no expectation) analgesic >Open analgesic therapy (expectation +) analgesic <

Specific treatment effect and placebo response – additive

True treatment effectTrue placebo effectNatural courseRegression towards meanOther time effectsUnidentified parallel interventions

Perceived treatment effectminusOther non-specific effect

= True treatment effect

Levine, J.D. & Gordon, N.C., Nature, 1984

Luana Colloca and Fabrizio Benedetti, Neuroscience, 2005

As the drug has analgesic effect only in association with placebo procedure it’s action is not directed to pain pathway but to expectation pathway