Chronic noncancer pain management R Gunadi Bandung
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Chronic non cancer Pain
Rachmat Gunadi Wachjudi
Departement of Internal Medicine
Dr Hasan Sadikin Hospital
Bandung
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Pain as the 5th Vital Sign• Consider pain the fifth vital sign and assess patients for
pain every time you check for pulse, blood pressure, core temperature, and respiration.
• Urge your colleagues to take their patients' complaints of pain seriously. Remind them not to put patients in the
position of asking for a favor when they want pain relief. • Inform patients that they deserve to have their pain
evaluated and treated. • Work to implement the APS
Quality Improvement Guidelines for the Treatement of Acute Pain and Cancer Pain
in your own practice setting. (JAMA, 274, 1874-1880) • Wear your Fifth Vital SignTM button and make opportunities
to explain the importance of pain evaluation and treatment to other healthcare professionals and to the public.
http://www.ampainsoc.org/
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Pain is a significant issue
• #1 Admitting diagnosis in US• #1 Reason for missed work in US• Chronic pain costs the US $100B / year in
direct medical costs, lost income and productivity
• Pain is the 5th vital sign (JCAHO)• Patients have a right to adequate pain
control (JCAHO)
Stewart et al, Work-related cost of pain in the US, IASP/10th World Congress on Pain 2002, as cited by Dr. John Stamatos, Medscape.com.
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Prompt Pain Management is Vital• The sooner pain is
managed the more likely patients are to return to normal daily living activities
J. McGill, J. Occupational Medicine, 1968
94%
19%
2%
0% 50% 100%
Length
of Tim
e O
ffW
ork
Percentage Returning to Work
<90 days >90 days <2 yrs
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Types of Pain
1. Acute
2. Cancer, acute or chronic
3. Chronic non-cancer
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Diagnosis
First-Tier Pain Therapies
Second-Tier Pain Therapies
Advanced Pain Therapies
Chronic Pain Treatment Continuum
Chronic Pain Treatment Continuum
NSAIDsTENSPsychological RxNerve Blocks
OpioidsNeurolysisThermal Procedures
Source: Implantable Technologies: Spinal Cord Stimulation and Implantable Drug Delivery Systems, Elliot Krames, MD, Pacific Pain Treatment Center, SF, www.painconnection.org
Physical RxOTC pain meds
NeurostimulationImplantable Drug PumpsSurgical InterventionNeuromodulation
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Targeting your Approach
NOCICEPTIVE PAIN
arthropathies
ischemic disorders
visceral pain
NEUROPATHIC PAIN
neuropathy
PHN
post-stroke pain (central)
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Principles of TreatmentReduction of Pain:
Behavioral, Meds, Blocks, Surgery, Complementary
There is no magic bullet, no single cure
Rehabilitation:
Reconditioning & Prevention
Coping:
Management of Residual Pain
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Treatment Objectives
Decrease the frequency and / or severity of the pain
General sense of feeling better
Increased level of activity
Return to work
Decreased health care utilization
Elimination or reduction in medication usage
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Pain
Step 1Nonopioid Adjuvant
Pain persisting or increasing
Step 2Opioid for mild to moderate pain
Nonopioid Adjuvant
Pain persisting or increasing
Pain persisting or increasing
Step 3Opioid for moderate to severe pain
Nonopioid Adjuvant
Invasive treatments
Opioid Delivery
Quality of Life
Modified WHO Analgesic Ladder
Proposed 4th Step
The WHOLadder
Deer, et al., 1999
8 -10
4 - 7
1 - 3
Pain Severity
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Using Pharmacological Options Safely
Pharmacokinetics
Pharmacodynamics
Compliance
Cost
Polypharmacy
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Despite all the advances in medical technology….
Complete relief of symptoms (pain) often an unrealistic goal once pain becomes chronic
More realistic to seek ways to limit disability despite pain
That is, manage pain to limit its impact
Goucke CR. The management of persistent pain. Med J Aust 2003; 178(9): 444-447. Loeser JD. Mitigating the dangers of pursuing cure. In: Cohen MJM, Campbell JN, eds. Pain Treatment Centers at a Crossroads: A Practical and
Conceptual Reappraisal. Seattle, IASP Press, 1996:101-108.
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PAIN PERSISTING
PHYSICALDETERIORATION(eg. muscle wasting, joint stiffness)
FEELINGS OF DEPRESSION,HELPLESSNESS,IRRITABILITY
SIDE EFFECTS(eg. stomach problems lethargy, constipation)
© M K Nicholas PhDPain Management & Research CentreRoyal North Shore HospitalSt Leonards NSW 2065AUSTRALIA
EXCESSIVESUFFERING & DISABILITY
Chronic pain often accompanied by other problems that interact
Influence of workplace, home, treatment providers
A BIOPSYCHOSOCIAL PERSPECTIVE
REDUCEDACTIVITY
UNHELPFULBELIEFS &THOUGHTS
REPEATEDTREATMENTFAILURES
LONG-TERMUSE OF ANALGESIC,SEDATIVE DRUGS
LOSS OF JOB, FINANCIALDIFFICULTIES, FAMILYSTRESS
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Pain - current view
Pain is an end-product of many interacting processes in the nervous system (including the brain).
The relationship between injury and pain is quite variable.
Knowledge of cause of pain is not sufficient to tell us how much pain a person will have or its impact.
Diagnosis (eg. “Lumbar Discogenic Pain”) is a poor guide to prediction of disability (Caragee et al, Spine Journal, 2005)
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Treatment principles
Pain as a symptom
Find the cause and fix it
Pathology oriented
Works well in acute pain
Well accepted by patient and doctor
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Treatment principles
Pain as a symptom
Find the cause and fix it
Works well here
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Treatment principles
Pain as a symptom
Find the cause and fix it
Does all headaches have a pathology?
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Treatment principles
Pain as a symptom
Control the symptom
Passive
Long term effects and side effects
Case specific
What are the options?
There is no magic bullet, no single cure
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Symptom control
Medications
Antipyretics (paracetamol)
NSAID
Opioids
Antidepressants
Anticonvulsants
Steroids, muscle relaxants, etc.
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Symptom control
Paracetamol
Effective in OA knees
Amadio Curr. Ther. Res. 1983
Effectiveness ~ Ibuprofen
Bradley N. Eng. J. Med. 1991
Safe and economical, NSAID sparing for elderly
Nikles Am. J. Ther. 2005
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Symptom control
Paracetamol
Evidence in OA only
Hepatic and renal toxicity do occur
Medication induced headache
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Symptom control
Medications
Antipyretics (paracetamol)
NSAID
Opioids
Antidepressants
Membrane stabilisers (anticonvulsants)
Steroids, muscle relaxants, etc.
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Symptom control
NSAID
Best evidence from rheumatoid arthritis
Also good for cancer pain
Effective in 5 out of 10 placebo-trials for LBP
Effective in 4 out of 9 Panadol-trials for LBP
Doubtful value for non-specific musculoskeletal pain
Koes Ann. Rheum. Dis. 1997
Eisenberg J. Clin. Onco. 1994
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24
NSAIDS
-> not approved by FDA for the whole range of rheumatic diseases but all are probably effective in: ¤ rheumatoid arthritis ¤ seronegative spondyloarthropathies e.g.> psoriatic arthritis > arthritis associated w/ inflammatory bowel disease ¤ osteoarthritis ¤ localized musculoskeletal syndromes e.g. sprains and strains, low back pain ¤ gout – except tolmetin -->ineffective for gout
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Chemical Class Prototype Analgesia Antipyresis Antiinflammatory
Salicylates Aspirin +++ +++ +++
Para-aminophenols Acetaminophen +++ +++ Marginal
Indoles Indomethacin +++ ++++ ++++
Pyrrol acetic acids Tolmentin, mefenamic acid
+++ +++ +++
Propionic acids Ibuprofen, naproxen
++++ +++ ++++
Enolic acids Phenylbutazone, piroxicam
+++ +++ ++++
Alkanones Nabumetone ++ ++ +++
Sulfonamide Celecoxib ++++ +++ ++++
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Treatment of chronic inflammation requires use of these agents at doses well above those used for analgesia
and antipyresis
the incidence of adverse drug effects is increased.
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Common Adverse Effects
Platelet Dysfunction Gastritis and peptic ulceration with bleeding
(inhibition of PG + other effects)Acute Renal Failure in susceptible
Sodium+ water retention and edemaAnalgesic nephropathy
Prolongation of gestation and inhibition of labor.Hypersenstivity (not immunologic but due to PG
inhibition)GIT bleeding and perforation
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Symptom control
Medications
Antipyretics (paracetamol)
NSAID
Opioids
Antidepressants
Membrane stabilisers (anticonvulsants)
Steroids, muscle relaxants, etc.
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Symptom control
Opioids
Gold standard for cancer pain management
(mostly) cheap and readily available
Administered at every route
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Efficacy of opioids in chronic non-cancer pain: systematic review
Kalso et al. Pain 2004;112:372-80
Reduction in Pain Intensity Following Oral Opioid Treatment
* 30% is the suggested clinically relevant decrease in pain intensity in chronic pain
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Symptom control
Opioids
Controversial for non-cancer pain
Limited (but positive) evidence of efficacy
Extensive side effects
Tolerance
Dependence
Divergence
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Symptom control
Opioids
Controversial for non-cancer pain
“Physicians should make every effort to control indiscriminate prescribing, even under pressure from
patients…”
Ballantyne N. Eng. J. Med. 2003
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Symptom control
Opioids
Controversial for non-cancer pain
“Opioids are our most powerful analgesics, but politics, prejudice, and our continuing ignorance still impede
optimum prescribing”
McQuay Lancet 1999
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Paracetamol up to 4g/day
Gastrolintestinalrisk
Renal risk
Cardiovascularrisk
Avoid NSAIDs/COX-2 inhibitors
Long termFlares
• Paracetamol / tramadol weak opioid compinations*
• Tramadol• Strong opioid
COX-2 inhibitor
NSAIDs+PPI
Paracetamal /Tramadol
•Tramadol•Strong opioids
* 2nd choice
Clinical Rheumatol (2006) 25 (Suppl 1): S22-S29
2006 Guideline in Treatment Moderate to Severe Pain in OA patients with Risk Factors
WGPM ( The Working Group on Pain Management ) Recommendation at the 2nd meeting in EULAR 2005
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Symptom control
Opioids
Practical guidelines for non-cancer pain
Exhaust other methods
Aim at functional improvement
Limit prescription authority, monitor behavior
Slow release, avoid injectables
Opioid contract
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Symptom control
Medications
Antipyretics (paracetamol)
NSAID
Opioids
Antidepressants
Membrane stabilisers (anticonvulsants)
Steroids, muscle relaxants, etc.
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Symptom control
AntidepressantsAnalgesic at below mood altering doses
NNT for diabetic neuropathy ~ 3.4
Collins J. Pain & Sym. Manag. 2000
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Symptom control
AntidepressantsAnalgesic at below mood altering doses
NNT for post-herpetic neuralgia ~ 2.1
Collins J. Pain & Sym. Manag. 2000
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Symptom control
AntidepressantsHow good is NNT of 2.1 to 3.4?
It is not good for this
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Symptom control
AntidepressantsHow good is NNT of 2.1 to 3.4?
It is really good for pain
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Symptom control
Antidepressants
Major problem: side effects
NNH (minor) ~ 2.7
No consensus which one is best
Classically TCA
SSRI: seemed more specific on mood
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Symptom control
Medications
Antipyretics (paracetamol)
NSAID
Opioids
Antidepressants
Membrane stabilisers (anticonvulsants)
Steroids, muscle relaxants, etc.
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Symptom control
Anticonvulsants
Carbamazepime for trigeminal neuralgia
NNT ~ 2.6
NNH ~ 3.4
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Symptom control
Anticonvulsants
NNT for diabetic neuropathy (red) ~ 2.7
NNT for post-herpetic neuralgia (white) ~ 3.2
Collins J. Pain & Sym. Manag. 2000
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Symptom control
Anticonvulsants
Gabapentin
Less organ damage
No drug interaction
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Symptom control
Intervention
Nerve
Counter-stimulation
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Symptom control
Nerve block
Where to cut
How to cut
What is left behind
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Symptom control
Nerve block
Where to cut
How to cut
What is left behind
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Symptom control
Transcutaneous Electrical Nerve Stimulation(TENS)
Product of Gate theory
Better than placebo in short term
Minimal side effects
No long term benefit
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Symptom control
Spinal cord stimulation
Patient controlled
No medication
Permanent (almost)
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Symptom control
Spinal cord stimulation
Failed back surgery
Isolated neuropathy
Ischemic heart disease
Peripheral vascular disease
Pain relief as a therapy
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Treatment principles
Pain as a symptom
Find the cause and fix it
Symptomatic control
Pain as a disease
How is this disease like?
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Pain as a disease
Pain
Depression
Think negative
In-activity
MedicalDependence
InsomniaSocially deprived
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Pain as a disease
Our contribution
“Degenerative”
“Bone spurs”
“Nothing wrong”
“It is in your mind”
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Pain as a disease
Need a multi-disciplinary approach
Clinical psychology
Physiotherapy
Occupational therapy
Nursing
Social work / vocational training
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Pain as a disease
Alleviate their depression
Motivate them to mobilise despite pain
Encourage active coping
Reduce dependency on medical input
Stop searching for a cause
Stop giving analgesics together with side effects
Cognitive behavioral therapy
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Pain as a disease
Cognitive behavioral therapy
Pain intensity (VAS)
0
1
2
3
4
5
6
7
8
9
Pre
Post
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Pain as a disease
Cognitive behavioral therapy
Analgesic consumption (types)
0
0.5
1
1.5
2
2.5
3
Pre
Post
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Pain as a disease
Cognitive behavioral therapy
Pain is the same, but
More active
Less depressed
Less doped
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Pain as a specialty
Getting established
IASP and its 65 global chapters
Over 300000 members of multiple specialties
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Pain as a specialty
Anaesthesiology
Orthopediac surgery
Neurosurgery
Oncology / palliative care
Neurology
Rheumatology
Rehabilitative medicine
Psychiatry
Radiology
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Pain as a specialty
… is to specialize in everthing!
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Pain as a specialty
Opportunity to work with other doctors
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Summary
Chronic pain is common (1 in 5 people)It is a risk factor for disabilityThe presence of mental disorders increases risk of
disability in those with chronic painCurative treatment is unlikely (no magic bullet)Interventions need to be targeted against identified
risk factors (bio – psycho – social) Challenge: Collaborative approach offers best
chance of success
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Treatment of Pain
Options:• Non-pharmacologic• Medications
•Acetaminophen•Nonsteroidal anti-inflammatory drugs
•Opioids •Antidepressants & anticonvulsants•Adjuvants
Invasive proceduresCopyright © 2003 American Society of Anesthesiologists. All rights reserved
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Opioids - Key messages
Pain is prevalent, underestimated, debilitating
We have effective analgesics need careful pain assessment and drug titration to achieve optimal
balance: safety + tolerability + efficacy
Strong opioids play a pivotal role in non-cancer and cancer pain treatmentOpiophobia
education and example
understanding addiction, abuse, dependenceaddiction uncommon in pain patients
Level 1 evidence based Guidelines
Rich BA. Ethics of opioid analgesia for chronic noncancer pain. Pain Clinical Updates. Dec 2007
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Thank You
Dr. John J. Bonica“Father of pain medicine”