an overview of pain management

1. Chronic non cancer Pain
Rachmat Gunadi Wachjudi
Departement of Internal Medicine
Dr Hasan Sadikin Hospital
Bandung

2. 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 Can
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/

3. 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/10 th World Congress on
Pain 2002, as cited by Dr. John Stamatos, Medscape.com.

4. Prompt Pain Management is Vital
• The sooner pain is
Lengt h of Tim e Of f
managed  the more 2%
likely patients are to
Work
19%
return to normal daily 94%
living activities
0% 50% 100%
Percent age Ret ur ning t o Work
< 90 days > 90 days < 2 yrs
J. McGill, J. Occupational Medicine, 1968

5. Types of Pain
1. Acute
2. Cancer, acute or chronic
3. Chronic non-cancer

6. Chronic Pain Treatment Continuum
Advanced Pain
Second-Tier Therapies
Pain Therapies
First -Tier Pain
Therapies
Neurostimulation
Implantable
Diagnosis Drug Pumps
Surgical Intervention
Opioids Neuromodulation
Neurolysis
Thermal
NSAIDs Procedures
TENS
Psychological Rx
Nerve Blocks
Physical Rx
OTC pain meds
Chronic Pain Treat ment Cont inuum
Source: Implantable Technologies: Spinal Cord Stimulation and Implantable Drug Delivery Systems,
Elliot Krames, MD, Pacific Pain Treatment Center, SF, www.painconnection.org

7. Targeting your Approach
NOCICEPTIVE PAIN
arthropathies
ischemic disorders
visceral pain
NEUROPATHIC PAIN
neuropathy
PHN
post-stroke pain (central)

8. Principles of Treatment
Reduction of Pain:
Behavioral, Meds, Blocks, Surgery, Complementary
There is no magic bullet, no single cure
Rehabilitation:
Reconditioning & Prevention
Coping:
Management of Residual Pain

9. 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

10. Modified WHO Analgesic
Ladder Quality of Life Pain Severit
Invasive treatments
Proposed 4 th Opioid Delivery
Step
Pain persisting or increasing
Step 3 8 -10
Opioid for moderate to severe pain
±Nonopioid±Adjuvant
Pain persisting or increasing
Step 2
Opioid for mild to moderate pain 4-7
The WHO ±Nonopioid± Adjuvant
Ladder Pain persisting or increasing
Step 1
± Nonopioid 1-3
± Adjuvant
Pain
Deer, et al., 1999

11. Using Pharmacological Options
Safely
Pharmacokinetics
Pharmacodynamics
Compliance
Cost
Polypharmacy

12. 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.

13. Chronic pain often accompanied by other problems that interact
REDUCED
ACTIVITY PHYSICAL
DETERIORATION
(eg. muscle wasting,
joint stiffness)
UNHELPFUL
BELIEFS &
THOUGHTS
PAIN FEELINGS OF EXCESSIVE
PERSISTING DEPRESSION, SUFFERING
REPEATED HELPLESSNESS,
TREATMENT IRRITABILITY
& DISABILITY
FAILURES
LONG-TERM
USE OF ANALGESIC,
SEDATIVE DRUGS SIDE EFFECTS
(eg. stomach problems
lethargy, constipation)
LOSS OF JOB, FINANCIAL
DIFFICULTIES, FAMILY
STRESS
© M K Nicholas PhD
Pain Management & Research Centre
Influence of workplace, A BIOPSYCHOSOCIAL PERSPECTIVE Royal North Shore Hospital
St Leonards NSW 2065
AUSTRALIA
home, treatment providers

14. 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)

15. 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

16. Treatment principles
Pain as a symptom
Find the cause and fix it
Works well here

17. Treatment principles
Pain as a symptom
Find the cause and fix it
Does all headaches have a pathology?

18. 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

19. Symptom control
Medications
Antipyretics (paracetamol)
NSAID
Opioids
Antidepressants
Anticonvulsants
Steroids, muscle relaxants, etc.

20. 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

21. Symptom control
Paracetamol
Evidence in OA only
Hepatic and renal toxicity do occur
Medication induced headache

22. Symptom control
Medications
Antipyretics (paracetamol)
NSAID
Opioids
Antidepressants
Membrane stabilisers (anticonvulsants)
Steroids, muscle relaxants, etc.

23. 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

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 24

25. 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 ++++ +++ ++++

26. 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.

27. 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 edema
Analgesic nephropathy
Prolongation of gestation and inhibition of labor.
Hypersenstivity (not immunologic but due to PG
inhibition)
GIT bleeding and perforation

28. Symptom control
Medications
Antipyretics (paracetamol)
NSAID
Opioids
Antidepressants
Membrane stabilisers (anticonvulsants)
Steroids, muscle relaxants, etc.

29. Symptom control
Opioids
Gold standard for cancer pain management
(mostly) cheap and readily available
Administered at every route

30. Efficacy of opioids in chronic non-cancer
pain: systematic review
Reduction in Pain Intensity Following Oral Opioid Treatment
* 30% is the suggested clinically relevant
Kalso et al. Pain 2004;112:372-80 decrease in pain intensity in chronic pain

31. Symptom control
Opioids
Controversial for non-cancer pain
Limited (but positive) evidence of efficacy
Extensive side effects
Tolerance
Dependence
Divergence

32. 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

33. 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

34. 2006 Guideline in Treatment Moderate to Severe
Pain in OA patients with Risk Factors
Paracetamol up to 4g/day
Cardiovascular Renal Gastrolintestinal
risk risk risk
Avoid NSAIDs/ Flares Long term
COX-2 inhibitors
• Paracetamol / tramadol COX-2 NSAIDs Paracetamal /
weak opioid compinations* inhibitor +PPI Tramadol
• Tramadol •Tramadol
• Strong opioid •Strong opioids
* 2nd choice
Clinical Rheumatol (2006) 25 (Suppl 1): S22-S29
WGPM ( The Working Group on Pain Management ) Recommendation at the 2nd meeting in EULAR 2005

35. 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

36. Symptom control
Medications
Antipyretics (paracetamol)
NSAID
Opioids
Antidepressants
Membrane stabilisers (anticonvulsants)
Steroids, muscle relaxants, etc.

37. Symptom control
Antidepressants
Analgesic at below mood altering doses
NNT for diabetic neuropathy ~ 3.4
Collins J. Pain & Sym. Manag. 2000

38. Symptom control
Antidepressants
Analgesic at below mood altering doses
NNT for post-herpetic neuralgia ~ 2.1
Collins J. Pain & Sym. Manag. 2000

39. Symptom control
Antidepressants
How good is NNT of 2.1 to 3.4?
It is not good for this

40. Symptom control
Antidepressants
How good is NNT of 2.1 to 3.4?
It is really good for pain

41. 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

42. Symptom control
Medications
Antipyretics (paracetamol)
NSAID
Opioids
Antidepressants
Membrane stabilisers (anticonvulsants)
Steroids, muscle relaxants, etc.

43. Symptom control
Anticonvulsants
Carbamazepime for trigeminal neuralgia
NNT ~ 2.6
NNH ~ 3.4

44. Symptom control
Anticonvulsants
NNT for diabetic neuropathy (red) ~ 2.7
NNT for post-herpetic neuralgia (white) ~ 3.2
Collins J. Pain & Sym. Manag. 2000

45. Symptom control
Anticonvulsants
Gabapentin
Less organ damage
No drug interaction

46. Symptom control
Intervention
Nerve
Counter-stimulation

47. Symptom control
Nerve block
Where to cut
How to cut
What is left behind

48. Symptom control
Nerve block
Where to cut
How to cut
What is left behind

49. Symptom control
Transcutaneous Electrical Nerve Stimulation
(TENS)
Product of Gate theory
Better than placebo in short term
Minimal side effects
No long term benefit

50. Symptom control
Spinal cord stimulation
Patient controlled
No medication
Permanent (almost)

51. Symptom control
Spinal cord stimulation
Failed back surgery
Isolated neuropathy
Ischemic heart disease
Peripheral vascular disease
Pain relief as a therapy

52. Treatment principles
Pain as a symptom
Find the cause and fix it
Symptomatic control
Pain as a disease
How is this disease like?

53. Pain as a disease
Insomnia
Depression Socially deprived
Pain Medical
Dependence
Think negative
In-activity

54. Pain as a disease
Our contribution
“Degenerative”
“Bone spurs”
“Nothing wrong”
“It is in your mind”

55. Pain as a disease
Need a multi-disciplinary approach
Clinical psychology
Physiotherapy
Occupational therapy
Nursing
Social work / vocational training

56. 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

57. Pain as a disease
Cognitive behavioral therapy
Pain intensity (VAS)
9
8
7
6
5 Pre
4 Post
3
2
1
0

58. Pain as a disease
Cognitive behavioral therapy
Analgesic consumption (types)
3
2.5
2
Pre
1.5
Post
1
0.5
0

59. Pain as a disease
Cognitive behavioral therapy
Pain is the same, but
More active
Less depressed
Less doped

60. Pain as a specialty
Getting established
IASP and its 65 global chapters
Over 300000 members of multiple specialties

61. Pain as a specialty
Anaesthesiology
Orthopediac surgery
Neurosurgery
Oncology / palliative care
Neurology
Rheumatology
Rehabilitative medicine
Psychiatry
Radiology

62. Pain as a specialty
… is to specialize in everthing!

63. Pain as a specialty
Opportunity to work with other doctors

64. Summary
Chronic pain is common (1 in 5 people)
It is a risk factor for disability
The presence of mental disorders increases risk of
disability in those with chronic pain
Curative 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

65. Treatment of Pain
Options:
• Non-pharmacologic
• Medications
• Acetaminophen
• Nonsteroidal anti-inflammatory drugs
• Opioids
• Antidepressants & anticonvulsants
• Adjuvants
Invasive procedures
Copyright © 2003 American Society of Anesthesiologists. All rights reserved

66. 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 treatment
Opiophobia
education and example
understanding addiction, abuse, dependence
addiction uncommon in pain patients
Level 1 evidence based Guidelines
Rich BA. Ethics of opioid analgesia for chronic noncancer pain.
Pain Clinical Updates. Dec 2007

67. Thank You
Dr. John J. Bonica
“Father of pain medicine”