chronic noncancer pain management r gunadi bandung

Chronic non cancer Pain

Rachmat Gunadi Wachjudi

Departement of Internal Medicine

Dr Hasan Sadikin Hospital

Bandung

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/

http://www.ampainsoc.org/pub/qi.htm

http://www.ampainsoc.org/pub/qi.htm

http://www.ampainsoc.org/advocacy/pdf/fifth_vital_sign.pdf

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.

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

Types of Pain

1. Acute

2. Cancer, acute or chronic

3. Chronic non-cancer

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

http://www.painconnection.org/

Targeting your Approach

NOCICEPTIVE PAIN

arthropathies

ischemic disorders

visceral pain

NEUROPATHIC PAIN

neuropathy

PHN

post-stroke pain (central)

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

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

Pain

Step 1Nonopioid Adjuvant

Pain persisting or increasing

Step 2Opioid for mild to moderate pain

Nonopioid Adjuvant



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

Using Pharmacological Options Safely

Pharmacokinetics

Pharmacodynamics

Compliance

Cost

Polypharmacy

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.

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

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)

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


Pain as a symptom


Works well here


Pain as a symptom


Does all headaches have a pathology?


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

Symptom control

Medications

Antipyretics (paracetamol)

NSAID

Opioids

Antidepressants

Anticonvulsants

Steroids, muscle relaxants, etc.

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

Symptom control

Paracetamol

Evidence in OA only

Hepatic and renal toxicity do occur

Medication induced headache

Symptom control

Medications


NSAID

Opioids

Antidepressants

Membrane stabilisers (anticonvulsants)


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

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 ++++ +++ ++++

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.

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

Symptom control

Medications


NSAID

Opioids

Antidepressants



Symptom control

Opioids

Gold standard for cancer pain management

(mostly) cheap and readily available

Administered at every route

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

Symptom control

Opioids

Controversial for non-cancer pain

Limited (but positive) evidence of efficacy

Extensive side effects

Tolerance

Dependence

Divergence

Symptom control

Opioids


“Physicians should make every effort to control indiscriminate prescribing, even under pressure from

patients…”

Ballantyne N. Eng. J. Med. 2003

Symptom control

Opioids


“Opioids are our most powerful analgesics, but politics, prejudice, and our continuing ignorance still impede

optimum prescribing”

McQuay Lancet 1999

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

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

Symptom control

Medications


NSAID

Opioids

Antidepressants



Symptom control

AntidepressantsAnalgesic at below mood altering doses

NNT for diabetic neuropathy ~ 3.4

Collins J. Pain & Sym. Manag. 2000

Symptom control

AntidepressantsAnalgesic at below mood altering doses

NNT for post-herpetic neuralgia ~ 2.1


Symptom control

AntidepressantsHow good is NNT of 2.1 to 3.4?

It is not good for this

Symptom control

AntidepressantsHow good is NNT of 2.1 to 3.4?

It is really good for pain

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

Symptom control

Medications


NSAID

Opioids

Antidepressants



Symptom control

Anticonvulsants

Carbamazepime for trigeminal neuralgia

NNT ~ 2.6

NNH ~ 3.4

Symptom control

Anticonvulsants

NNT for diabetic neuropathy (red) ~ 2.7

NNT for post-herpetic neuralgia (white) ~ 3.2


Symptom control

Anticonvulsants

Gabapentin

Less organ damage

No drug interaction

Symptom control

Intervention

Nerve

Counter-stimulation

Symptom control

Nerve block

Where to cut

How to cut

What is left behind

Symptom control

Transcutaneous Electrical Nerve Stimulation(TENS)

Product of Gate theory

Better than placebo in short term

Minimal side effects

No long term benefit

Symptom control

Spinal cord stimulation

Patient controlled

No medication

Permanent (almost)

Symptom control

Spinal cord stimulation

Failed back surgery

Isolated neuropathy

Ischemic heart disease

Peripheral vascular disease

Pain relief as a therapy


Pain as a symptom


Symptomatic control

Pain as a disease

How is this disease like?

Pain as a disease

Pain

Depression

Think negative

In-activity

MedicalDependence

InsomniaSocially deprived

Pain as a disease

Our contribution

“Degenerative”

“Bone spurs”

“Nothing wrong”

“It is in your mind”

Pain as a disease

Need a multi-disciplinary approach

Clinical psychology

Physiotherapy

Occupational therapy

Nursing

Social work / vocational training

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

Pain as a disease


Pain intensity (VAS)

0

1

2

3

4

5

6

7

8

9

Pre

Post

Pain as a disease


Analgesic consumption (types)

0

0.5

1

1.5

2

2.5

3

Pre

Post

Pain as a disease


Pain is the same, but

More active

Less depressed

Less doped

Pain as a specialty

Getting established

IASP and its 65 global chapters

Over 300000 members of multiple specialties

Pain as a specialty

Anaesthesiology

Orthopediac surgery

Neurosurgery

Oncology / palliative care

Neurology

Rheumatology

Rehabilitative medicine

Psychiatry

Radiology

Pain as a specialty

… is to specialize in everthing!

Pain as a specialty

Opportunity to work with other doctors

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

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

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

Thank You

Dr. John J. Bonica“Father of pain medicine”

chronic noncancer pain management r gunadi bandung

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