dr. nancy - the need of pain relief, menado 2015
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![Page 1: dr. Nancy - The Need of Pain Relief, Menado 2015](https://reader035.vdocuments.mx/reader035/viewer/2022081521/587176411a28ab230b8b504b/html5/thumbnails/1.jpg)
THE NEED OF PAIN RELIEF IN CANCER PAIN N Margarita Rehatta
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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
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Basic`s of Pain Management
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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
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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
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Influenceperception of pain intensity
Bio - Pain Pathway & Integrated Response
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Why Pain need to be alleviated
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The body response to
stress
ACTH -Endorphin
CS
NEEPIENK
Pain
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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
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Pathophysiology and mechanismsof cancer pain
Nociceptive (somatic and visceral) Neuropathic Psychogenic Idiopathic / unrelated to cancer
Fundamental in assessment&
determine therapy
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- 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
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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
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Global Improvement Ratings
Physical functioning Emotional
functioning Adverse symptom (Drug) Efficacy
issues.
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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
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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
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WHO Analgesic Ladder for treating cancer pain,since 1986
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Step up –Step Down adaptation Ladder
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The Analgesia Balance
ANALGESIASIDE-EFFECTSRISKSCOST
ACUTE PAIN vs CANCER PAIN
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Cancer Pain
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It is not only about alleviated the Pain It is also about modulating the Body
System to a better quality of ( end) life
care
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Semoga bermanfaat
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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
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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
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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