Your Attitudes

determines
your Altitudes

Pain Management in daily

practice for Primary care

dr. Suparto, Sp.An

Department of Anesthesiology
Faculty of Medicine
Christian Krida Wacana University
Jakarta

Learning Objectives
1.
2.
3.
4.
5.
6.

Definition of pain
Physiology of pain
Classification of pain
Effects of pain
Pain assessment
Pain control

Hippocratic precepts:
the first duty of medicine is to cure sometimes,
to relieve often, to comfort always

Pain
- unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage.

International Association for the Study of Pain, 1979

Sensation
Noxious (Pain)
High threshold receptors, conducted by smaller,
lightly myelinated (A) and unmyelinated (C) nerve
fibers

Non-noxious (light touch, pressure,

temperature)
Low threshold receptors,
conducted by large myelinated
(A) nerve fibers

Peripheral sensitization
Painful stimulus

o Prostaglandins produced in

response to tissue injury;

increase sensitivity of
nociceptor (pain)

Pain-sensitive tissue

Prostaglandin

Mast cell

Substance P

Histamine
Bradykinin
Substance P

3
Nociceptor

Blood
vessel

o Nociceptor then releases

substance P, which dilates
blood vessels and increases
release of inflammatory
mediators, such as
Bradykinin (redness & heat)
o Substance P also proses
degranulation of mast
cells, which release
histamine (swelling)

PERCEPTION

TRANSDUCTION

TRANSMISSION

MODULATION

SENSATION

SpinalCord

Dorsalroot
Peripheral
nerve

I
II
III

IV

INPUT

VI
IX

REFLEKS

VII
VIII
LAMINA REXED

Categorizing Pain
Nociceptive pain
Caused by activation or
sensitization of peripheral
nociceptors initiated by
tissue injury;
it can be secondary to an
incision, inflammation, or
disease.
ex: Acute osteoarthritis,
Post operative pain,
exercise injuries

Neuropathic pain
Pain related to disease or
injury of the peripheral or
central nervous system
(extending to the spinal
cord)
Described as: burning,
shooting, tingling,
stabbing, or like a vise or
electric shock.
ex: Neuropathic low back
pain, Post herpetic
neuralgia, Diabetic
polyneuropathy

Two types of Nociceptive Pain

Somatic Pain
Visceral Pain

Somatic Pain
Superficial described as sharp, stabbing, well
localized
Typically arises from the skin, subcutaneous tissues,
and mucous membranes.

Deep described as dull, aching quality, less well

localized
Typically arises from skeletal muscles, tendons, joint
or bones

Pain from surgical incision, 2nd stage of labor,

peritoneal irritation

Visceral Pain
Due to a disease process or abnormal function
of an internal organ or its covering (eg parietal
pleura, pericardium or peritoneum)
Dull, Difuse, Poorly localized
Associated with either abnormal sympathetic or
parasympathetic activity causing nausea,
vomiting, sweating and changes in blood
pressure and heart rate.

 Parietal pain is typically sharp

Described as a stabbing sensation either
localized to the area around the organ or
referred to a distant site.

 Typically radiates with the same dermatome

origin as the diseased viscus
Occurs as rhythmic contractions of smooth
muscles
A cramping type accompanies
gastroenteritis, gallbladder disease, ureteral
obstruction, menstruation, distension of
uterus during 1st stage of labor

Acute and Chronic pain:

Acute pain
Trauma or surgery
Easier to manage than chronic pain
Related to a form of tissue damage resulting in
excitation of nociceptor nerve ending
Chronic pain
may be due to nociception but in which
psychological and behavioral factors often play a
major role
Lasting 3 months

Effects of Pain
Components of the Surgical Stress Response
a) Neuro-endocrine
b) Cardiovascular
catecholamines: vasoconstriction,
c) Respiratory
Dec
FRC work myocardial contractility
myocardial
d) Gastrointestinal
platelet adhesiveness
heart rate
Impaired
diaphragmatic
Immobility
dysrhythmias
sphincteric
tone
fibrinolysis
Function(reflex
inhibition
sphincteric
tone
e) Genitourinary
Insomnia
-muscle
angina
smooth
tone
Activation
of
coagulation
glucagon:
hyperglycemia
of
phrenic
nerve)
Anxiety
smooth-muscle
tone
MI
cascade
f) Immunologic/
Insulin, = protein
anabolism
Atelectasis
Helplessness
-CHF
Ileus
= Pneumonia
urinary
retention
Coagulation
Fear
incidence of thromboembolic
phenomena
g) General Well Being

Assessing Pain
Tell me about any pain you have
For each pain, consider the following:
Palliative factors: What makes it better?
Provocative factors: What makes it worse?
Quality: What is it like?
Radiation: Where does it spread to?
Severity: How bad is it?
Temporal factors: Is it constant? Does it come
and go?

Analgesic history:

What has helped in the past?

What has not helped in the past?
Show me exactly what you are taking now
How much and how often?
Does it help the pain? Does it relieve the pain or
only reduce it?
Does your medicine do anything that you dont
like?

Pain Assessment
Self-Report:
Visual Analog Scale
Numeric Rating Scale
Faces Pain Scale

Numeric Rating Scale

0 1 2
No pain

8 9 10
Worst pain

Principal of pain management

Pain as the Fifth Vital Sign
Multimodal analgesic approach
It is easier to keep pain at bay rather than
trying to control it after it has resurfaced

3 step ladder for pain relief

Multimodal Pain Control

Inflammation
NSAID, Selective COX-2 Inhibitors
Analgesia
Paracetamol
Opioid
NMDA Antagonist
Anticonvulsant
Non-pharmacologic therapy
Psychological support
TENS (Transcutaneous Electric Nerve Stimulation)
Acupunture
Physiotherapy
Complementary therapies

Adjuvant drugs:
Antidepressant
Alpha 2 Agonist
Steroids
Antiemetic
Management of drug related side effects
Antacids
Laxatives/stool softeners

NSAID mechanism of Action

Inhibition of PG-mediated amplification of chemical
and mechanical irritants on the sensory pathway.
Inhibits COX (prostaglandin synthetase)
Blocks response to inflammatory substances,
bradykinins, acetylcholine, serotonin
mediation of peripheral inflammatory
response

Opioid Receptors
RECEPTOR

RESPONSE ON ACTIVATION

(mu)

Analgesia, respiratory depression, miosis

euphoria, reduced GI motility

(kappa)

Analgesia, dysphoria, miosis,

psychotommetic effects

(delta)

Analgesia, facilitation of Mu receptor

located supraspinally
located at spinal level

Undesirable Effects of Opioids

Respiratory depression
Sedation
Nausea and Vomiting
Suppression of cough reflex
Psychic and Physical dependence
Tolerance
Constipation

Agonists: Mu receptor

Morphine: oral, IV, IM, intrathecal, epidural

Meperidine: IV, IM, epidural
Fentanyl: transdermal, transmucosal, IV
Tramadol: oral, IV, transmucosal

Agonist-antagonists: kappa, sigma/ no activity on

Mu; potential to reverse effect of agonist
Nalbuphine: IM, IV
Butorphanol: IM, IV

Ethical Consideration
Give regular analgesics of sufficient strength for
continuous pain
Ensure pain control by titrating analgesic doses
without overdosing
Recognize that analgesics are for pain control
and arent to be used as sedatives
Recognize our own limitations and request
advice from specialist pain relief services

Pain management is more of an art

than a science

Thank you