DR SUNITA PANTA

ANAESTHESIOLOGIST
ASSOCIATE PROFESSOR
SHREE BIRENDRA HOSPITAL
 Pain

Major public health problem

Pain management -Pain medicine -Algiatry

 branch of medicine employing an interdisciplinary
approach for easing the suffering and improving the
quality of life of those living with pain.
 History

First attested in English in 1297

Word pain meaning penalty comes from
 French -peine
 Latin –poena
 Greek –poine

Archaeologists have uncovered clay tablets

dating back as far as 5,000 BC which reference
the cultivation and use of the opium poppy to
cease pain
 International Association for the
Study of Pain (IASP)
International professional organization promoting
research, education and policies for the
knowledge and management of pain.
founded in 1973, under the leadership of John
Bonica.
publishes the scientific journal Pain.
brings together scientists, clinicians, healthcare
providers and policymakers to stimulate and
support the study of pain and to translate that
knowledge into improved pain relief worldwide
 IASP definition of pain

1975
 an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage
 Chemical Mediators of pain
Excitatory Inhibitory
Neurotransmitters Receptors Neurotransmitters Receptors
Subs P NK-1 Acetylcholine Muscarinic
CGRP Enkephalins Mu,delta,kappa
Glutamate NMDA B-endorphins Mu, delta, kappa

Aspartate NMDA,AMPA Noradrenaline A1

ATP P1,P2 GABA A,B

Histamine
Glycine

Prostaglandins Adenosine A1

Serotonin 5HT,5HT3
Pain Pathways
Rexed’s Spinal Cord Lamina

Lamina I -C fibres
Lamina I, III, IV -A delta fibres
Lamina I-VI -Modulation of pain
 Gate control theory

 Melzack and Wall

 Pain Mechanisms: A New Theory (1965 )
Spinal cord has input from large and small fibres
 Small fibres- nociceptive open gate-inc transmission
 Large fibres- not necessarily nociceptive –close gates- red transmission
Implications
 Central neuraxial blocks impede pain transmission from
periphery to center
 Descending inhibitory processes are of great interest in the

research arena
 Classification

Acute/Chronic
Somatic/ Visceral
Physiological/Clinical

Cinical
 Nociceptive/Neuropathic
 Nociceptive pain

Nociceptive pain is caused by stimulation of peripheral

nerve fibers (nociceptors) that respond only to stimuli
approaching or exceeding harmful intensity

 Nociceptive pain may also be divided into

 visceral
 Somatic
 Neuropathic pain

Neuropathic pain is caused by damage or disease

affecting any part of the somatosensory system

Neuropathic pain is often described as

 burning
 tingling
 electrical
 stabbing
 pins and needles
Nociceptive Neuropathic
 Activation/sensitisation of  Result of injury or acquired
peripheral nociceptors in abnormality of
normal tissue central/peripheral neural
 Normal response structures
 Primary/secondary  Abnormal
hyperalgesia  Allodynia/Hyperalgesia
 No corelation b/w injury and
pain
 Triggered by minor stimuli
 Acute/Chronic

Traditionally, the distinction between acute and chronic

pain has relied upon an arbitrary interval of time from
onset;
 acute to pain that lasts less than 30 days,
 chronic to pain of more than six months duration,
 subacute to pain that lasts from one to six months.
 Common types of pain and
typical drug management
minor trauma
 NSAIDs (opioids not recommended)
severe trauma, such as a wound,
burn, bone fracture, or severe sprain

 opioids

Sprain and strain or pulled muscle

 NSAIDs,
 muscle relaxants
Minor pain after surgery
 paracetamol, NSAIDs

 opioids rarely needed

Severe pain after surgery

 opioids (combinations of opioids )
Dental pain
 paracetamol, NSAIDs
Renal Colic
 paracetamol, NSAIDs, opioids
 Chronic pain

Persists beyond normal course of acute disease or

reasonable time for healing to occur – 1 to 6 months
Nociceptive/neuropathic/combination
May not have clearly identifiable cause
Attenuated/absent neuroendocrine stress response
Have sleep/affective mood disorders
Chronic pain management
 Mission
improve the quality of lives of patients with chronic
cancer and non-cancer pain.
objective is to restore function and manage chronic pain
using a multi-pronged approach by addressing medical,
physical and psychological aspects of pain.
 Common pain conditions

 Headaches
 Orofacial pain
 Myofascial pain
 Low back pain - herniated discs, arthritis
 Phantom and Stump pain
 Postherpetic neuralgia
 Chronic post-surgical or post-traumatic pain
 Complex regional pain syndrome I and II
 Painful diabetic neuropathy
 Cancer pain.
 Evaluation

Self-report - most reliable measure

History
 Detailed questionnaire- character of pain
 Psychosocial
Examination
 Systemic (neurological ,musculoskeletal)
Investigations
 Xray,CT, MRI
VAS –Visual analog scale
 To assess intensity
 the patient may be asked to locate their pain on a scale of 0 to 10,
with 0 being no pain at all, and 10 the worst pain they have ever felt.
McGill Pain Questionnaire
 Quality can be established
 by having the patient complete the indicating which words best
describe their pain.
Treatment
 WHO

In September 2008, estimated that

 Approx 80 % of the world population has either no or
insufficient access to treatment for moderate to severe pain.
Reasons for deficiencies
 cultural, societal, religious, and political attitudes, including
acceptance of torture.
 the biomedical model of disease, focused on pathophysiology

rather than quality of life

 Other reasons - inadequate training, personal biases or fear of

prescription drug abuse.

 Inadequate treatment

Inadequate treatment of pain is widespread

IASP advocates
 relief of pain should be recognized as a human right
 chronic pain considered as disease in its own right
 pain medicine should have the full status of a specialty.
 Specialty- China , Australia
 subspecialty – anesthesiology , physiatry , neurology , palliative
medicine and psychiatry .
 Treatment Modalities

Pharmacological
Interventional
 World Health Organization
Pain ladder
first described for use in cancer pain, but it can be used
by medical professionals as a general principle when
dealing with analgesia for any type of pain.
the three-step WHO Analgesic Ladder provides
guidelines for selecting the kind and stepping up the
amount of analgesia.
The exact medications recommended will vary with the
country and the individual treatment center,
If, at any point, treatment fails to provide adequate pain
relief, the doctor and patient move onto the next step.
WHO Pain Ladder
 Step I

For non severe pain prompt oral administration of drugs

when pain occurs, starting with non-opioid drugs such as
 Acetaminophen

 Non-steroidalanti-inflammatory drugs
 COX-2 inhibitors
 Step II

If complete pain relief is not achieved, a mild opioid are

added to the existing non-opioid regime
 Codeine phosphate

 Dihydrocodeine

 Tramadol

 Dextropropoxyphene
 Step III

If insufficient, a mild opioid is replaced by a stronger

opioid, while continuing the non-opioid therapy,
escalating opioid dose until the patient is pain free or at
the maximum possible relief without intolerable side
effects
 Morphine
 Fentanyl
 Buprenorphine
 Oxymorphone, Oxycodone, Hydromorphone
 Severe Pain

If the initial presentation is severe pain, this stepping

process should be skipped and a strong opioid should be
started immediately in combination with a non-opioid
analgesic
 Opioids

Opioids are
efficacious analgesics in chronic malignant pain
 modestly effective in nonmalignant pain

Morphine – most common

Fentanyl
less histamine release and thus fewer side effects.
 also be administered via transdermal patch which is convenient
for chronic pain management.
Oxycodone
 suitable for acute intractable pain or breakthrough pain
 Adjuvants

Gabapentin and Pregabalin widely used

Twenty-nine studies studied efficacy of gabapentin at
daily doses of 1200 mg or more in 12 chronic pain
conditions
Gabapentin provides pain relief of a high level in
about a third of people who take if for painful
neuropathic pain.

 Moore RA, Wiffen PJ, Derry S, McQuay HJ.

 Pain Research and Nuffield Department of Clinical
Neurosciences, Churchill Hospital, Oxford
 Adjuvants

Other drugs with anticholinergic properties are useful

useful in painful musculoskeletal conditions due to their
muscle relaxant properties particularly
 orphenadrine, cyclobenzaprine, trazodone

Clonidine has found use as an analgesic itself as well as

to potentiate the effects of opioids
 Cannabinoids

Chronic pain is one of the most commonly cited reasons

for the use of medical marijuana
 2012 Canadian survey found that 84% of respondents reported
using medical marijuana for the management of pain.
Cannabinoids exhibit comparable effectiveness to
opioids in models of acute pain and even greater
effectiveness in models of chronic pain.
 2013 review study published in Fundamental & Clinical
Pharmacology,
 Interventions

Epidural injections
Nerve blocks
Sympathetic blocks
Trigger point injections
Radiofrequency thermoablation
Neurostimulation
Intrathecal drug delivery system.
 Intrathecal drug delivery
systems

Pain relief through spinal drug delivery systems involves

implanting a small pump with a catheter that delivers
medication directly to the spinal cord where pain signals
travel.
 the pump is fully implanted under the skin.
 drug refilled 4-6 weeks interval at pain clinic
Pulsed radiofrequency, Neuromodulation, Nerve
ablation
 used to target the site responsible for persistent nociception
implicated as the source of chronic pain
Spinal cord stimulator
 is an implantable medical device
 creates electric impulses near the dorsal surface of the spinal

cord
 provides paresthesia that alters the perception of pain
 Other Methods

TENS - diabetic neuropathy

Physical medicine and rehabilitation
 employs diverse physical techniques such as thermal agents,
electrotherapy as well as therapeutic exercise
Acupuncture
 An analysis of the 13 highest quality studies of pain treatment
with acupuncture, was unable to quantify the difference in the
effect on pain of real, sham and no acupuncture
 British Medical Journal January 2009
 Psychological approach

Lifestyle changes, Relaxation and biofeedback

 Useful in in the management of chronic low back pain and fibromyalgia
.

Cognitive Behavioral Therapy (CBT)

 helps patients with pain to understand the relationship between the pain
physiology with thoughts, emotions and behaviors.
Proforma