Pain Management in Daily Practice For Primary Care: Dr. Suparto, SP - An
Pain Management in Daily Practice For Primary Care: Dr. Suparto, SP - An
Pain Management in Daily Practice For Primary Care: Dr. Suparto, SP - An
1. Definition of pain
2. Physiology of pain
3. Classification of pain
4. Effects of pain
5. Pain assessment
6. Pain control
Hippocratic precepts:
TRANSDUCTION
TRANSMISSION
MODULATION
SENSATION
Spinal Cord
I
Dorsal root
C II
III
Peripheral IV
nerve
A V
INPUT VI X
VII
IX
REFLEKS VIII
LAMINA REXED
Categorizing Pain
Nociceptive pain Neuropathic pain
Caused by activation or Pain related to disease or
sensitization of peripheral injury of the peripheral or
nociceptors initiated by central nervous system
tissue injury; (extending to the spinal
cord)
it can be secondary to an
Described as: burning,
incision, inflammation, or
shooting, tingling,
disease.
stabbing, or like a vise or
ex: Acute osteoarthritis, electric shock.
Post operative pain,
ex: Neuropathic low back
exercise injuries
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
c) Respiratory catecholamines: vasoconstriction,
d) Gastrointestinal Dec FRC work myocardial contractility
myocardial
↑platelet
↑sphincteric adhesiveness
tone heart rate
Impaired -diaphragmatic
dysrhythmias
e) Genitourinary ↓↑sphincteric
fibrinolysis tone
Immobility
Hipersecretion
Function(reflex
- angina
gastric acid
inhibition
Activation
Insomnia
↓↓smooth of coagulation
f) Immunologic/ ofsmooth
glucagon:
phrenic-
muscle
muscle tone
tone
hyperglycemia
nerve)
MI
cascade
Anxiety
↓Insulin, ↓= protein anabolism
- Atelectasis
CHF
Coagulation Helplessness
═ urinary
═ retention
Ileus
= Pneumonia
═ incidence of thromboembolic
═ Fear
g) General Well Being phenomena
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 don’t
like?”
Pain Assessment
Self-Report:
0 1 2 3 4 5 6 7 8 9 10
No pain 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”
MULTIMODAL TREATMENT
Multimodal or multipharmacological treatment
has been recognized as a mainstay treatment of
many diseases.
• Hypertension Asthma
• Congestive heart Sepsis
• Diabetes Chemotherapy, ect.
m1 k3 2 located supraspinally
m2 k1 1 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 aren’t 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