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

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1 Pain 1

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5 Pain An 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

6 MYTHS Anesthetics mask symptoms Patient will harm itself if there s no pain Pain is difficult to assess

7 The Truth! Pain is BAD: Decreased cardiovascular function Decresed appetite Slows wound healing Decreased immune function Greater chance of infection Increased fear and anxiety

8 از لحاظ فیزیولوژیک درد چهار مرحله دارد ( تحریک ) STIMULATION ( انتقال ) TRANSMISSION )درک ) PERCEPTION ( متعادل کردن درد( MODULATION 8

9 Mechanism 9

10 Process #2 Transmission Impulse spinal cord brain stem thalamus central structures of brain pain is processed. Neurotransmitters are needed to continue the pain impulse from the spinal cord to the brain opioids (narcotics) are effective analgesics because they block the release of neurotransmitters

11 Process #4 Modulation of Pain Changing or inhibiting pain impulses in the descending tract (brain spinal cord) Descending fibers also release substances such as norepinephrine and serotonin (referred to as endogenous opioids or endorphins) which have the capability of inhibiting the transmission of noxious stimuli. Helps explain wide variations of pain among people. Cancer pain responds to antidepressants which interfere with the reuptake of serotonin and norepinephrine which increases their availability to inhibit noxious stimuli.

12 Process #3 Perception of Pain The end result of the neural activity of pain transmission It is believed pain perception occurs in the cortical structures behavioral strategies and therapy can be applied to reduce pain. Brain can accommodate a limited number of signals distraction, imagery, relaxation signals may get through the gate, leaving limited signals (such as pain) to be transmitted to the higher structures.

13 Classification of Chronic Pain Nociceptive -soft tissue -bone -skeletal muscle -smooth muscle Nerve Compression Neuropathic Nerve Injury

14 تفاوتهای این دو نوع درد درد ای Nociceptive درد ای و ريپاتیک آسیت ث اعػبة )گب سبثق ضرث یب آسیت ج د دارد اهب گب یچ سبثق ای وی ت اى یبفت( درد هج ن ک هکبى آى یس هج ن است حبلت ثرق گرفتگی س زش یب از ایي دست دارد ثسیبر هطکل دار بی ضذ غرع ضذ افسردگی س حلق ای آسیت ث ثبفت ثذى )عضل استخ اى یبپ ست( درد تیس ثب هکبى هطخع ضذیذ پبسخ ث درهبى ه بست است NSAID ب استبهی في هخذر ب علت درد مشخصات درد درمان ر پبتی دیبثتی درد ثعذ از یر س رپس درد بی هسهي ثعذ از عول درد پطت استئ آرتریت مثال 15

15 Classification of Pain Acute Chronic 16

16 Postoperative pain can be divided into: Acute pain is experienced immediately after surgery (up to 7 days) Pain which lasts more than 3 months after the injury is considered to be chronic pain

17 درد مسمه بسیار خ شایىذ شایع مقایسه دو نوع درد درد حاد بسیار خ شایىذ وادر ر ایی از درد مقايمت ي يابستگی ب داري ا شایع وادر مشکالت ريحی ي رياوی عم ما يج د وذارد اغلب م ج د است علت بذوی ي فیسیکی ياضح کامال بارز است بسیار واچیس است درگیری محیط ي خاو اد یک جس تقریبا ثابت است وادر بی خ ابی ب ب د فعالیت درمان قطعی درد ي بیماری زمیى ای ا ذاف درماوی شایع وادر افسردگی 18

18 Describing pain only in terms of its intensity is like describing music only in terms of its loudness von Baeyer CL; Pain Research and Management 11(3) 2006; p

19 PAIN HISTORY Description: severity, quality, location,frequency, aggravating & alleviating factors Previous history Context: social, cultural, emotional, spiritual factors

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21 Patient Assessment 22

22 Treatment 23

23 Treatment Non-pharmacologic Pharmacologic 24

24 Non-Pharmacologic Stimulation Therapy: electrical nerve stimulation Psychological Intervention relaxation training, and hypnosis, have proven effective in the management of postprocedure pain and in cancer-related pain 25

25 Pharmacologic Therapy 26

26 General Treatment Principles In general, common causes of treatment failure is Under-dosing When treating chronic pain, elimination and prevention of pain is best accomplished by using analgesics at fixed time intervals rather than on an as-needed basis Effective analgesic therapy begins with an accurate assessment of the patient 28

27 W.H.O. ANALGESIC LADDER By the Clock 1 Non-opioid +/- adjuvant 2 Weak opioid +/- adjuvant 3 Strong opioid +/- adjuvant

28 Guidelines for Cancer pain The WHO 3-step Analgesic Ladder Pain persisting or increasing Pain Pain persisting or increasing Non opioid (antipyretic) + adjuvants Step 1. Weak opioid +non opioid + adjuvants Step 2. Strong opioid +non opioids + adjuvants Step 3. 90% respond well to oral medicines

29 Adjuvant Analgesics first developed for non-analgesic indications subsequently found to have analgesic activity in specific pain scenarios Common uses: pain poorly-responsive to opioids (eg. neuropathic pain), or with intentions of lowering the total opioid dose and thereby mitigate opioid side effects.

30 Adjuvants Used In Palliative Care General / Non-specific corticosteroids cannabinoids (not yet commonly used for pain) Neuropathic Pain gabapentin antidepressants ketamine topiramate Clonidine Pregabaline Bone Pain bisphosphonates (calcitonin)

31 CORTICOSTEROIDS AS ADJUVANTS inflammation edema } tumor mass effects spontaneous nerve depolarization

32 Steroids: MOA inhibit phospholipase A2>>> inhibits prostoglandin/leukotrienes Membrane Phospholipid Phospholipase A2 Steroids inhibit here COX-2 Arachidonic Acid NSAIDS inhibit here COX-1 Bad Prostaglandins Pain/Inflammation Thromboxane Platelets Good Prostaglandins GI Protection Renal Blood Flow

33 Pain Level Description Numerical Rating (0 to 10 Scale) Mild pain 1 3 Moderate pain 4 6 WHO Therapeutic Recommendations Nonopioid analgesic: taken on a regular schedule, not as needed (prn) Example Medicines for Initial Therapy Acetaminophen 650 mg every 4 hr Acetaminophen 1,000 mg every 6 hr Ibuprofen 600 mg every 6 hr Acetaminophen 325 Add opioid for moderate pain mg/codeine 60 mg every 4 hr (e.g., moderate potency Acetaminophen 325 analgesic). Use on a mg/oxycodone 5 mg every 4 schedule, not prn hr Tramadol 50 mg every 6 hr Severe pain 7 10 Switch to a high potency (strong) opioid; administer on a regular schedule Morphine 15 mg every 4 hr Hydromorphone 4 mg every 4 hr Morphine controlled release 60 mg every 8 hr 35

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36 Dosing The management of chronic pain is also best accomplished by around-the-clock administration As-needed schedules are to be used in conjunction with around-the-clock regimens and are used when patients experience breakthrough pain 38

37 TOLERANCE A normal physiological phenomenon in which increasing doses are required to produce the same effect Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

38 PHYSICAL DEPENDENCE A normal physiological phenomenon in which a withdrawal syndrome occurs when an opioid is abruptly discontinued or an opioid antagonist is administered Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

39 PSYCHOLOGICAL DEPENDENCE and ADDICTION A pattern of drug use characterized by a continued craving for an opioid which is manifest as compulsive drug-seeking behaviour leading to an overwhelming involvement in the use and procurement of the drug Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

40 60 میلي گرم هروئین عمق جهنم روز ترک 8-7 دو هفته موقع بیداري 18 تا 24 ساعت وابستگي احساس ضعف خمیازه لرز عرق عطسه ترشحات 12 ساعت بعد از آخرین مصرف

41 Type of Pain Nonopioids Opioids Other Medications Comments Chronic low back pain Acetaminophen, NSAIDs Short-term use for mild-to-moderate flare-ups TCAs, AEDs Acetaminophen and NSAIDS first; opioids in selected patients; AEDs or TCAs if neuropathic symptoms Fibromyalgia Acetaminophen, NSAIDs Long-term use not recommended Tramadol, TCAs; AEDs Acetaminophen and NSAIDs considered first; tramadol may be better alternative than opioids Neuropathic pain Acetaminophen or NSAIDs are rarely effective Considered firstline therapy but usually are tried after AEDs and/ or TCAs, tramadol, lidocaine 5% patch TCAs, AEDs, SNRIs, trama dol, topical (e.g., 5% lido caine patch, capsaicin) Gabapentin, 5% lidocaine patch, tramadol, nortrip tyline, desipramine, all considered first-line agents; opioids considered first-line agents but usually are tried after above 43

42 توضیحات عوارض حداکثر دوز دوز رایج نام دارو ثرای زیر 14 سبل ت غی وی ض د حذاکثر تب یک فت هػرف ض د عبرض کجذی در غ رت هسو هیت اثر ثیطتر ثر ی ا عقبد خ ى Acetaminophen Tynelol Panadol Mefenamic acid Ponstan Naproxen Aleve الی 650 ر 4 سبعت یب 500 الی 1000 هیلی گرم ر 6 سبعت اثتذا 500 هیلی گرم سپس 250 هیلی گرم ر 6 سبعت اثتذا 500 هیلی گرم سپس 500 ر 12 سبعت یب 250 ر 6 تب 8 سبعت 1000 Ibuprofen Advil 200 الی 400 هیلی گرم ر 6 الی 8 سبعت ث ط ر 400 OTC هیلی گرم ر 8 سبعت د ز اطفبل 5 الی 10 هیلی گرم ث ازای ر کیل زى ثذى ر 6 تب 8 سبعت کن عبررض تریي حذاکثر د ز ثرای هػرف ثط ر OTC NSAID ایي دار ث تر است در اطفبل زیر 6 هب استفبد ط د Celecoxib Celebrex Cobix 100 د ثب در ر ز یب 200 یک ثبر در ر ز 200 افسایص د ز هػرفی از 200 ثبعث افسایص هطکالت قلجی عر قی هیط د احتوبل ایجبد هطکالت قلجی تبخیر در ترهین استخ اى Diclofenac Voltaren 25 تب 50 هیلی گرم ر 6 الی 8 سبعت 100 هیلی گرم از فرآ رد آ ست ر ص یک تب حذاکثر د ثبر در ر ز 200 ضی ع ثیطتر عبرض کجذی Indomethacin Indocin 25 ر زی 2 الی 3 ثبر هی ت اى تب ر زا 150 یس د ز را افسایص داد قرظ آ ست ر ص را هی ت اى ر ز ییک تب 2 عذد در حوالت حبد قرس 25 ر 6 سبعت 200 تب 400 هیلی گرم ر 8 سبعت Tolmetin 1800 Meloxicam Mobic Piroxicam feldene تب 15 هیلی گرم یک ثبر در ر ز هیلی گرم 2 ثبر در ر ز یب 20 هیلی گرم ر زی یک ثبر هطبث ترکیجبت ه بر ک ذ اختػبغی COX2 ث 44 علت ط ل اثر ثل ذ اثر کبهل آى ضبیذ ثعذ از یک فت ظب ر ض د پر عبرض تریي NSAID ع ارؼ عػجی ثیطتریي ع ارؼ پ ستی ثیطتریي ع ارؼ پ ستی

43 Patient Control Analgesia (PCA)

44 Treatment of Neuropathic Pain Pharmacologic treatment Opioids Steroids Anticonvulsants gabapentin, topiramate TCAs (for dysesthetic pain, esp. if depression) NMDA receptor antagonists: ketamine, methadone Anesthetics Radiation therapy Interventional treatment Spinal analgesia Nerve blocks

45 با تشکر