Acute and Chronic Pain

Contents :
• Introduction
• Factors influencing pain response
• Pain assessment
• Types of pain
• Transition from acute to chronic pain
• Analgesics during pain process
• WHO Step Ladder
• Cancer pain
References :
• Fishman, Scott M. Ballantyne, Jane C. Rathmell, James P. Bonica’s Management
of Pain 4th ed. Lippincott Williams & Wilkins; 2010
• Gohil, Dhwani Dr. Pain & Pain Pathways. Education, Health & Medicine; 2011
• Kate, Nilesh Dr. Physiology of Pain Sensation. Health & Medicine; 2015
• Morgan, Edward G. Mikhail, Maged S. Murray, Michael J. Clinical
Anesthesiology 6th ed. McGraw-Hill Companies; 2018
• Miller, Ronald D, Miller’s Anesthesia 9th ed. Elseiver-Health Sciences Division;
2020
Scenario
Wanita, 28 tahun datang ke UGD dengan nyeri perut hebat.
Apa yang anda lakukan sebagai dokter UGD ?
 Introduction
• Pain as the 5th vital sign (American Pain Society, 2003)
• Whatever the person says it is, existing whenever the
experiencing person says it does (McCaffery & Pasero,
1999)
• Emphasizes the highly subjective nature of pain
• Pain is protective mechanism or a warning to prevent further
injury
 Factors Influencing Pain Response
1. Developmental factors
2. Physiological factors
Fatique, genes, neurological functioning
3. Social factors
Attention, previous experience, family and social support, spiritual
factors
4. Psychological factors
Anxiety, coping style
5. Cultural factors
 Pain Assessment
❑ History taking :
• Pain at different locations as chief presenting complain
• Rulling out red flags / warning signals
• Past history
• Psychological assessment
• Personal history, including sleep, bladder and bowel habit
• Treatment history
• Family history
Pain history consists of :
Mnemonic for Pain Assessment
Pain Intensity Tools
• Verbal rating score
• Binary scale
• Numerical rating scale
• Faces rating scale
• Visual analog score
• McGill Pain questionnaire
Red flags / warning signals
✔ Pain with major trauma ✔ Loss of vision
✔ Suspecting tumor ✔ Loss of bladder control, with
✔ Suspecting infection, with retention and incontinence
fever, rigor, vomiting, etc ✔ Loss of bowel control with
✔ Unconsciousness
inability to force to pass stool
✔ Motor weakness ✔ Sudden onset pain which is
progressing rapidly
✔ Progressive sensory deficits
✔ Not relieved by analgesic within
a few days
Pain Assessment
❑ General observation :
• Sign of distress 🡪 respiratory / cardiac involvement ?
• Facial appearance 🡪 anxious face, depressed face, moon face
(cushing’s syndrome / long term steroid tx), myxedema face
(hypothyroidism), mask – like face (parkinsonism), starring look
(hyperthyroidism), nephrotic face
• Gait and posture
• Mental state
• Built and nutrition
• State of clothing
 Types of Pain
• Acute pain
Recent onset, commonly associated with spesific injury, lasting from
second to 6 months
• Chronic pain
Constant or intermittent pain, persists beyond the expected healing
time, seldom attributed to a spesific cause or injury, lasts for 6 months
or longer
• Cancer related pain
May be acute or chronic, can be directly associated with cancer, result
of cancer treatment, associated with other diseases
Acute Pain
Acute pain is the normal, predicted physiologic response to
an adverse chemical, thermal, or mechanical stimulus,
associated with surgery, trauma, or acute illness.

` (Federation of State Medical Board of the United Stated 1999.)

Acute pain
mechanism
Preemptive Analgesia
An anti nociceptive treatment that prevents establishment of altered
processing of afferent input, which amplifies postoperative pain
✔ Start before surgery
✔ Prevents the establishment of central sensitization caused by
incisional injury (covers only in the period of surgery)
✔ Prevents the establishment of central sensitization caused by
incisional and inflammatory injuries

General anesthesia may attenuate the transmission of afferent injury

from the periphery to the spinal cord and brain, but it doesn’t block the
transmission
Treatment of preemptive analgesia
Systemic opioids
• Pure agonist : morphine, oxymorphone, meperidine, hydromorphone,
fentanyl
• Partial agonist, mixed agonist – antagonist : buprenorphine,
butorphanol
• Pure antagonist (reversal of agonists) : naloxone
Non opioid analgesics
Acetaminophen, NSAIDs like (diclofenac, ibuprofen)
Treatment of preemptive analgesia
Regional anesthetic techniques
• Intrathecal analgesia
• Epidural analgesia (superior pain relief and attenuate stress response
to surgery, continuous infusion during and after surgery)
• Combined of epidural anesthesia + adjuvants 🡪 intraoperative
analgesia and postoperative pain effectively
Peripheral nerve blocks
Cryoanalgesia
Procedure used to temporarily block nerve conduction along peripheral
nerve pathways by inserting a small probe to freeze the target nerve
Nociceptive Pain
▪ Pain proportionale to degree of actual tissue damage
▪ Sustained primarily via nociceptive system
▪ Involves sensitization of nociceptors prostaglandine, bradykinin,
serotonin, histamine and acetylcholine
▪ Silent nociceptors are activated by inflammation and contribute to
nociception
▪ Can be acute or chronic
▪ Ex : acute burns, bone fractures, other somatic and visceral pain
 Withdrawl Reflex
⮚ A spinal reflex, intended to
protect body from damaging
stimuli.
⮚ It is polysinaptic reflex
⮚ Causing stimulation of
sensory, association and
motor neurons
Reflex have 5 components
1. Sensory receptor
2. Sensory neuron
3. Integration center (CNS)
4. Motor neuron
5. Effector
Neuropathic Pain
▪ Pain initiated or caused by a 10 lession or dysfunction in the nervous
system
▪ Lancinating, continuous burning
▪ Accompanied by allodynia, hyperalgesia
▪ Large unmet therapeutic need
⮚ Mainstay treatments : TCA, anticonvulsant / antiepileptic (pain
relieve achieved < 50% patients, suboptimal adverse event
profiles)
Neuropathic pain signs
Chronic Pain
Chronic pain is a pain that persists beyond normal tissue
healing time, which is assumed to be three – six months.
Pain that continuous when it should not

The International Association for study of pain (IASP)

Chronic Pain Characteristics
• Persistence beyond nociception (pain without nociception)
• Beyond expectation
• Difficults to treat and costly
• Produce suffering and reduced quality of live (QoL)
• Subjective personal experience
• Cannot be seen, except by behaviour
• No biologic value as a symptom
• Life permanently disrupted
http://www.slideshare.net/Painspecialist/understanding-pain-short
Adapted from Ashburn and Straats, 1999
All chronic pain was once acute,
but not all acute pain becomes chronic
Shipton EA Anaesth Intensive Care. 2011;39(5):824-36.

• Chronic pain is not prolonged acute pain

• Chronic pain must be considered and treated
as a disease
 Post operative Pain
Acute post operative pain : Chronic post operative pain :
Surgery ▪ Pain lasting more than 1 month
after surgey
▪ Risk factor :
Tissue trauma / nerve injury ⮚Repeat surgery
⮚Catastrophyzing
Inflammation due to release ⮚Anxiety
inflammatory mediators ⮚Genetic predisposition
⮚Radiation tx to area
⮚Untreated moderate to severe
Hyperalgesia and Allodynia post op pain
(increased response to neurons) ⮚Neurotoxic chemotx
⮚Depression
Post operative pain management
▪ Opioids
▪ Drugs :
✔ Acetaminophen (paracetamol)
✔ NSAIDs (ibuprofen, ketorolac, naproxen)
✔ COX inhibitor (aspirin)
✔ Ketamine (subanesthetic doses, effective adjuvant for pain
associated with central sensitization, like severe acute pain,
neuropathic pain, opioid resistant pain)
✔ Antidepressants and SSRI (for acute neuropathic pain)
 Transition From Acute to Chronic Pain
• Sensitization
✔ Peripheral and Central Sensitization
o Responsible for most continuing pain and
hyperalgesia post injury
o May be the result of normal noxious stimuli from
injured and inflamed tissue
o Abnormal input from injured nerves or ganglia
Peripheral sensitization
o Tissue damage releases sensitizing “soup” of cytokines &
neurotransmitter
o COX mediated PGE release
o Sensitized nociceptors exhibit a decreased treshold for activation &
increased rate of firing
o Plays an important role in central sensitization, hyperalgesia &
allodynia
Central sensitization
o Activation “wind up” of dorsal horn nociceptors
o Neuronal plasticity : modulation, modification (new pain – sensing
fibers form)
o Decreased central inhibition of pain transmission
o Prime role in chronic pain, particularly neuropathic pain
Peripheral and
Central sensitization
Central sensitization leads to secondary
hyperalgesia
o Repeated impulse activity in C nociceptive neurons 🡪 sensitization of
spinothalamic tract neurons over time
o Previously subtreshold impuls reach treshold 🡪 initiate action
potential, increases in spontaneous activity
o Mechanisms of spinal and supraspinal
o Enlargement of area in periphery, where stimulus will activate
neurons
o N-methyl D aspartate (NMDA) receptor and substances P
mechanisms
Central sensitization “actors”
o N-methyl D aspartate (NMDA) receptor plays a central role
o Endogenous mediators influence excitability of spinal neurons :
prostaglandins, nitric oxide, opioids, adrenergic agonist

⮚ Protaglandins and nitric oxide 🡪 influence excitability of spinal

neurons
⮚ Opioids and adrenergic agonist 🡪 produce analgesia via
presynaptic C fiber neurotransmitter release & postsynaptic
hyperpolarization of 2nd order neurons
⮚ Intrathecal morphine + O2 agonist or NSAIDs as substantial
analgesic synergy
Central sensitization and dysfunctional pain
Analgesics During Pain Processes
WHO Step Ladder
 Cancer Pain Concept
Cancer Pain is the sum of 4 components :
1. Physical noxious stimuli
2. Emotional discomfort TOTAL PAIN
3. Interpersonal conflicts
4. Nonacceptance

Dr. Cicely Saunders, 1967, founder of first hospice in London

Nature of Cancer Pain
▪ Nociceptor is stimulated by tumor
▪ Cancer cells + macrophage + inflammation 🡪 high level of COX 2
enzyme 🡪 high level of prostaglandin
▪ Peripheral sensitization 🡪 increase enzyme COX 2 🡪 inflammation
▪ Tumor induced acidosis (massive apoptosis), due to inflammatory
cells invade neoplastic tissue 🡪 release H+. Massive apoptosis also
contribute release H+ 🡪 increase acidosis
▪ Tumor induced distention of sensory fibers 🡪 neuropathic pain
▪ Central sensitization 🡪 chronic pain
▪ Two ascending pathway are activated
Cancer Pain
Cause of cancer pain :
1. Pain associated with direct tumor (infiltration, bone metastatic)
2. Pain associated with cancer therapy (chemotx, surgery, radiation)
3. Pain unrelated to cancer (RA, OA, headache)
4. Due to cancer debility (decubitus)

According to American Cancer Society, chronic cancer pain may

involve Persistent Pain and Breaktrough Pain
Persistent pain is continuous and may last all day
Types of Cancer Pain :
o Neuropathic pain
o Bone pain
o Visceral or soft tissue pain
o Phantom pain
o Breaktrough pain
Breaktrough Pain
• A brief flare up of severe pain
• Occurs even while patient is regularly taking pain medication
• Usually comes on quickly
• May last from a few minutes to an hour
• Many patients experiences a number of episodes of breaktrough pain
each day
• As a result from cancer or cancer treatment
• Treated with strong, short acting pain medications that work faster
than persistent pain medications
 Administration analgesics for cancer patient
5 essential concepts :
✔ By mouth
✔ By the clock
✔ By the ladder
✔ By individual
✔ With attention to
detail
Role of COXIB in cancer pain
Celecoxib is the rational use for the cancer pain management,
particularly in advance stage, because :
• Celecoxib is strong antiinlammation
• Analgesic
• Antipyretic
• Carcinoprotective (prevent angiogenesis, tumor growth and
metastase)
• Simple administration
Step Ladder for
Cancer Pain
Thank you