Pain Management In Best Practice

Pain Management

In Best Practice

dr. Hardhi Pranata, Sp.S, MARS

PDHMI (Perkumpulan Disiplin Herbal Medik Indonesia)

21 Maret 2021

-PAIN

unpleasant sensory & emotional

Psychological & certain autonomic (involuntary) responses behavioural reactions provoked by tissue damage.

A COMPLEX CONSTELLATON:

Pain & Covid-19

•Chronic pain management during the coronavirus

disease 2019 (COVID-19) pandemic is a challenging

process, especially with growing evidence that

COVID-19 infection is associated with headache,

myalgia, referred pain, and widespread

hyperalgesia

Tallawy et al., 2020

• Biochemical Theories pain-producing, pain- mediating and

pain chemoreceptors are located in the brain Endogenous

opiates – inhibits pain by blocking substance P. in

Periacquedactal gray area

• Chemical pain mediators and inhibitors:

Bradykinin, Histamine, prostaglandin

Theory of Pain:

•Glutamate - Central •Substance P - Central •Brandykinin - Peripheral •Prostaglandins – Peripheral •Aspartate

Pain

Initiators

•Serotonin •Endorphins •Enkephalins

Pain

Inhibitors

NEUROTRANSMITTERS

•Dynorphin •GABA •Glycine

PAIN CLASSIFICATION

1. Acute

2. Chronic :

a) Non malignant

b) Malignant

Types of Pain Nociceptive Somatic Visceral Neuropathic Peripheral Central Mixed

TYPES OF PAIN

Modulation

Mediators of Nociceptive Pain

• Nociceptors are specifically designed receptors to detect stimuli that may cause harm to the body, which may be mechanical, chemical or thermal in nature. • A_ᵟ fibres mediate sharp localised pain

• C fibres mediate dull and burning pain

3. Mixed Pain

2. Neuropathic:

Nociceptive pain may be somatic or visceral in origin.

-Visceral pain: Originates in nociceptors located in the hollow organs and smooth muscles; it is often referred. E.g. Dysmenorrhea, gastritis, appendicitis or acute pancreatitis

-Somatic pain: Originates from musculoskeletal, joint or cutaneous nociceptors and is often well localized. E.g. Gout, osteoarthritis, skin incision and trauma-induced pain.

3. Mixed Pain

2. Neuropathic:

1. Nociceptive:

▪ Caused by pressure on &/or destruction of

peripheral, autonomic or central nervous system structures.

▪ May arise from a lesion or trauma, infection, compression or tumour invasion.

▪ Described as burning, shooting, tingling.

▪ Does not respond well to standard analgesics.

3. Mixed Pain

2. Neuropathic:

Peripheral Neuropathic Pain: Central Neuropathic Pain:

3. Mixed Pain

2. Neuropathic:

1. Nociceptive:

• Central post stroke pain • Neuropathic associated with

spinal cord injury

• Traumatic brachial plexus injury • Diabetes Mellitus

• Carpel tunnel syndrome • Post herpetic neuralgia

Recognizing Neuropathic Pain

Be alert for common verbal descriptors of neuropathic pain:

Burning Tingling Shooting Electric shock-like Numbness

3. Mixed Pain

2. Neuropathic:

INSTRUMENTS FOR ASSESSING

PAIN PERCEPTION

• VISUAL ANALOGUE SCALES(VAS)

Goals of Pain Management

Therapy

1) Decreased pain

2) Decreased healthcare utilization

o

Decreased “shopping” for care

o

Decreased emergency room visits

3) Improved functional status

o

Increased ability to perform activities of daily living

o

Return to employment

Pregabalin GENERAL APPROACH TO PAIN THERAPY

Management

• Non-Pharamcological treatment

• Pharmacological treatment:

• Analgesics

• Adjuvants

• Others

PAIN THERAPY

Non-pharmacological

Intervention Phar macologicalIntervention

• Superficial Heat • Exercise • Cryotherapy • Acupuncture • Acupressure • etc • Non opioid • Weak opioid • Strong opioid

PHARMACOLOGICAL INTERVENTION

WHO 3-step Analgesic ladder

_{Pharmacological}

Intervention

Analgesic ladder in action:

◼ Step 1: non-opioid analgesics (Paracetamol

and Aspirins, NSAIDS)

◼ Step 2: mild opioid is added (not

substituted) to step 1

◼ Step 3: Opioid for moderate to severe pain

is used and titrated to effect

• Used in full doses for the most part.

• All have a ceiling effect to their analgesia (a maximum dose past which no further analgesia can be expected).

• COX-2 inhibitors may be associated with fewer side-effects

a) Analgesics (Non-opioids)

Pharmacological Intervention

• Use

cytoprotection

with NSAIDs only in

patients who have symptoms suggestive of

GI distress or who are at high risk of ulcer

formation.

• For cytoprotection use sulcrafate or

misoprostol.

Pharmacological Intervention

b) Analgesics (

Weak

Opioids)

• Codeine & codeine combination products

USEFUL

• Morphine , hydromorphone, fentanyl,

oxycodone , methadone.

c) Analgesics (

Strong

Opioids)

Adjuvant analgesics (coanalgesics)

▪ Are medications that when added to primary

analgesics, further improve pain control.

▪ may themselves also be primary analgesics (e.g.

tricyclic antidepressant medications for postherpetic

neuralgia).

▪ They can be added into the pain management plan at

any step in the WHO ladder.

▪ Cyclic Antidepressants: o Amitriptyline

▪ Anticonvulsants:

o Carbamazepine - Valproic acid - Gabapentin - Pregabalin ▪ Local Anesthetics:

o Lidocaine

Other modalities

▪ Nerve blocks, epidural blocks and ablative

neurosurgical procedures may be effective in pain

management.

OMAI

OHT

Terstandar kandungannya Uji pra-klinik keamanan & khasiatnya

eg:

Herbapain Bodrex Herbal Kiranti pegel linu Rheumakur

Neo Rheumacyl Herbal Pain Neosendi

Dismeno

Obat Bahan Alam Indonesia Fitofarmaka

Uji praklinik & uji klinik

eg:

• Inlacin (Kayu Manis) untuk diabetes mellitus • Redacid untuk gastritis

• Stimuno (meniran) untuk meningkatkan imunitas

• Disolf untuk stroke

Herbal Anti-Nyeri/ Inflamasi

Cengkeh

(

Syzygium aromaticum

)

Kandungan utama: Eugenol. Kaempferol, Quercetin

Uji PraKlinik: Dapat mengurangi radang pada tikus dengan cara menghambat induksi InterLeukin-8 (IL8) pada makrofag

Herbal Anti-Nyeri/ Inflamasi

Jahe

(

Zingiber officinale

)

Kandungan utama: Cineol, Gingerol, Zingiber

Uji Laboratoris: Mengahambat sintesa prostaglandin dan leukotriene Indikasi: AntiNyeri, Anti-radang sendi

Herbal Anti-Nyeri/ Inflamasi

Cabe

(

Capsicum annum L.

)

Kandungan utama: Capcaisin, Zea Xanthine, Lutein

Uji PraKlinik: Capcaisin menyebabkan rasa nyeri terbakar pada daerah kulit melalui mekanisme pelepasan neuro-peptide (substansi P) sehingga menghilangkan nyeri nociceptive & neuropatik

Herbal Anti-Nyeri/ Inflamasi

Serai

(

Cymbopogon citratus)

Kandungan utama: Cytronelal, Geraniol

Uji PraKlinik: Ekstrak rebusan serai menginhibisi nyeri Indikasi: Sebagai Minuman untuk mengurangi nyeri

Herbal Anti-Nyeri/ Inflamasi

Temulawak

(

Curcuma xanthorrhiza)

Kandungan utama: Curcumin, Xanthorizol, Turmeron Uji Klinik: (Nyoman Kertia, 1997) 22 pasien OA lutut Diberikan 15mg curcuminoid + 200mg atsiri temulawak - 2x sehari ---- selama 14 hari

Herbal Anti-Nyeri/ Inflamasi

Kunyit

(

Curcuma longa)

Kandungan utama: Curcumoid, Turmeron, Zingiberon Uji PraKlinik: Menghambat fase lipo-oksigenase dan siklo-oksigenase sehingga sintesa prostaglandin-2 menurun Indikasi: Anti-Nyeri, Anti-Radang sendi

Herbal Anti-Nyeri/ Inflamasi

Mahkota Dewa

(

Phaleria macrocarpa)

Kandungan utama: Alkaloid, Flavonoid, Lignan, Saponin Cara Kerja: Menghambat fase lipo-oksigenase dan siklo-oksigenase sehingga sintesa prostaglandin-2 menurun Indikasi: Nyeri kepala, nyeri otot

Penggunaan DLBS1442 DALAM

MenGURANGI Nyeri

Mekanisme Kerja DLBS1422

• Kandungan flavonoid, fenol, terpenoid, terbukti dapat mengurangi inflamasi dengan cara menekan pelepasan prostaglandin oleh jalur penghambatan COX-2

• Selain itu, aktivitas antioksidan dari Mahkota Dewa juga berperan dalam penghambatan nitric oxide (NO) yang berperan dalam proses inflamasi

Uji Praklinik Serbuk Ekstrak Kering Tumbuhan DLBS1442 (mahkota dewa)

sebagai Antinyeri

Soemardji AA, Safitri D, Rahmawati SF. Preclinical study of DLBS1442 as analgesic (Siegmund method). Institut Teknologi Bandung, Bandung 2016. Data on file.

Tujuan penelitian

untuk menguji aktivitas DLBS1422 dalam meredakan nyeri

Dosis penggunaan

200 mg atau 0.2 gram untuk orang dewasa (70 kg) setara dengan dosis 0,026 g/kgBB mencit

Obat pembanding

Natrium diklofenak dan Ibuprofen (dosis obat pembanding yang digunakan setara dengan dosis pemakaian pada manusia dewasa 70 kgBB)

42

Profil jumlah geliatan mencit setiap 10 menit selama waktu pengamatan

Kesimpulan:

Dari hasil analisis statistik, kelompok yang diberikan dosis rendah (0,026 g/kgBB) dan

dosis tengah (0,052g/kgBB) memiliki geliatan/writhing response (respons rasa sakit)

yang lebih rendah secara bermakna dibandingkan dengan kelompok kontrol

Soemardji AA, Safitri D, Rahmawati SF. Preclinical study of DLBS1442 as analgesic (Siegmund method). Institut Teknologi Bandung, Bandung 2016. Data on file.

Symptomatic treatment of

premenstrual syndrome and/or

primary dysmenorrhea with

DLBS1442, a bioactive extract of

Phaleria macrocarpa

45

Pain in the stomach Breast Pain Back Pain

Headache

Dari penelitian ini didapatkan bahwa efektivitas dari DLBS1442 (Predimenol) dapat meringankan simptom nyeri yang disebabkan oleh PMS dimana secara keseluruhan menunjukkan VAS score yang lebih rendah setelah diberikan DLBS1442

Tjandrawinata RR, et al. Symptomatic treatment of premenstrual syndrome and/or primary dysmenorrhea with DLBS1442, a bioactive extract of Phaleria macrocarpa. International Journal of General Medicine 2011:4 465– 476

DLBS1442

• Memiliki efek anti-inflamasi dengan cara menekan COX2-mRNA • Sehingga terjadi penurunan Prostaglandin-E2 (PGE2)

• Buah mahkota dewa juga menghambat xanthine oksidase dan lipo-oksigenase

• DLBS1442 berfungsi sebagai moderate anti-inflamasi

Hasil formulasi dari ekstraksi teknologi tinggi dari buah mahkota dewa (Phalia marcocarpa) pada uji laboratorium

RAMUAN IMUNOMODULATOR

Komposisi:

- Sambiloto, Meniran, Akar Manis, Jahe Emprit, Daun Jambu Mede

Kandungan: Lakton, kolmegin, andographolid

Khasiat: Anti nyeri, Anti radang, Anti virus, Anti bakteri SAMBILOTO (Andrographis paniculata)

Kandungan: Phylantin, Mirantin MENIRAN (Phyllanthus urinaria)

Kandungan: Gingerol, Shogaol, Zingiberol

Khasiat: Anti kembung, Anti mual, Anti radang, Anti bakteri

JAHE EMPRIT (Zingiber officinale var. amarumdengan)

Khasiat: Mengurangi sesak napas, mengurangi dahak, anti virus, anti nyeri

DAUN JAMBU MEDE (Anacardium occidentale)

RAMUAN IMUNOMODULATOR

Kandungan: Flavonoid, Glycyrrhizin, Licorice

Khasiat: Melancarkan pernapasan, mengurangi batuk,

anti nyeri lambung, anti bakteri

RAMUAN IMUNOMODULATOR

TERIMA KASIH

THANK YOU