pain management in best practice

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Pain ManagementIn 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:

International Association for the Study of Pain (IASP)

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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:

BIOCHEMICAL THEORY

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

Pain Initiators

•Serotonin•Endorphins•Enkephalins

Pain Inhibitors

NEUROTRANSMITTERS

•Dynorphin•GABA•Glycine

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PAIN CLASSIFICATION

1. Acute

2. Chronic :

a) Non malignant

b) Malignant

Types of Pain

Nociceptive

Somatic Visceral

Neuropathic

Peripheral Central

Mixed

TYPES OF PAIN

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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.

• Aᵟ fibres mediate sharp localised pain

• C fibres mediate dull and burning pain

3. Mixed Pain2. Neuropathic:1. Nociceptive:

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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.


▪ 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.


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Peripheral Neuropathic Pain:Central Neuropathic Pain:


• 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


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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

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Pregabalin

GENERAL APPROACH TO PAIN THERAPY

Management

• Non-Pharamcological treatment

• Pharmacological treatment:

• Analgesics

• Adjuvants

• Others

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PAIN THERAPY

Non-pharmacological

Intervention

Pharmacological

Intervention

• Superficial Heat• Exercise• Cryotherapy• Acupuncture• Acupressure• etc

• Non opioid• Weak opioid• Strong opioid

PHARMACOLOGICAL INTERVENTION

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WHO 3-step Analgesic ladderPharmacological

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

Pharmacological Intervention

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• 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)


• 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.


a) Analgesics (Non-opioids)

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b) Analgesics (Weak Opioids)

• Codeine & codeine combination products

USEFUL

• Morphine , hydromorphone, fentanyl,

oxycodone , methadone.

c) Analgesics (Strong Opioids)

USEFUL

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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

Adjuvants for Neuropathic Pain

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Other modalities

▪ Nerve blocks, epidural blocks and ablative

neurosurgical procedures may be effective in pain

management.

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OMAI

OHT Terstandar kandungannyaUji pra-klinik keamanan & khasiatnya

eg:HerbapainBodrex HerbalKiranti pegel linuRheumakurNeo Rheumacyl Herbal PainNeosendiDismeno

Obat Bahan Alam Indonesia

FitofarmakaUji 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 caramenghambat induksi InterLeukin-8 (IL8) pada makrofag

Indikasi: Nyeri pada gigi, dan sebagai topikal

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Jahe (Zingiber officinale)

Kandungan utama: Cineol, Gingerol, Zingiber

Uji Laboratoris: Mengahambat sintesa prostaglandin dan leukotriene

Indikasi: AntiNyeri, Anti-radang sendi


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

Indikasi: Topikal menghilangkan nyeri pada otot

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Serai (Cymbopogon citratus)

Kandungan utama: Cytronelal, Geraniol

Uji PraKlinik: Ekstrak rebusan serai menginhibisi nyeri

Indikasi: Sebagai Minuman untuk mengurangi nyeri


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

Indikasi: AntiNyeri, Anti-radang sendi

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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


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

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Penggunaan DLBS1442 DALAM MenGURANGI Nyeri

Mekanisme Kerja DLBS1422

• Kandungan flavonoid, fenol, terpenoid, terbukti dapat mengurangiinflamasi dengan cara menekan pelepasan prostaglandin oleh jalurpenghambatan COX-2

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

Hendra et al. Antioxidant, Anti-inflammatory and Cytotoxicity of Phaleria macrocarpa (Boerl.) Scheff Fruit. BMC Complementary and Alternative Medicine 2011:11;1-10.

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Uji Praklinik Serbuk Ekstrak Kering Tumbuhan DLBS1442 (mahkota dewa)

sebagai Antinyeri

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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)

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Metode Penelitian

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Profil jumlah geliatan mencit setiap 10 menit selama waktupengamatan

Kesimpulan:Dari hasil analisis statistik, kelompok yang diberikan dosis rendah (0,026 g/kgBB) dandosis tengah (0,052g/kgBB) memiliki geliatan/writhing response (respons rasa sakit)yang lebih rendah secara bermakna dibandingkan dengan kelompok kontrol


Symptomatic treatment of premenstrual syndrome and/or primary dysmenorrhea with DLBS1442, a bioactive extract of Phaleria macrocarpa

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

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Pain in the stomach Breast Pain Back Pain

Headache

Dari penelitian ini didapatkan bahwaefektivitas dari DLBS1442 (Predimenol) dapat meringankan simptom nyeri yang disebabkan oleh PMS dimana secarakeseluruhan 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 mahkotadewa (Phalia marcocarpa) pada uji laboratorium

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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

Khasiat: Anti virus, Anti bakteri

MENIRAN (Phyllanthus urinaria)

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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)


Kandungan: Flavonoid, Glycyrrhizin, Licorice

Khasiat: Melancarkan pernapasan, mengurangi batuk, anti nyeri lambung, anti bakteri


AKAR MANIS (Glycyrrhiza glabra)

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TERIMA KASIH

THANK YOU

pain management in best practice

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