Transcript PAIN PATHWAY

 CASE
LBP caused by OA
 PAIN PATHWAY
 PAIN SENSITIZATION
 PAIN MANAGEMENT
Role of Pain Medications in the Pain Pathway
Prevention of Pain Sensitization
Pain Management Guidelines
 56 year old, Female, Public School Teacher
 DM type 2, well
controlled
 Obese Type 2
 Complaints : Hip and knee pain
 Other complaints: “ngalay of her lower
extremeties”
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What is the cause of the patient’s pain?
Based on his history what type of pain is he
experiencing?
 Nociceptive
 Neuropathic
 Mixed
 Acute
 Chronic
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Pain, the predominant symptom in OA, is
multidimensional in its nature and mediated
through a variety of factors.
Osteoarthritis (OA) chronic pain, involve
nociceptive as well as nonnociceptive
components, including neuropathic
components, due to peripheral inflammation
and central sensitization
C. S. Bonnet and D. A. Walsh
Mart van de Laar, Joseph V. Pergolizzi Jr, Hans-Ulrich Mellinghoff The Open
Rheumatology Journal, 2012, 6, 320-330 1874-3129/
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Many patients with chronic lower back pain
have no radiculopathic or anatomic
abnormalities that could explain their
symptoms.
Evidence suggests that sensitization of the
central nervous system (CNS) may
perpetuate the perception of pain in the
absence of ongoing tissue damage.
Borenstein DG. Epidemiology, etiology, diagnostic evaluation, and treatment of low
back pain. Curt Opin Rheumatol. 2001;13:128-134.
Bingham B et al. (2008) The molecular basis of pain and its clinical implications in rheumatology
TRANSDUCTION
Journal of Medicinal Chemistry, 2007, Vol. 50, No. 11
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SYNAPTIC TRANSMISSION
Journal of Medicinal Chemistry, 2007, Vol. 50, No. 11
Ascending and
Descending
Modulation
 Perception
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Journal of Medicinal Chemistry, 2007, Vol. 50, No. 11
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What will be your goal in managing this
patient’s pain?
 Decrease Pain score by -2 from baseline
 Increase ability to perform ROM exercises
 Prevent chronicity/sensitization of pain

The pain experience in OA results from
interactions between inflammation and other
features of the disease including:
 radiological severity,
 innervation of articular structures,
 central and peripheral sensitization and
 psychological factors
The Journal of Pain, Vol 10, No 9 (September), 2009: pp 895-926
American Family Physician, Gottschalk et.al MAY 15, 2001 / VOLUME 63, NUMBER 10
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Ultimately, multimodal approaches that
address multiple sites along the pain pathway
may prove necessary to adequately prevent
central sensitization in many surgical
procedures.
American Family Physician, Gottschalk et.al MAY 15, 2001 / VOLUME 63, NUMBER 10
Working Group A.M.A.D.E.U.S. Basic Course in Treatment of Chronic Pain, Cologne 2003.
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What will be the factors that you will consider
in choosing the right pharmacologic
intervention? (based on your priority)
 Efficacy of the drug- alleviate the amount of pain
the fastest
 Side-effect profile of the drug
 Mode of Action- targets majority of the processes
in the pain pathway
 Pain Management Guidelines
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Although pain is the most pressing problem facing
people with OA, adequate pain relief is frequently not
achieved maybe because:
 (a) lack of professional medical attention,
 (b) failure to incorporate nonpharmacological
measures such as weight loss and exercise into the
treatment plan, and
 (c) overreliance on monotherapy.
Arthritis Foundation, Association of State and Territorial Health Officials, Centers for Disease Control and
Prevention. National arthritis action plan. A public health strategy. Internet: CDC; 1999 [cited September 26, 2003]
Selective and
nonselective NSAIDs
Mild Pain
X
Moderate Pain
X
X
Anti-inflammatory effect
X
Pediatric Use
X
Patients with renal failure
Patients with CV Risks
X
X
Neuropathic Pain
Geriatric Use
X
X
Severe Pain
Acute Vs Chronic Pain
Tramadol/paracetamol
combination
X
can still be used to patients
with moderate renal
impairment
X
Pergolizzi Jr et al Journal of Pain Research 2012:5 327–346
American Family Physician, Gottschalk et.al MAY 15, 2001 / VOLUME 63, NUMBER 10
PAIN MEDICATION
NSAIDs
TRANSDUCTION
TRANSMISSION
x
Local Anesthetics
x
Anti-epileptic drugs
x
Opioids
x
Peripheral and Spinal
Nerve Blocks
x
Epidural and intrathecal
analgesics
x
Antidepressants
SNRIs
DESCENDING
MODULATION
x
X
x
January 2009 Vol 5 No 1 Bingham et.al.
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Potential advantages of a fixed-dose
tramadol/paracetamol analgesic product:
 include a broader analgesic spectrum
 a complementary pharmacokinetic profile
 potentially synergistic analgesic effect
 greater convenience (possibly resulting in better
compliance, thus, improved therapy)
 an improved ratio of efficacy to adverse effects.
Pergolizzi Jr et al Journal of Pain Research
2012:5 327–346
Tramadol/Paracetamol: Rationale
Result of combination:
–Fast onset of action
–Prolonged action
Drug Effect
APAP
peak = 30 min
T1/2 = 2 hrs
TRAMADOL
peak = 2-3 hrs
T1/2 = 6 hrs
TIME
In combination, T1/2 extends to 7-9 hours
Pergolizzi Jr et al Journal of Pain Research 2012:5 327–346
Osteoarthritis
Low Back Pain
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NSAIDs are commonly prescribed for knee
OA pain. However, flare ups of OA pain or
poor control with NSAIDs alone are common
and necessitate the addition of other
analgesics with different mechanisms, such
as tramadol
The purpose of this study is to compare the efficacy
of tramadol 37.5 mg/acetaminophen 325 mg
combination tablets (tramadol/APAP) with that of
nonsteroidal anti-inflammatory drugs (NSAIDs) as
maintenance therapy following tramadol/APAP and
NSAID combination therapy in knee osteoarthritis
(OA) pain which was inadequately controlled by
NSAIDs.
 DESIGN: This was a randomized, multicenter, open
comparative study in out-patients at six sites.
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Why do you think it is a better choice to use
Tramadol/APAP FDC as a maintenance drug
for OA pain compared to NSAIDs?
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Our speculation is that in our subjects with
inadequately controlled knee OA pain, chronic
continuous pain stimuli from diseased joints might
have caused sustained activation of sensory fibers
supplying the dorsal horn in the spinal cord and
change in the nature of the pain and resulted in
central sensitization and making pain refractory to
NSAIDs.
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Tramadol is reported to have a dual
mechanism of action which are good for the
control of central sensitization;
 μ-opioid receptor binding and
 inhibiting reuptake of serotonin and
norepinephrine.
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It is therefore probable that tramadol/APAP
add-on therapy eased central sensitization
and made it easier to control knee OA pain.
In conclusion, when added to NSAID,
tramadol/APAP was generally well tolerated and
significantly improved knee OA pain which was
previously refractory to NSAID therapy.
 In those subjects who showed favorable response to
tramadol/APAP and NSAID combination therapy,
both tramadol/APAP and NSAIDs were effective at
maintaining the pain-reduced state and there was
no significant difference in efficacy between
tramadol/APAP and NSAIDs.
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Considering the Long-term treatment with
NSAIDs can cause various side effects,
Tramadol/Paracetamol can therefore be
considered as the good candidate for
maintaining pain improved state of
Osteoarthritis patients
- http://www.who.int/cancer/palliative/painladder/en/