%

1. 2. 3. 4. 5. 6. 7. 8. 9. 10 89.7 85.5 79.9 67.8 56.6 50.0 48.1 44.0 36.9 36.9 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

%
34.1 32.2 31.8 31.3 30.4 22.9 22.5 19.1 18.3 16.4

(total pain)

Somatic Depression Anger

Total Pain

Anxiety

    

?
? ? ?

->

 

(Visual Analogue Scale, VAS) (Face Pain Scale)

(Numeric Rating Scale)

0 1 2 3 4 5 7 8 9 10

(Verbal Descriptor Scale, VDS)

   

Nociceptive

tissue injury

Generally opioid responsive

Inflammatory Steroids and NSAIDS

prostaglandin mediated

Neuropathic -

nervous system injury

Anticonvulsants, antiarrythmics, antidepressants Less opioid responsive

Nociceptive Pain:
An appropriate physiological response to painful stimuli
Pain
Ascending input Descending modulation Dorsal horn Spinothalamic tract Dorsal root ganglion

Trauma

Peripheral nerve

Peripheral nociceptors

Nociceptive pain

Noxious stimuli are transduced into electrical activity at the peripheral terminals of unmyelinated C-fiber and thinly myelinated A -fiber nociceptors by specific receptors or ion channels sensitive to heat, mechanical stimuli, protons and cold. This activity is conducted to the spinal cord and, after transmission in central pathways, to the cortex, where the sensation of pain is experienced.

Inflammatory pain

Damaged tissue, inflammatory and tumor cells release chemical mediators creating an inflammatory soup that activates or modifies the stimulus response properties of nociceptor afferents. This, in turn, sets up changes in the responsiveness of neurons in the CNS.

Neuropathic Pain:
Pain caused by lesion or dysfunction of the nervous system Anatomical location: Peripheral nerve Nerve root Spinal cord Brainstem Thalamus Cortical / Subcortical

Neuropathic pain

Neuropathic pain arises from lesions to or dysfunction of the nervous system. Conditions affecting the peripheral nervous system, as in carpal tunnel syndrome, the spinal cord after traumatic injuries or the brain after stroke, can all cause neuropathic pain, which is characterized by a combination of neurological deficits and pain.

somatic pain ;

visceral pain ->

->

neuropathic pain

allodynia hyperalgesia hyperpathia

burning, paresthesia

numberness .

Acute Duration
Chronic Nociceptive

Pathophysiology
Neuropathic

WHO  By the  By the  By the

B mouth clock ladder

By the clock
Over Medication
Around-the-Clock (ATC) Medication Pain Relief Threshold Therapeutic Window

By the ladder


Acetaminophen paracetamol NSAIDs codeine, dihydrocodeine, tramadol, co-proxamol comorphine,diamorphine

1st:  2nd:  3rd:



breakthrough pain


dosedoserelated pain incidental pain breakthrough pain -> ->

( (1)

NSAID) (2)

(3)


(4)

NSAID NSAID

NSAID (adjuvant)

NSAID

NSAID
Normal Tissue Arachidonic Acid Inflammation Site Cytokines + Growth factors COX-2 Inducible NSAIDs Physiolgical Prostaglandin Production Normal Functions Pathological Prostaglandin Production Inflammation, pain, fever COX-2 Inhibitors

COX-1 Constitutive

(opioid receptors) mu delta kappa endorphins enkephalins receptors

(full agonist) /


(partial agonist) (antagonist) (2)

(1)

(codeine)

4~6 120 10 codeine codeine codeine 10

Tramadol opioid non-opioid nonopioid receptor

Serotonin Noradrenaline morphine Tramadol codeine

(Ceiling effect), , 50~100mg 400mg. 400mg.

Tramadol, q4~6h, 200mg,

(morphine)


2~3 4 morphinemorphine-3glucuronide(Mglucuronide(M-3-G) morphine-6-glucuronide(M-6-G) morphine- glucuronide(MM-6-G M-6-G



: IV: SC : Oral= 3: 2: 1

(morphine)


: 1. , 2. 3. 4. : : : , , , , , , : , ,

Fentanyl -> Fentanyl (transdermal use) fentanyl 72 , , , 12 , 12 morphine 25mcg

-> -> , -> 60mg

Demerol (Pethidine, Meperidine) pethidine , 2-3 norpethidine,

(ceiling effect)

/ Morphine Codeine Demerol Tramadol Fentanyl IV 10 130 75 100 0.1 Oral 30 200 300 120 ( 3:1 1.5:1 4:1 1.2:1 3-6 2-4 2-4 2-4 1-3 )

 

Regular: Morphine # q4h Rescue: 24 (24hr basebaseline dose) 1/6 (or 12%) Sleep: add 50%~100% qhs and skip sleeping time Adjust: regular dosage + rescue dosage

Durogesic 25mcg q3d + MST 60 1# Q12H, , . , ? Rescue dose ?

2 ,
 

180mg qd, 90mg

qd SC qd. Rescue dose= 90/6=15 mg SC q4hPRN rescue dose, , ?

 

90 mg, , 120mg 240mg, , MST(60) 2# q12H Durogesic 50mcg q3d rescue dose 40mg prn.

(Adjuvant analgesics)
     

(corticosteroids) (antidepressant) (anticonvulsants) (antiarrhythmics) (bisphosphonate) (other adjuvants)

Nerve block Spinal analgesia Add Anti-arrhythmia NMDA GABA inhibitor Antidepressant and Anticonvulsant Antidepressant or Anticonvulsant

Step 4

Step 3

Step 2

Step 1

(physical therapies)


(TENS,transcutaneous electrical nerve stimulation)

(invasive analgesic procedures)



(relaxation therapy)

     

(benefit/risk calculus), (