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CURRICULUM VITAE
Nama : dr. Andi M. Takdir Musba, Sp.AnTTL : Pare-Pare, 31 Oktober 1974Alamat rumah : JL. Datuk Ditiro II No. 15 Makassar 90214, IndonesiaTelp / Hp : 0411-452113 / 0811463304Email : takdir1974@yahoo.comAlamat kantor : Bagian Ilmu Anestesi, Perawatan Intensif & Manajemen
Nyeri Fakultas Kedokteran UNHAS / RS. Dr. Wahidin Sudirohusodo Jl. Perintis Kemerdekaan Km.11 Tamalanrea Makassar-90245
Telp/HP/Fax/Email: 0411-582583-589777 /Fax. 0411-590290 / anestesiologi_unhas@yahoo.co.id
CURRICULUM VITAE
Riwayat Pendidikan :- Dokter Umum tahun 1999 Fakultas Kedokteran Universitas Hasanuddin- Spesialis Ilmu Anestesi tahun 2007 Fakultas Kedokteran Universitas
HasanuddinPelatihan / Kursus :- Tahun 2003 : Kursus Perioperative, Surabaya, Indonesia- April 2006 : Pain Management Workshop and Refresher Course,
Makassar- November 2006 : Acupuncture and TCM Workshop, Makassar oleh Fakultas
Kedokteran Universitas Hasanuddin dan Xiamen University, China
- Februari - April 2008 : Course on Clinical Pain Management Program, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Maret 2008 : Interventional Pain Management Workshop, Bangkok
OPTIMALIZATION OF THE 3-STEPLADDER WHO
A.M.TAKDIR MUSBA
DEPARTMENT OF ANESTHESIOLOGY ,INTENSIVE CARE AND PAIN MANAGEMENT FACULTY OF MEDICINE , HASANUDDIN UNIVERSITY
TOTALPAIN
SOMATIC SOURCE
ANXIETY
ANGERDEPRESSION
Non-cancer pathologyCancer
Symptoms of debility Side-effects of theraphy
Loss of social position Loss of job prestige and incomeLoss of role in family Chronic fatigue and insomnia Sense of helpessness Disfigurement
Bureaucratic bungling Friends who do not visit Delay in diagnosis Unavailable doctorsIrritabilityTherapeutic failure
Fear of hospital or nursing homeWorry about familyFear of deathSpiritual unrest
Fear of painFamily financesLoss of dignity and bodily controlUncertainty about future
WHO 1986
J.Loeser (1980)
Concept of nociception, pain, suffering and pain behaviour
Pain behaviourSuffering
Pain
Nociception
HISTORY OF 3-STEP LADDER WHO 1980 – WHO establishes Cancer Control Programme
Cancer prevention Early diagnosis with curative treatment Pain relief and palliative care
1986 – ” Cancer Pain Relief “ published by WHO Step Ladder WHO
Updated on 1996
Worldwide acceptance protocol Today, worldwide consensus favouring its used for
management of all pain associated with serious illness
Dr. Kathleen M. FoleyPain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center in New York City
Former Chair WHO Expert Committee on Cancer Pain Relief and Active Supportive Care (1982-1998) group that drafted the WHO guidelines
Early evidence support the Ladder
Observational studies 3220 patients studied, retrospective Reported proportion of patients achieved
adequate control 2361 (71%) achieved control
Ventafridda et al 1987 Prospective 10 year study, 1995
2118 patients with cancer pain Opioids given
orally (83%), parenterally (9%), spinally (2%) Pain relief
Good 76% Satisfactory 12% Inadequate 12%
Zech et al 1995
Systematic reviews for the Ladder
1995, Jadad et al 8 studies (1982-1995) adequate pain management in 69-100%’
2006, Ferriera et al 17 studies (8 overlap with earlier review) adequate pain management in 45-100 %
WHO study , 2007 Most expert in developing and developed countries
follow the WHO analgesic ladder for cancer related pain relief.
“LOGICAL APPROACH TO CANCER PAIN CONTROL“
WHO Analgesic LADDER
WHO Analgesic LADDER
Step ladder represent
SPECIFIC DRUG CLASS SPECIFIC TYPE OF PAIN BASED ON INTENSITY OF PAIN COMBINED WITH ADJUVANT
5 phrases of 3-step ladder1. By the mouth 2. By the clock 3. By the ladder4. Individualized for the patient5. Attention to detail
WHO Cancer pain relief principles
Assessment pain severity is essential Started in appropriate level Analgesia given regularly Prescription for breakthrough pain Consider adjuvant drugs PCT and /or NSAIDs should be used
at all step Morphine is the strong opioid choice Opioid rotation
Who ladder in practice Analgesics are the cornerstone of
good cancer pain management Most experts in developing and
developed countries follow the WHO analgesic ladder and WHO guidelines for cancer related pain relief.
Barriers to pain management educating patients and caretakers access to medicines DOCTOR knowledge
Doctor’s problem
Opiophobia Pk/Pd
e.g. Drugs doses and interval Regular assessment Limited time Mis-interpretation of the ladder
Common ladder mis-nterpretations
starting at step 1 for moderate to severe pain
the ladder is restricted to opioids Weak and strong opioid combined rotating around analgesics at steps 1
or 2 despite inadequate pain relief
Criticism to WHO ladder Usefulness of weak opioids in step 2
Weak opioids no better than NSAIDs alone ( Eisenberg et al , 1994, McNicol, 2006 ) High doses weak opioid Vs Low doses strong opioid
( Gronds et 1999 )
Moving directly from step 1 to step 3 was possible ( Maltoni et al, 2005, Mercadante et al 2006 )
Strong opioids for first-line treatment of pain in patients with terminal cancer. ( Marinangeli, 2004 )
New formulations of opioid ( Davis MP, 2006 )
Strong Opioid Availability in Indonesia
Long acting opioid preparations : Fentanyl patch, morphine sustained release
Short acting opioid preparations : ?
INTRAVENOUS OPIOID
Opioid – principles of using Opioid titration Opioid rescue dose Opioid rotation Opioid side-effect management Opioid sparing strategies
Opioid Titration Guidelines Titrate with short–acting hydrophilic
opioid; can be given at interval based on the time to peak serum level as needed; oral ~ 1 hour , sc ~ 30 min, iv ~ 10 min.
Calculate 24 hrs requirements and convert to long-acting opioid
Opioid Dose EscalationAlways increase by a percentage of the present dose based upon patient’s pain rating and current assessment
Mild pain 1-3/10
Moderate pain4-6/10
25-50% increase Severe pain7-10/10
50-100% increase
Opioid Rescue Dose
Used for breakthrough pain. Dose:
Approximately 10% of daily dose equivalent.
Frequency : Oral every 1 - 2 hours Parenteral every 15 - 30 minutes
Opioid Rotation
Oral dose ( mg )
Opioid Parenteral iv/sc/im( mg )
150 Meperidine 50150 Tramadol 100150 Codeine 5015 Morphine 5- Fentanyl 0.050
Morphine 50 mg PO in 24 hrs = fentanyl patch 25 mcg/hr
Equianalgesic doses Opioids
Example : Opioid converting to Fentanyl patch
Determine consistent daily opioid use and fentanyl patch equianalgesic
Convert from PCA opioid : reduce basal rate 50% for first 12
hr, discontinued after 12 hr and keep PCA bolus dose in first 24 hr
Parenteral opioid : reduce infusion 50% for first 12 hr, discontinue after 12 hr, continue breakthrough dose
Oral long acting : apply patch with long acting dose equianalgesic , discontinue long-acting preparation, continue breakthrough dose
Opioid-sparing strategiesAnalgesic adjuvants
e.g. Antiemetics, Laxatives, Antidepressant, Anticonvulsant, Corticosteroid, Anxiolytics, NMDA antagonist
Alternate route (e.g. intraspinal)Anaesthetic/Neurolytic proceduresPM&R approachesCognitive therapyComplementary therapies
e.g., acupuncture, massage, music therapy
A. The 3-step analgesic ladder developed by the World Health Organization. WHO. Cancer Pain Relief. Geneva: WHO; 1986. B. The proposed 4th step. Miguel R. Interventional Treatment of Cancer Pain: The Fourth Step in
the World Health Organization Analgesic Ladder? Cancer Control 2000, 7 (2): 149-56.
Interventional pain management
INTERVENTION PAIN TECHNIQUE CAN BE USED AT EACH STEP DEPENDING ON THE PATIENT’S NEED
Foley K., WHO Cancer Pain Release, 2006, Vol.19
CONCLUSION
Although simple, appropriate use of the WHO Pain Ladder give marked efficacy and low risk complication
Still many barrier to optimalize the ladder such doctor knowledge and drug availability in our country.
“ Total pain “
G. T. Linklater and M. E. F. Leng Recent advances in pain management in palliative careCurrent Anaesthesia & Critical Care (2001) 12, 296-301
Please keep in mind ………
"relief of psychological, social and spiritual problems is paramount. Attempting to relieve pain without addressing the patient's non-physical concerns is likely to lead to frustration and failure.“
WHO Guideline , 1986
Thank you
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