Pain Management Pharmachology and Non Pharmacology

Abstract
Paramedicine and the emergency medical services have been moving in the direction of
advancing pharmaceutical intervention for the management of pain in both acute and
chronic situations. This coincides with other areas of advanced life support and patient
management strategies that have been well researched and continue to benefit from the
increasing evidence. Even though paramedic practice is firmly focused on
pharmacological interventions to alleviate pain, there is emerging evidence proposing a
range of nonpharmacological options that can have an important role in pain
management. This review highlights literature that suggests that paramedicine and
emergency medical services should be considering the application of complementary and
alternative therapies which can enhance current practice and reduce the use of
pharmacological interventions.
Paramedis dan pelayanan pengobatan telah berpindah tujuan yang mempercepat campur
tangan farmasi dalam peneglolaan sakit da;am kedua situasi yaitu gawat dan terus
menerus. Bertepatan dengan tempat lain yang mempercepat dukungan hidup dan strategi
mengurus pasien telah diteliti dan selanjutnya manfaat dari peningkatan bukti. Meskipun
PADA PRAKTIKNYA SUNGGUH SUNGGUH FOKUS PADA CAMPUR TANGAN
PENGOBATAN UNTUK MENGURANGI SAKIT, ADA BUKTI MUNCUL
MUNGUSULKAN JANGKAUAN PILIHAN TANPA OBAT YANG MEMILIKI
SEBUAH PERAN PENTING DALAM MENGURUS/MENANGANI ORANG SAKIT.
TINJAUAN INI MENYOROTI SUMBER YANG DIUSULKAN BAHW PARAMEDIS
DAN PELAYAN PENGOBATAN GAWAT DARURAT HARUS BERDASARKAN
PENERAPAN SALING MENGISI DAN TERAPI ALTERNATIF YANG DAPAT
MENINGGIKAN PRAKTEK PADA SAAT INI DAN MENGURANGI
PENGGUNAAN CAMPUR TANGAN PENGOBATAN.
1. Introduction
Pain is a common complaint among patients cared for by paramedics [1]. Cases attended
by paramedics involve patients who report pain as their chief complaint and symptom
that instigated an ambulance call for assistance. In other cases, the sensation of pain will
be a component of a constellation of symptoms, and the patient’s report of pain will be an
important diagnostic cue that guides the clinical examination. Paramedics will also
encounter patients who report persistent pain, but where the pain is unrelated to their
current health crisis.
Paramedics have an important role in identifying and reducing the burden of pain. The
alleviation of pain is important from a humanitarian perspective, with freedom from pain
considered as a basic human right [2]. Pain is also associated with significant morbidity,
and as the study of pain evolves, the relationship between poorly managed acute pain and
the development of chronic pain syndromes is becoming recognized [3].
Patients who seek medical care may understandably expect relief from pain, with a study
of patients presenting to an emergency department finding a majority that expected relief
from their pain, with a significant proportion expecting complete relief [4]. Regardless of
the health care setting, pain is a frequently reported symptom. For paramedics, an
encounter with a patient reporting pain is a common event [5].
The provision of reassurance and comfort for the relief of pain and distress has been
described as a primary goal of paramedics and emergency medical services (EMS) [6].
However, reassurance alone may provide inadequate relief of pain. Prior to the
introduction of advanced levels of training and clinical guidelines for the administration
of analgesics, the management of pain in patients who were injured relied on techniques
such as splinting fractures so that the immobilized limb was less likely to move and
exacerbate tissue injury resulting in further pain. While there are still rudimentary skills
used, paramedic practice has advanced and become more specialised and now includes
the administration of a range of pharmacological agents to relieve or minimize pain
[7, 8]. These now include opioids, nonsteroidal anti-inflammatories, paracetamol,
NMDA-receptor antagonists, methoxyflurane, and local anaesthetics for nerve blocks.
Morphine is commonly used for the treatment of pain, and this drug is considered the
“gold standard” against which other analgesics are measured [9]. The efficacy of opioids
such as morphine and fentanyl for the management of severe pain in the paramedic
practice setting has been established [10].
Over the last two decades, this escalating reliance upon pharmaceuticals for pain
management practice has been borne in part by the need to respond to societal
expectations. In addition, pain management has been identified as a key performance
indicator by some EMS. In Australia, the Council of Ambulance Authorities (CAA) has
identified that the quality of pain relief is a surrogate measure of compassion and caring
and has recently recommended that EMS develop and adopt clinical performance
indicators that include the reduction of pain [22]. However, this is not a binding
recommendation and national data relating to the adoption of pain management
performance indicators by Australian EMS is not widely available.
The acknowledgement of pain management as an important component of paramedic
practice is reflected by the use of evidence-based guidelines for the relief of pain.
However, these almost exclusively focus on acute pain and pharmacological
interventions. References to nonpharmacological therapies in Australian clinical
guidelines for paramedics are uncommon, with the exception of traditional measures such
as splinting, cooling, and reassurance. References to complementary and alternative
therapies such as acupuncture are rare in the paramedic literature and resources that
support paramedic education [23, 24]. Although uncommon in Australian paramedic
curricula, nonpharmacological therapies for pain relief feature consistently in the practice
of several allied health disciplines, with cognitive-behavioral and complementary
therapies included in the International Association for the Study of Pain Core Curriculum
for Health Professionals [25].
Nonpharmacological interventions to alleviate pain rely on the inhibition of pain
signalling. Pain arises from nociceptive transmission through small afferents to the spinal
cord and then to higher brain nuclei and the cerebral cortex. Nociceptive signals are
mediated by peripheral and central components that may facilitate or inhibit this input
[26]. These signals are modulated by midbrain networks which exert bidirectional control
over nociceptive transmission through the spinal cord. Several neurotransmitters are
involved in mediating nociceptive signals including substance P which facilitates
transmission and endogenous opioid-based compounds that inhibit transmission [27].
Rasa sakit adalah keluhan umum di kalangan pasien yang dirawat oleh paramedis [1].
Kasus yang dihadiri oleh paramedis melibatkan pasien yang melaporkan rasa sakit
sebagai keluhan utama dan gejala yang memicu ambulans meminta bantuan. Dalam kasus
lain, sensasi rasa sakit akan menjadi komponen konstelasi gejala, dan laporan nyeri
pasien akan menjadi isyarat diagnostik penting yang memandu pemeriksaan klinis.
Paramedis juga akan menemui pasien yang melaporkan rasa sakit terus-menerus, namun
di mana rasa sakit tersebut tidak terkait dengan krisis kesehatan mereka saat ini.
Paramedis memiliki peran penting dalam mengidentifikasi dan mengurangi beban rasa
sakit. Pengentasan rasa sakit itu penting dari perspektif kemanusiaan, dengan kebebasan
dari rasa sakit dianggap sebagai hak asasi manusia [2]. Nyeri juga terkait dengan
morbiditas yang signifikan, dan saat studi tentang nyeri berkembang, hubungan antara
nyeri akut yang ditangani dengan buruk dan pengembangan sindrom nyeri kronis dikenali
[3].
Pasien yang mencari perawatan medis dapat dengan mudah mengharapkan bantuan dari
rasa sakit, dengan sebuah penelitian terhadap pasien yang menghadiri sebuah departemen
gawat darurat menemukan mayoritas yang mengharapkan bantuan dari rasa sakit mereka,
dengan proporsi yang signifikan mengharapkan kelegaan yang lengkap [4]. Terlepas dari
pengaturan perawatan kesehatan, rasa sakit adalah gejala yang sering dilaporkan. Bagi
paramedis, pertemuan dengan pasien melaporkan rasa sakit adalah kejadian yang umum
[5].
Penyediaan jaminan dan kenyamanan untuk menghilangkan rasa sakit dan kesusahan
telah digambarkan sebagai tujuan utama paramedis dan layanan medis darurat (EMS) [6].
Namun, kepastian saja bisa memberikan rasa sakit yang tidak memadai. Sebelum
diperkenalkannya tingkat lanjut panduan pelatihan dan klinis untuk pemberian analgesik,
penanganan rasa sakit pada pasien yang terluka bergantung pada teknik seperti fraktur
belat sehingga anggota tubuh yang tidak bergerak cenderung tidak bergerak dan
memperburuk cedera jaringan sehingga menghasilkan sakit lebih lanjut Meskipun masih
ada keterampilan dasar yang digunakan, praktik paramedis telah maju dan menjadi lebih
terspesialisasi dan sekarang mencakup pemberian berbagai agen farmakologis untuk
mengurangi atau meminimalkan rasa sakit [7, 8]. Ini sekarang termasuk opioid, anti-
inflamasi nonsteroid, parasetamol, antagonis reseptor NMDA, methoxyflurane, dan
anestesi lokal untuk blok saraf. Morfin biasanya digunakan untuk pengobatan rasa sakit,
dan obat ini dianggap sebagai "standar emas" yang dengannya analgesik lainnya diukur
[9]. Efektivitas opioid seperti morfin dan fentanil untuk penanganan nyeri parah pada
setting praktik paramedis telah ditetapkan.
Selama dua dekade terakhir, ketergantungan yang meningkat pada obat-obatan untuk
praktik manajemen rasa sakit ini sebagian ditanggung oleh kebutuhan untuk merespons
harapan masyarakat. Selain itu, manajemen nyeri telah diidentifikasi sebagai indikator
kinerja utama oleh beberapa EMS. Di Australia, Dewan Otoritas Ambulans (CAA) telah
mengidentifikasi bahwa kualitas penghilang rasa sakit adalah ukuran pengampunan belas
kasih dan perhatian dan baru-baru ini merekomendasikan agar EMS mengembangkan dan
menerapkan indikator kinerja klinis yang mencakup pengurangan rasa sakit [22]. Namun,
ini bukan rekomendasi yang mengikat dan data nasional terkait penerapan indikator
kinerja manajemen nyeri oleh Australian EMS tidak tersedia secara luas.
Pengakuan manajemen rasa sakit sebagai komponen penting dari latihan paramedis
tercermin dari penggunaan pedoman berbasis bukti untuk menghilangkan rasa sakit.
Namun, ini hampir secara eksklusif berfokus pada nyeri akut dan intervensi
farmakologis. Referensi untuk terapi nonpharmacological dalam pedoman klinis
Australia untuk paramedis jarang terjadi, kecuali tindakan tradisional seperti belat,
pendinginan, dan kepastian. Referensi untuk terapi komplementer dan alternatif seperti
akupunktur langka dalam literatur paramedis dan sumber daya yang mendukung
pendidikan paramedis [23, 24]. Meskipun jarang terjadi dalam kurikulum paramedis
Australia, terapi nonpharmacological untuk fitur penghilang rasa sakit secara konsisten
dalam praktik beberapa disiplin kesehatan sekutu, dengan terapi kognitif-perilaku dan
komplementer termasuk dalam Asosiasi Internasional untuk Studi Kurikulum Inti Sakit
untuk Profesional Kesehatan [25].
Intervensi nonfarmakologis untuk mengurangi rasa sakit bergantung pada penghambatan
pemberian sinyal nyeri. Nyeri timbul dari transmisi nociceptive melalui aferen kecil ke
sumsum tulang belakang dan kemudian ke otak yang lebih tinggi dan korteks serebral.
Sinyal nociceptive dimediasi oleh komponen perifer dan pusat yang dapat memfasilitasi
atau menghambat masukan ini [26]. Sinyal ini dimodulasi oleh jaringan otak tengah yang
menggunakan kontrol dua arah terhadap transmisi nociceptive melalui sumsum tulang
belakang. Beberapa neurotransmitter terlibat dalam mediasi sinyal nociceptive termasuk
substansi P yang memfasilitasi transmisi dan senyawa berbasis opioid endogen yang
menghambat transmisi [27].
Nonpharmacological analgesia therefore involves the inhibition of nociceptive input by

activating separate antinociceptive outputs. Procedures such as transcutaneous electrical
nerve stimulation (TENS) and acupoint stimulation rely on inhibiting the nociceptive
signal to induce an analgesic effect.
Nonpharmacological approaches to the relief of pain are more commonly associated with
nonacute settings and may be classified as follows:(i)psychological interventions
(including distraction, stress management, hypnosis, and other cognitive-behavioral
interventions),(ii)acupuncture and acupressure,(iii)transcutaneous electrical nerve
stimulation,(iv)physical therapies (including massage, heat/cold, physiotherapy,
osteopathy, and chiropractic).
These approaches to pain management may complement or indeed substitute
pharmacological therapy in some types of pain. Chronic pain (which is also commonly
encountered in paramedic practice) is one situation where a range of interventions may be
used to manage complex health problems such as cancer pain, lower back pain, and
specific diseases associated with pain such as endometriosis. Evidence of efficacy is
variable, and this may be due to the type of pain, type of intervention, patient
characteristics, skill and experience of the clinician, and heterogeneous study
populations. For example, significant variability in the efficacy of acupuncture has been
reported in the literature [28].
The use of these therapies to manage acute pain, such as pain arising from trauma or
tissue injury associated with inflammation or ischemia, is rarely described in the
literature. The role of alternatives in pharmacotherapy is acknowledged by the Australian
and New Zealand College of Anaesthetists (ANZCA), albeit as adjunctive or
complementary therapy [29]. When describing pain management in the emergency health
setting, the ANZCA recommends “ice, elevation, and splinting for injuries” as well as
reassurance as the mainstays of nonpharmacological management of pain [29].
This paper will appraise the current evidence of nonpharmacological interventions for
pain management in the paramedic practice setting, either as complementary therapies or
as alternatives to pharmacological interventions. Our review will focus upon acupuncture
and acupressure, TENS, and the use of warming as all simple measures that may be
implemented and would potentially complement current paramedic pain management
guidelines. This contributes to the knowledge base for paramedic pain management
practice and should inform future research that seeks to establish the role for
nonpharmacological therapies in the relief of pain. For data sources, electronic literature
searches were conducted using Medline, Embase, the Cochrane Library, and Cinahl
(EBSCO). The search terms used were “paramedic” OR “CAM” OR “acupuncture” OR
“acupressure” OR “TENS.”
Oleh karena itu analgesia nonfarmakologis melibatkan penghambatan masukan
nociceptive dengan mengaktifkan keluaran antinociceptive yang terpisah. Prosedur
seperti stimulasi saraf listrik transkutaneous (TENS) dan stimulasi asupoint bergantung
pada penghambatan sinyal nociceptive untuk menginduksi efek analgesik.
Pendekatan nonfarmakologis untuk menghilangkan rasa sakit lebih sering dikaitkan
dengan pengaturan nonakut dan dapat diklasifikasikan sebagai berikut: (i) intervensi
psikologis (termasuk gangguan, manajemen stres, hipnosis, dan intervensi perilaku
kognitif lainnya), (ii) akupunktur dan akupresur, (iii) stimulasi saraf elektrik
transkutaneous, (iv) terapi fisik (termasuk pijat, panas / dingin, fisioterapi, osteopati, dan
chiropractic).
Pendekatan terhadap manajemen nyeri ini bisa melengkapi atau memang mengganti
terapi farmakologis pada beberapa jenis rasa sakit. Nyeri kronis (yang juga biasa ditemui
dalam praktik paramedis) adalah satu situasi di mana berbagai intervensi dapat digunakan
untuk mengatasi masalah kesehatan yang kompleks seperti nyeri pada kanker, nyeri
punggung bagian bawah, dan penyakit spesifik yang terkait dengan rasa sakit seperti
endometriosis. Bukti kemanjuran bervariasi, dan ini mungkin karena jenis rasa sakit, jenis
intervensi, karakteristik pasien, keterampilan dan pengalaman klinisi, dan populasi
penelitian heterogen. Sebagai contoh, variabilitas yang signifikan dalam keberhasilan
akupunktur telah dilaporkan dalam literatur [28].
Penggunaan terapi ini untuk mengatasi nyeri akut, seperti nyeri yang timbul dari trauma
atau cedera jaringan yang berhubungan dengan peradangan atau iskemia, jarang
dijelaskan dalam literatur. Peran alternatif dalam farmakoterapi diakui oleh Australian
and New Zealand College of Anesthetists (ANZCA), meskipun sebagai terapi tambahan
atau pelengkap [29]. Saat mendeskripsikan manajemen nyeri dalam pengaturan kesehatan
darurat, ANZCA merekomendasikan "es, ketinggian, dan belat untuk luka-luka" serta
kepastian sebagai penyebab utama penanganan nyeri nonfarmakologis [29].
Makalah ini akan menilai bukti intervensi nonfarmakologis saat ini untuk manajemen
nyeri dalam pengaturan praktik paramedis, baik sebagai terapi komplementer atau
sebagai alternatif intervensi farmakologis. Kajian kami akan berfokus pada akupunktur
dan akupresur, TENS, dan penggunaan pemanasan sebagai semua tindakan sederhana
yang mungkin diterapkan dan berpotensi melengkapi pedoman pengelolaan nyeri
paramedis saat ini. Ini berkontribusi pada basis pengetahuan untuk praktik manajemen
nyeri paramedis dan harus menginformasikan penelitian masa depan yang bertujuan
untuk menetapkan peran terapi nonfarmakologis dalam menghilangkan rasa sakit. Untuk
sumber data, penelusuran literatur elektronik dilakukan dengan menggunakan Medline,
Embase, Cochrane Library, dan Cinahl (EBSCO). Istilah pencarian yang digunakan
adalah paramedis ATAU CAM atau akupunktur atau akupresur ATAU TENS.
2. Transcutaneous Electrical Nerve Stimulation (TENS)

Alternative approaches to paramedic-initiated analgesia such as TENS have been
reported in the literature [30,31]. However, research into the use of nonpharmacological
interventions in paramedic practice is limited. This lack of research may reflect the
developing status of paramedic practice as an allied health profession. There may also be
limited impetus for research in this area if nonpharmacological interventions are deemed
to be inappropriate for the management of pain associated with acute trauma or health
emergencies, particularly in an environment where the time taken for each interval in the
patient care process is a closely monitored performance indicator. The drive to minimize
time spent with each patient is designed to improve operational effectiveness, and this
may restrict the use of nonpharmacological therapies that require extended time to deliver
the care compared with the intravenous titration of opioids. Furthermore, attitudes among
paramedics and service providers regarding the utility of nonpharmacological
interventions to relieve pain may inhibit clinical trials that compare the efficacy of these
therapies.
Although TENS has been clinically used for over three decades, the mechanisms by
which analgesia is produced are only recently being described [32]. Gate control theory is
the most common theory used to support the effect of inhibiting pain by TENS. Gate
control theory describes how a stimulus that activates nonnociceptive fibers can inhibit
pain. Pain is reduced when the area is rubbed or stimulated due to activation of
nonnociceptive fibers inhibiting the nociceptive response in the dorsal horn of the spinal
cord [33]. In TENS, nonnociceptive fibers are selectively stimulated with electrodes in
order to produce this effect and thereby inhibit pain [33].
TENS appears to produce both segmental and descending pain inhibition since inhibition
remains after spinalization (removal of descending inhibition) in the animal model [34].
Adenosine also appears to play a role in TENS analgesia since caffeine (adenosine
receptor antagonist) significantly reduces the analgesic effect resulting from activation of
large diameter fibers [35]. Additionally, concentrations of endogenous opioids have been
shown to increase in cerebrospinal fluid following TENS procedure [36].
TENS uses electric current produced by a portable device to stimulate the nerves for
therapeutic purposes. Previous intervention trials investigating the effect of TENS on
pain are shown in Table 1. One randomized double-blinded study investigating TENS in
an EMS setting showed that TENS intervention in female patients () with acute pelvic
pain (salpingitis, ovarian cyst, dysmenorrhea, vaginal infection, and vaginal trauma)
reduced pain, anxiety, heart rate, nausea, and arteriolar vasoconstriction with an
improvement of overall patient satisfaction compared with those () treated with sham
TENS [11]. The effect of TENS producing pain relief was further supported in another
study in which patients suffering from acute posttraumatic hip pain felt less pain and
anxiety with TENS intervention compared with those treated with sham TENS [12].
These observations suggest that TENS could be an effective and fast-acting pain
treatment with applications within paramedic practice.
Table 1: Intervention trials investigating the effect of TENS on pain.
Pendekatan alternatif untuk analgesia yang diawali dengan paramedis seperti TENS telah
dilaporkan dalam literatur [30,31]. Namun, penelitian tentang penggunaan intervensi
nonfarmakologis dalam praktik paramedis terbatas. Kurangnya penelitian ini mungkin
mencerminkan status pengembangan praktik paramedis sebagai profesi kesehatan sekutu.
Mungkin juga ada dorongan terbatas untuk penelitian di bidang ini jika intervensi
nonfarmakologis dianggap tidak sesuai untuk penanganan rasa sakit yang terkait dengan
trauma akut atau keadaan darurat kesehatan, terutama di lingkungan di mana waktu yang
diperlukan untuk setiap interval dalam proses perawatan pasien adalah indikator kinerja
yang dipantau secara ketat. Dorongan untuk meminimalkan waktu yang dihabiskan
dengan setiap pasien dirancang untuk meningkatkan efektivitas operasional, dan ini
mungkin membatasi penggunaan terapi nonpharmacological yang memerlukan waktu
yang lama untuk memberikan perawatan dibandingkan dengan titrasi opioid intravena.
Selanjutnya, sikap antara paramedis dan penyedia layanan mengenai kegunaan intervensi
nonfarmakologis untuk mengurangi rasa sakit dapat menghambat uji klinis yang
membandingkan keefektifan terapi ini.
Meskipun TENS telah digunakan secara klinis selama lebih dari tiga dekade, mekanisme
dimana analgesia diproduksi baru-baru ini dijelaskan [32]. Teori kontrol gerbang adalah
teori yang paling umum digunakan untuk mendukung efek penghambatan rasa sakit oleh
TENS. Gerbang teori kontrol menggambarkan bagaimana stimulus yang mengaktifkan
serat nonnociceptive dapat menghambat rasa sakit. Nyeri berkurang saat daerah tersebut
digosok atau distimulasi karena pengaktifan serat nonnosis yang menghambat respons
nociceptive di tanduk dorsal sumsum tulang belakang [33]. Di TENS, serat nonnosis
digunakan secara selektif dirangsang dengan elektroda untuk menghasilkan efek ini dan
dengan demikian menghambat rasa sakit [33].
TENS tampaknya menghasilkan penghambatan rasa sakit segmental dan turun sejak
penghambatan tetap terjadi setelah pemintalan (penghilangan inhibisi turun) pada model
hewan [34]. Adenosin juga tampaknya berperan dalam analgesia TENS karena kafein
(antagonis reseptor adenosin) secara signifikan mengurangi efek analgesik akibat
pengaktifan serat berdiameter besar [35]. Selain itu, konsentrasi opioid endogen telah
terbukti meningkat pada cairan serebrospinal mengikuti prosedur TENS [36].
TENS menggunakan arus listrik yang dihasilkan oleh perangkat portabel untuk
merangsang saraf untuk tujuan terapeutik. Uji coba intervensi sebelumnya yang
menyelidiki efek TENS pada nyeri ditunjukkan pada Tabel 1. Satu penelitian acak buta
ganda yang menyelidiki TENS dalam setting EMS menunjukkan bahwa intervensi TENS
pada pasien wanita () dengan nyeri pelvis akut (salpingitis, kista ovarium, dismenore,
vagina infeksi, dan trauma vagina) mengurangi rasa sakit, kegelisahan, denyut jantung,
mual, dan vasokonstriksi arteriolar dengan peningkatan kepuasan pasien secara
keseluruhan dibandingkan dengan yang diobati dengan kotoran tiruan [11]. Efek dari
TENS yang menghasilkan penghilang rasa sakit selanjutnya didukung dalam penelitian
lain di mana pasien yang menderita nyeri pinggul posttraumatic akut merasakan sedikit
rasa sakit dan kecemasan dengan intervensi TENS dibandingkan dengan mereka yang
diobati dengan TENS palsu [12]. Pengamatan ini menunjukkan bahwa TENS dapat
menjadi pengobatan nyeri efektif dan cepat dengan aplikasi dalam praktik paramedis.
Tabel 1: Uji coba intervensi yang menyelidiki efek TENS pada rasa sakit.
3. Acupuncture, Electroacupuncture, and Acupressure

Stimulation of specific points on the body, commonly known as acupuncture, is widely
recognized as a therapeutic procedure used to treat pain and illness [37, 38]. Acupoint
stimulation such as manual acupuncture involves the penetration and manipulation of a
fine needle through the skin into specified points on the body to evoke a sensation known
as de-qi [39]. Treatment procedures that involve acupoint stimulation also include
electroacupuncture and acupressure. Electroacupuncture requires delivery of electrical
current through the inserted needle. Acupressure requires the use of fingers and hands to
stimulate acupoints on the body to relieve pain and clinical symptoms [40]. More than
360 acupoints are located along 14 meridian channels that cover the body in a weblike
interconnecting matrix [41]. Each acupoint is recognized as having a defined therapeutic
action; however, a combination of acupoints is often stimulated to induce a therapeutic
effect [41].
The potential mechanism for acupuncture analgesia is via the descending pain
modulation pathways. The nucleus raphe magnus (NRM) in the midbrain is a significant
neural site for descending analgesia via expression of serotonin [42]. NRM inhibits
ascending pain signalling by projection neurons to the dorsal horn of the spinal cord. The
NRM is part of a central pain modulatory system comprising the midbrain periaqueductal
grey (PAG) and the ventromedial medulla (RVM) recruited to suppress or facilitate
responses to noxious stimuli (PAG-RVM system). Endogenous opioid peptides are
present in the neural soma and terminals of these nuclei. Electroacupuncture has been
shown to enhance the expression of serotonin and reduce the release of substance P
during electroacupuncture inhibition of acute nociceptive responses [43]. The dorsolateral
pontine tegmentum is another midbrain site mediating spinal cord nociceptive signalling
by providing noradrenergic innervations of the spinal cord. Involvement of noradrenergic
receptors in rat spinal cord has also been demonstrated during electroacupuncture
analgesia [44]. Together, these studies suggest that acupuncture evokes central pathways
to inhibit the pain signal.
The World Health Organisation recommends the use of acupuncture for a substantial
number of diseases [37]. The efficacy of acupuncture is formally endorsed by the
National Institute of Health and recognized by the American Medical Association [45]. In
a Cochrane Review paper on the efficacy of acupuncture for lower back pain, the results
showed that acupuncture is more effective for pain relief than no treatment or sham
procedure [46]. Moreover, when acupuncture is added with conventional therapy, it was
shown to relieve pain and enhance function better than conventional therapies alone.
Acupressure works with the same acupoints and meridians as acupuncture. The only
difference between two interventions is that acupressure stimulates the acupoints with
finger pressure rather than by fine needles. Previous intervention trials investigating the
effect of acupressure on pain are shown in Table 2. In the first known study to investigate
the effects of acupressure on pain in the paramedic practice setting, researchers allocated
adult patients () to one of three treatment arms. Group 1 used true acupressure points LI4
(Hegu), PC9 (Zhongchong), PC6 (Neiguan), BL60 (Kunlun), and GV20 (Baihui), while
Groups 2 and 3 involved sham acupressure point and no acupressure, respectively [13].
Group 1 patients reported reduced pain and anxiety with these changes which was
significantly greater than either Group 2 or Group 3. Group 1 patients also demonstrated
a statistically significant decrease in heart rate compared with patients that were treated
with sham acupressure () or did not receive the intervention (). Patient satisfaction scores
after treatment were significantly better in Group 1.
Table 2: Intervention trials investigating the effect of acupressure on pain.
Stimulasi titik-titik tertentu pada tubuh, umumnya dikenal sebagai akupunktur, secara
luas dikenal sebagai prosedur terapeutik yang digunakan untuk mengobati rasa sakit dan
penyakit [37, 38]. Stimulasi akupuntur seperti akupunktur manual melibatkan penetrasi
dan manipulasi jarum halus melalui kulit ke titik-titik tertentu pada tubuh untuk
membangkitkan sensasi yang dikenal sebagai de-qi [39]. Prosedur perawatan yang
melibatkan stimulasi acupoint juga meliputi electroacupuncture dan akupresur.
Elektroakupunktur membutuhkan penyerahan arus listrik melalui jarum yang disisipkan.
Akupresur membutuhkan penggunaan jari tangan dan tangan untuk menstimulasi titik
akupuntur pada tubuh untuk menghilangkan rasa sakit dan gejala klinis [40]. Lebih dari
360 titik akupuntur terletak di sepanjang 14 saluran meridian yang menutupi tubuh dalam
matriks interkoneksi yang menyerupai web. [41]. Setiap akupoint diakui memiliki
tindakan terapeutik yang pasti; Namun, kombinasi titik akupuntur sering dirangsang
untuk menginduksi efek terapeutik [41].
Mekanisme potensial untuk analgesia akupunktur adalah melalui jalur modulasi nyeri
turun. Inti raphe magnus (NRM) di otak tengah adalah tempat syaraf yang signifikan
untuk analgesia turun melalui ekspresi serotonin [42]. NRM menghambat sinyal nyeri
menaik oleh neuron proyeksi ke tanduk punggung sumsum tulang belakang. NRM adalah
bagian dari sistem modulasi nyeri pusat yang terdiri dari otak tengah periaqueductal gray
(PAG) otak tengah dan medula ventromedial (RVM) yang direkrut untuk menekan atau
memfasilitasi respons terhadap rangsangan berbahaya (sistem PAG-RVM). Peptida
opioid endogen hadir di saraf soma dan terminal nuklei ini. Electroacupuncture telah
terbukti dapat meningkatkan ekspresi serotonin dan mengurangi pelepasan zat P selama
penghambatan electroacupuncture terhadap respons nociceptive akut [43]. Tegmentum
porselen dorsolateral adalah situs otak tengah lainnya yang memediasi sinyal nociceptive
sumsum tulang belakang dengan memberikan sandaran noradrenergik pada sumsum
tulang belakang. Keterlibatan reseptor noradrenergik pada sumsum tulang belakang juga
telah ditunjukkan selama analgesia electroacupuncture [44]. Bersama-sama, penelitian ini
menunjukkan bahwa akupunktur membangkitkan jalur sentral untuk menghambat sinyal
rasa sakit.
Organisasi Kesehatan Dunia merekomendasikan penggunaan akupunktur untuk sejumlah
besar penyakit [37]. Efikasi akupunktur secara resmi disahkan oleh National Institute of
Health dan diakui oleh American Medical Association [45]. Dalam sebuah makalah
Cochrane Review mengenai kemanjuran akupunktur untuk nyeri punggung bagian
bawah, hasilnya menunjukkan bahwa akupunktur lebih efektif untuk menghilangkan rasa
sakit daripada prosedur perawatan atau kesalahan apapun. Apalagi bila akupunktur
ditambahkan dengan terapi konvensional, hal itu terbukti bisa mengurangi rasa sakit dan
meningkatkan fungsinya lebih baik daripada terapi konvensional saja.
Akupresur bekerja dengan akupoint dan meridian yang sama seperti akupunktur. Satu-
satunya perbedaan antara dua intervensi adalah bahwa akupresur merangsang titik
akupuntur dengan tekanan jari dan bukan dengan jarum halus. Uji coba intervensi
sebelumnya yang menyelidiki efek akupresur pada nyeri ditunjukkan pada Tabel 2. Pada
penelitian pertama yang diketahui untuk mengetahui efek akupresur pada nyeri pada
pengaturan paramedis, peneliti mengalokasikan pasien dewasa () ke satu dari tiga
kelompok pengobatan. Kelompok 1 menggunakan titik akupresur sejati LI4 (Hegu), PC9
(Zhongchong), PC6 (Neiguan), BL60 (Kunlun), dan GV20 (Baihui), sedangkan Grup 2
dan 3 melibatkan titik akupresur palsu dan tidak ada akupresur masing-masing [13].
Pasien kelompok 1 melaporkan berkurangnya rasa sakit dan kecemasan dengan
perubahan ini yang secara signifikan lebih besar daripada Kelompok 2 atau Kelompok 3.
Pasien kelompok 1 juga menunjukkan penurunan denyut jantung yang signifikan secara
statistik dibandingkan dengan pasien yang diobati dengan akupresur palsu () atau tidak
menerima intervensi (). Skor kepuasan pasien setelah perawatan secara signifikan lebih
baik pada kelompok 1.
Tabel 2: Uji coba intervensi yang menyelidiki efek akupresur terhadap rasa sakit
In a review paper on acupressure, it was shown that this procedure was effective for pain
in patients with dysmenorrhea, during labour, and in trauma [47]. In accord with this, a
randomized double-blinded study in 15 patients with distal radius fracture showed that
acupressure on GV20 and LI4 lowered pain, anxiety, and heart rate and raised patient
general satisfaction [17]. These findings suggest that stimulation with fingers on GV20
and LI4 may be a pain management option for patients with minor trauma during
ambulance transportation to a hospital. Promoting and encouraging acupressure on other
acupoints that fit within the context of analgesia may create a supportive environment of
pain management and is possibly an easy skill to teach all levels of paramedics.
The related technique of auricular acupressure treats the entire body through pressure on
a few points in the ear. In a randomized controlled study of 36 patients with
gastrointestinal illnesses (gastritis, cholecystitis, pancreatitis, and diverticulitis),
researchers compared acupressure in the ear with small plastic ball at the relaxation point
with a sham intervention [14]. Although both interventions showed no significant
changes in blood pressure and heart rate, greater improvements in anxiety and anticipated
perception of hospital treatment were reported with acupressure.
A small, randomized study showed that acupressure in the ear with 1 mm acupressure
plastic beads reduced the level of pain and anxiety as indicated by a reduced heart rate in
patients () with hip fracture compared with patients () in the sham group [16]. These
observations suggest that the application of pressure to auricular acupoints may offer
benefits for improving pain and anxiety. Comparable to auricular acupressure, Korean
hand acupuncture with hand patches consisting of a hard plastic ball was also effective in
producing analgesia [15]. A randomized study involving 100 patients with minor trauma
was conducted, with the groups divided evenly ( per group) into intervention and sham
acupressure groups. Significant improvements in nausea score, vasoconstriction, and
overall patient satisfaction were achieved with Korean hand acupuncture bilaterally on K-
K9 point located in the middle phalanx of the fourth finger. These simple techniques
could be quite easily taught to paramedic clinicians and we would propose further
experimental studies in paramedic practice. The ear is usually an area that is not injured
and is out of the way of body limbs, and gaining access to apply acupressure should not
be hampered by the condition of the patient. The use of acupoint pressure on the ear may
prove easily accessible in a range of situations that may have positive effects which assist
in relieving pain.
4. Effect of Warming Interventions on Pain

Another type of intervention that may be implemented by paramedics for pain control in
specific situations is active warming or resistive heating, and this has been examined in
several studies (Table 3). As opposed to passive heating, in which there is no external
source of heat used other than the person’s own body heat, active or resistive heating
involves using an external source of heat to warm the patient. This may be in the form of
a heated blanket or increased ambient temperature. A single-blinded randomized study
reported that fifty patients undergoing active warming with minor trauma including
limited bleeding, fractures, or contusions experienced less pain and anxiety with
increased overall patient satisfaction, thermal comfort, and core temperature compared
with another fifty undergoing passive warming [18]. A subsequent study, involving
patients with a diagnosis of cholelithiasis, showed that warming with an electric heating
blanket over the abdomen reduced pain, anxiety, and heart rate [19]. The subcutaneous
temperature increased accordingly with increasing skin temperature. Another study using
this technique published by the same group of researchers showed that patients
complaining of abdominal pain from renal colic experienced less pain, anxiety, nausea,
and heart rate with overall improvement of patient satisfaction [20].
Lastly, in a study of female patients with pelvic pain from cystitis, urolithiasis,
cholelithiasis, appendicitis, colitis, and rectal trauma, active warming over the abdomen
caused less pain, anxiety, and nausea, compared to passive warming [21]. These suggest
that active warming could be an adjunct to analgesic treatment at the emergency site.
Dalam makalah peninjauan tentang akupresur, ditunjukkan bahwa prosedur ini efektif
untuk nyeri pada pasien dengan dismenore, selama persalinan, dan trauma [47]. Sesuai
dengan ini, penelitian double-blinded acak pada 15 pasien dengan fraktur radius distal
menunjukkan bahwa akupresur pada GV20 dan LI4 menurunkan rasa sakit, kegelisahan,
dan denyut jantung dan meningkatkan kepuasan umum pasien [17]. Temuan ini
menunjukkan bahwa stimulasi dengan jari pada GV20 dan LI4 mungkin merupakan
pilihan manajemen nyeri untuk pasien dengan trauma ringan saat transportasi ambulans
ke rumah sakit. Mempromosikan dan mendorong akupresur pada titik akupresur lain
yang sesuai dengan konteks analgesia dapat menciptakan lingkungan penanganan nyeri
yang mendukung dan mungkin merupakan keterampilan yang mudah untuk mengajarkan
semua tingkat paramedis.
Teknik akupresur aurikuler yang terkait memperlakukan seluruh tubuh melalui tekanan
pada beberapa titik di telinga. Dalam penelitian terkontrol secara acak terhadap 36 pasien
dengan penyakit gastrointestinal (gastritis, kolesistitis, pankreatitis, dan divertikulitis),
para peneliti membandingkan akupresur di telinga dengan bola plastik kecil di titik
relaksasi dengan intervensi pura-pura [14]. Meskipun kedua intervensi tersebut tidak
menunjukkan adanya perubahan tekanan darah dan denyut jantung yang signifikan,
perbaikan kecemasan dan persepsi pengobatan rumah sakit yang lebih besar dilaporkan
terjadi dengan akupresur.
Sebuah penelitian kecil dan acak menunjukkan bahwa akupresur di telinga dengan
manik-manik plastik 1 mm akupresur mengurangi tingkat rasa sakit dan kecemasan
seperti yang ditunjukkan oleh penurunan denyut jantung pada pasien () dengan fraktur
pinggul dibandingkan dengan pasien () pada kelompok demam [16] . Pengamatan ini
menunjukkan bahwa penerapan tekanan pada auricular acupoints mungkin menawarkan
manfaat untuk meningkatkan rasa sakit dan kecemasan. Sebanding dengan akupresur
aurikuler, akupunktur tangan Korea dengan tempelan tangan yang terdiri dari bola plastik
keras juga efektif dalam memproduksi analgesia [15]. Sebuah penelitian acak yang
melibatkan 100 pasien dengan trauma ringan dilakukan, dengan kelompok dibagi secara
merata (per kelompok) menjadi kelompok intervensi dan akupresur palsu. Perbaikan
signifikan pada skor mual, vasokonstriksi, dan kepuasan pasien secara keseluruhan
dicapai dengan akupunktur tangan Korea secara bilateral pada titik K-K9 yang terletak di
barisan tengah jari keempat. Teknik sederhana ini bisa dengan mudah diajarkan kepada
dokter paramedis dan kami akan mengusulkan studi eksperimental lebih lanjut dalam
praktik paramedis. Telinga biasanya merupakan daerah yang tidak terluka dan berada di
luar tungkai tubuh, dan mendapatkan akses akupresur sebaiknya tidak terhambat oleh
kondisi pasien. Penggunaan tekanan acupoint di telinga dapat terbukti mudah diakses
dalam berbagai situasi yang mungkin memiliki efek positif yang membantu
menghilangkan rasa sakit.
4. Efek Intervensi Pemanasan pada Nyeri
Jenis intervensi lain yang mungkin dilakukan oleh paramedis untuk pengendalian nyeri
pada situasi tertentu adalah pemanasan aktif atau pemanasan resistif, dan ini telah
diperiksa dalam beberapa penelitian (Tabel 3). Berbeda dengan pemanasan pasif, di mana
tidak ada sumber panas eksternal yang digunakan selain panas tubuh orang itu sendiri,
pemanasan aktif atau resistif melibatkan penggunaan sumber panas eksternal untuk
menghangatkan pasien. Ini mungkin dalam bentuk selimut yang dipanaskan atau suhu
lingkungan yang meningkat. Sebuah studi acak tunggal-buta melaporkan bahwa lima
puluh pasien yang menjalani pemanasan aktif dengan trauma ringan termasuk
perdarahan, patah tulang, atau kontusi yang terbatas mengalami sedikit rasa sakit dan
kecemasan dengan peningkatan kepuasan pasien secara keseluruhan, kenyamanan termal,
dan suhu inti dibandingkan dengan lima puluh lainnya yang menjalani pemanasan pasif
[18 ]. Sebuah studi berikutnya, yang melibatkan pasien dengan diagnosis cholelithiasis,
menunjukkan bahwa pemanasan dengan selimut pemanas listrik di atas perut mengurangi
rasa sakit, kegelisahan, dan denyut jantung [19]. Suhu subkutan meningkat seiring
dengan meningkatnya suhu kulit. Studi lain yang menggunakan teknik ini yang
diterbitkan oleh kelompok peneliti yang sama menunjukkan bahwa pasien yang
mengeluh sakit perut akibat kolik ginjal mengalami sedikit rasa sakit, kegelisahan, mual,
dan denyut jantung dengan peningkatan kepuasan pasien secara keseluruhan [20].
Terakhir, dalam sebuah penelitian terhadap pasien wanita dengan nyeri pelvis dari sistitis,
urolitiasis, cholelithiasis, radang usus buntu, kolitis, dan trauma rektum, pemanasan aktif
di perut menyebabkan lebih sedikit rasa sakit, kegelisahan, dan mual, dibandingkan
dengan pemanasan pasif [21]. Ini menunjukkan bahwa pemanasan aktif bisa menjadi
tambahan untuk penanganan analgesik di tempat darurat.
5. Kesimpulan
5. Conclusion
There are many reasons why paramedicine and emergency care practice has been moving
in the direction of advanced pharmacological interventions for the management of pain in
both acute and chronic situations. This coincides with other areas of advanced life
support and patient management strategies that have been well researched and continue to
benefit from the increasing evidence. Even though paramedic practice is firmly focused
on pharmacological interventions to alleviate pain, there is a developing literature
suggesting that a range of nonpharmacological options may also have an important role
in managing pain in individuals cared for by paramedics.
As a developing profession, paramedicine should investigate multiple modalities and
consider complementary and alternative therapies that could be used to enhance pain
relief and potentially also reduce the reliance on pharmacological interventions as the
first-line approach to alleviating pain. If proven to be efficacious, the analgesic sparing
effect may translate into cost reductions and better patient outcomes with less adverse
reactions. However, further research is required to develop the level of evidence required
to support changes to practice. From the research that has been conducted, we can see
great potential value of conducting trials into the use of complementary therapies within
paramedic practice and would strongly encourage further research specifically that looks
into the use of simple techniques such as acupuncture (including electroacupuncture and
acupressure), TENS, and active warming.
Ada banyak alasan mengapa paramedicine dan perawatan darurat telah bergerak ke arah
intervensi farmakologis lanjutan untuk penanganan nyeri pada situasi akut dan kronis. Ini
bertepatan dengan bidang lain dari dukungan kehidupan lanjut dan strategi manajemen
pasien yang telah diteliti dengan baik dan terus mendapatkan keuntungan dari semakin
banyak bukti. Meskipun praktik paramedis sangat terfokus pada intervensi farmakologis
untuk mengurangi rasa sakit, ada literatur yang berkembang yang menunjukkan bahwa
berbagai pilihan nonfarmakologis mungkin juga memiliki peran penting dalam mengelola
rasa sakit pada individu yang dirawat oleh paramedis.
Sebagai profesi yang berkembang, paramedis harus menyelidiki beberapa modalitas dan
mempertimbangkan terapi komplementer dan alternatif yang dapat digunakan untuk
meningkatkan pereda nyeri dan berpotensi juga mengurangi ketergantungan pada
intervensi farmakologis sebagai pendekatan lini pertama untuk mengurangi rasa sakit.
Jika terbukti berkhasiat, efek hemat analgesik dapat diterjemahkan ke dalam reduksi
biaya dan hasil pasien yang lebih baik dengan reaksi yang kurang menguntungkan.
Namun, penelitian lebih lanjut diperlukan untuk mengembangkan tingkat bukti yang
dibutuhkan untuk mendukung perubahan praktik. Dari penelitian yang telah dilakukan,
kita dapat melihat nilai potensial yang besar dalam melakukan uji coba penggunaan terapi
komplementer dalam praktik paramedis dan akan sangat mendorong penelitian lebih
lanjut secara khusus yang melihat ke dalam penggunaan teknik sederhana seperti
akupunktur (termasuk electroacupuncture dan akupresur) , TENS, dan pemanasan aktif.
Conflict of Interests
The authors declare that there is no conflict of interests regarding the publication of this
paper.
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Most people are willing to do just about anything to escape the grips of chronic
pain. One of the first remedies offered to chronic pain sufferers is prescription
drugs. Prescription painkillers are very effective in most cases. However, the pain
relief they offer comes at a price for many.Some painkillers can negatively affect
other systems in your body, including your lymphatic system, your kidneys, and
your liver. Painkillers run the risk of becoming addictive. And as countless news
reports have shown, the results of addiction to painkillers can be devastating.The
fear of side effects and the dread of addiction has led some chronic pain sufferers
to look for non-pharmaceutical pain relief options. If this is true in your case, we
understand your concerns, and we are eager to work with you to create a pain
management treatment that fits into your acceptable parameter of care.
We are happy to offer our clients non-pharmaceutical pain management therapies.
What Is the Benefit of Non-Pharmaceutical Pain

Management Therapies?
If chronic pain is not treated, it affects your ability to live comfortably. Chronic
pain leads to diminished appetite, insomnia, and decreased energy. Chronic pain
affects the way that you interact with others. This can lead to diminished job
performance and strained personal relationships.
Non-pharmaceutical therapies decrease pain and can be used in addition to

pharmaceuticals or in lieu of pharmaceuticals. They offer the possibility to improve
your quality of life. As with any other treatment, each individual will respond
differently to different therapies, and there is no guarantee that any therapy will
provide 100 percent pain relief.
What Are Some Non-Pharmaceutical Pain Control

Options?
Heat: Doctors and healers have used heat as a way to minimize pain for centuries.
Heat can minimize muscle pain and control muscle spasms. Heat can be applied to
the affected area for between 20 minutes and 30 minutes every two hours for as
many days are needed to provide relief.
Massage Therapy: Massage therapy is beneficial for multiple reasons. First,
massage therapy can relax tense muscles. Massage therapy stimulates blood flow
and encourages the lymphatic system to remove toxins and proteins that can lead
to inflammation. Additionally, the human touch of massage therapy can have a
powerful pain reducing effect.
Transcutaneous Electrical Nerve Stimulation: This procedure uses a battery-

powered device that is placed on your skin. It delivers a mild electrical jolt to the
area that is causing pain. It is a safe yet effective pain control technique.
Spinal Cord Stimulation: During this procedure, an electrode is implanted close to

your spinal cord. It delivers mild electrical signals designed to relax the nerves that
cause your pain.
Acupuncture: Acupuncture is a therapy that has been used for centuries to provide

effective pain relief. While its use in Western medicine is relatively new, it has
quickly gone from being viewed as a form of alternative medicine to being included
in traditional Western medicine. During this procedure, thin needles are used to
balance the flow of energy through your body with the goal of reducing pain and
other uncomfortable symptoms.
Physical Therapy: Physical therapy teaches you how to heal yourself. It teaches

you how to improve your movements, improve your flexibility, and increase your
strength with the goal of decreasing your pain. Physical therapists are able to
provide you with exercises and flexibility techniques that you might not know exist.
Laughter: Laughter is the best medicine. While this might sound like a cliché
phrase, the truth is that doctors recognize that if a person is able to laugh and let
go of some of their fear, anxiety, and depression, this can have a positive impact
on their pain levels.
Ice: Ice reduces pain by reducing swelling and inflammation. It can stop tissue
damage and help the body recover. You can use an ice pack or simply crush ice in a
plastic bag. Cover the ice pack with a cloth, and put it on the area for 15 to 20
minutes once every hour.
Aromatherapy: Aromatherapy uses scents to relax you, relieve your stress, and
reduce your pain. Everything from flowers to herbs to oil extracts and to tree
fragrances can be used.
How We Can Help

We strongly believe that you have the right to help plan your care. That is why
during your initial consultation with us the first thing that we do is listen to you.
We want to learn about your health, about your condition, and what steps you have
already taken to try to address your pain.
We are keenly interested in what your pain management goals are, and we are
excited to work with you to make those pain management goals a reality. We will
create a comprehensive program designed to provide you with short-term and long-
term relief.
In the short term, we want to get you up and moving without pain. In the long-
term, we want to work with you to create pain management therapies designed to
allow you to live an active, happy life.
We understand that you may have come across some medical professionals who
were reluctant to provide you with the care you needed not using pharmaceuticals.
They may have doubted the reality of your pain or its severity.
This will never happen with us. We understand that all pain is real, that the pain
our clients feel is individualized, and that all pain can be managed.
We never give up on our clients. We will never give up on you. Contact us today,
and let us show you why so many people trust us to help them develop their non-
pharmaceutical pain management therapies.
Chronic Pain Management
 Medical practitioners
 Prescribe a psychostimulant medication
 Prescribing a Schedule 8 opioid or benzodiazepine
 Guides for Medical Practitioners
 Chronic Pain Management
 Attention Deficit Hyperactivity Disorder (ADHD)
 NSW Opioid Treatment Program (OTP)
 Frequently Asked Questions
 Notifying the loss or theft of accountable drugs
 Useful links and publications
 Legislation
 What's new
 Contact Pharmaceutical Services
 About Pharmaceutical Services
 Application forms for authority to prescribe
Information for Medical Practitioners

Facts and figures on chronic pain
The impact of chronic pain
The doctor-patient relationship
How to assess pain
What should a patient know about chronic pain and its management?
Developing a pain management plan
Treatment options for chronic pain
Good practices in the pharmacological management of chronic pain
Using opioids to manage chronic pain
Pain management and drug dependence
Do I need approval to prescribe pain medication?
Facts and figures on chronic pain
Pain is regarded as chronic when it does not go away and is experienced by a patient on most days of the week for at least 3
months.
About 1 in 5 Australians suffer from chronic pain.
A slightly higher proportion of females report having chronic pain than males do.
Prevalence tends to be higher in older individuals. At least 1 in 4 women aged 50 years or over report having chronic pain.
The leading cause of chronic pain is reported to be injury, commonly from playing sport, car accidents, home accidents and work
accidents.
Almost two-thirds of people with chronic pain report that their pain interferes with their daily activities.
It is common for a person with chronic pain to consult their GP about their pain, but patients also seek advice from medical
specialists (e.g. orthopaedic surgeons, rheumatologists, anaesthetists), and allied health professionals and alternative practitioners
including physiotherapists, pharmacists, chiropractors, masseurs, acupuncturists, and naturopaths.
Use of oral analgesics by people in chronic pain is common. Paracetamol and non-steroidal anti-inflammatory drugs are the most
frequently used, but a notable proportion of patients use vitamins, minerals and/or herbal and natural preparations.
[back to top]
The impact of chronic pain

Chronic pain can have an enormous impact on people. It may interfere with a person’s sleep patterns, their sexual activity, their
ability to work and conduct daily activities, and it can cause emotional distress and lead to serious mental health problems,
including depression.
The goals of pain treatment are to enhance functioning and reduce suffering and distress, while minimising the risk of adverse
effects. While it is rare to eliminate chronic pain completely, it should be possible to control pain to a tolerable level and allow
people to function at an acceptable level.
While acute pain can usually be attributed to an identifiable disease or damage process, finding an identifiable process for chronic
pain can be very difficult. Sometimes the cause of the pain cannot be determined. This does not make the pain any less real to the
patient.
[back to top]
The doctor-patient relationship

A collaborative doctor-patient relationship that is based on mutual respect and includes two-way communication is particularly
helpful for patients with chronic pain.
Patients who have good relationships with their doctors tend to be more satisfied with their care. There are several ways a doctor
can promote a good doctor-patient relationship:
 Empathise with the patient and take their complaint seriously. Whilst pain is a very subjective experience, it can be
measured with a numeric, visual or verbal scale. Information about a patient’s pain can also be obtained by asking the patient to
keep a pain diary.
 Maintain an optimistic and positive attitude in consultations.
 Resist the temptation to order investigations when the patient has already been thoroughly investigated – they are
unlikely to reveal anything new and may only distract patients from taking responsibility for the management of their pain.
 Educate your patient about chronic pain and its treatment, and address any unrealistic expectations they may have
formed.
 Discuss with the patient what you do and don’t know about their particular pain condition. Answer any questions your
patient may have. Be honest if you do not have answers to all of the questions your patient asks.
 Provide sufficient information to your patient about their treatment options and the pros and cons of each option.
Because the management of chronic pain typically involves a number of medical practitioners and allied health professionals,
some patients can be left feeling somewhat bewildered. To avoid this, it is important for the patient to have one person who
serves as the primary care doctor – someone who is familiar with the person’s medical history and can co-ordinate the patient’s
overall medical care. The GP is ideally placed to take on this role.
[back to top]
How to assess pain

Assessment of pain is essential to successful pain management. A pain assessment guides the selection of treatments, and
provides a baseline against which to measure a patient’s progress during treatment.
Physical examination is only one aspect of pain assessment. Self-reports are the most reliable indicators of pain severity or
intensity. Many patients have great difficulty in describing pain sensations.
A variety of pain measurement tools are available for doctors to use. They include numeric scales, visual analog scales, and
verbal rating scales. The numeric and visual scales typically appear as a horizontal line rated from ‘no pain’ at the left end to
‘worst possible pain’ at the right end. The patient marks the line according to the pain they feel. In verbal rating scales,
descriptors are used to rate the patient’s pain, e.g. no pain, mild pain, moderate pain, severe pain, worst possible pain. The tool
used should be appropriate to the patient’s cognitive development, language, culture and preference. For example, faces scales
(comprising a series of cartoon faces ranging from a happy face to a very sad/tearful face) are most appropriate for children who
may have difficulty translating their pain into a numerical value or a verbal descriptor.
Assessment tools have been developed that attempt to capture a more global picture of a patient’s pain experience. They consider
multiple dimensions of pain such as the characteristics of pain, the emotional aspects of pain, and functional impairment. More
widely known multidimensional scales include the Brief Pain Inventory (a short and long form is available), the McGill Pain
Questionnaire, the Behavioral Assessment of Pain Questionnaire, and the Pain Outcomes Questionnaire.
Pain diary
Ask the patient to keep a pain diary. The patient should record in the diary when the pain begins, where they feel it, how long the
pain lasts, how the pain feels (using standard pain scales to rate the pain helps to objectify it), what triggers it, what makes it
better, and what makes it worse.
Information collected in the pain diary will help you assess the effectiveness of treatment and help you identify potentially more
effective strategies for the patient to use.
Psychological, social and occupational functioning

A pain assessment should include evaluation of a patient’s psychological functioning. A person with chronic pain may develop
negative beliefs about their experience of pain or negative thoughts about themselves. A high proportion of people with chronic
pain also suffer from depression and anxiety. A person who has anxiety or depression often feels their pain more acutely and is
more disabled by it. If left untreated, anxiety or depression may increase and loom over all aspects of the patient’s life and make
pain control and return to normal life very difficult. People who have poor psychological functioning may need referral to a
psychologist who can help them with strategies for dealing with any detrimental thoughts, emotions or beliefs.
Assessment should include a measurement of the patient’s ability to perform household chores, work tasks, leisure interests, and
sleep. Tracking a patient’s participation in normal household activities, attendance at work, and participation in non-work-related
activities such as going out with family and friends and engaging in hobbies, provides a measure of how disabling pain is but also
an indication of progress during treatment.
Chronic illness has major effects on families of a patient with chronic pain. It may distress family members to see their loved one
in pain, but over time can lead to feelings of frustration, anger and resentment. Each member usually needs to make an
adjustment in response to the patient’s reduced ability to participate in activities of everyday living. For couples there may be a
loss of intimacy and a re-structure of roles. Families often experience a financial loss. Engaging family members in the
assessment and treatment process allows for the patient’s functioning at home to be evaluated and also provides family members
with the opportunity to better understand the problem of chronic pain and how to deal with it. Some families may need referral to
a psychologist, counsellor or family therapist.
[back to top]
What should a patient know about chronic pain and its

management?
Patient education should be an integral part of treatment for chronic pain. It commonly includes:
 Information about the nature of the pain, including the likely duration of symptoms
 Instruction on how to use a pain diary and pain measurement tools
 Discussion about the goals of therapy
 Information on methods of pain relief (medications available to treat chronic pain and non-pharmacological pain
management strategies that can be used) and the pros and cons of appropriate treatment options
 Addressing any fears the patient may have and any barriers there may be to pain management
Suitable written material can be provided. Pamphlets have been developed by theNSW Therapeutic Advisory Group for patients
with chronic pain, low back pain, and migraine.
Encourage your patient to check out reliable sources of information such as books, the internet, other health professionals, and
support organisations. Although there are many reputable sites on the internet, warn patients that some material on the internet
may be incorrect or misleading.
A number of other issues can be raised with the patient to facilitate treatment:
 Expectations about treatment must be realistic – complete relief from chronic pain is rare
 The exact cause of chronic pain cannot always be identified
 The patient should be responsible for the day-to-day management of their pain. A person who uses their own skills and
resources is much better placed to lead a normal life than one who relies solely on prescribed medication
 There are numerous self-management methods that patients can try to improve their quality of life, including relaxation
techniques, simple cognitive and behavioural strategies (e.g. distraction, visualisation, positive self-talk), physical exercises,
massage, hot/cold treatment, good sleep and rest patterns, and a healthy diet. The patient may initially need some basic
instruction on how to use some of these strategies
 A network of support people, such as family members, friends and fellow sufferers, can provide important emotional
and practical help for when it is needed

[back to top]
Developing a pain management plan

An important component of treatment is a pain management plan. This is a written document agreed upon by the patient, the GP,
and the pain management team.
A pain management plan should specify the goals of therapy, and a timeframe for reaching each goal. The goals should be
realistic and relevant. Examples of goals include: reducing the severity of pain, improving physical function, increasing activity
at home or work, increasing participation in social activities, reducing medication use, increasing self-management of pain and
related problems, improving mood, improving sleep patterns. The more specific the goals are written up, the easier they are for
patients to comprehend and for the progress of the treatment to be measured. For example, ‘walk to and from the shops every
day’ is better than ‘walk more often’.
The plan should outline all of the treatments or strategies to be used, when they are to be used, and any possible side effects.
The pain management plan can help GPs, Emergency Department physicians and locum practitioners to provide consistent care.
Liaison between senior Emergency Department physicians and the GP should occur as early as possible. Use ofChronic Disease
Management items on the Medicare Benefits Scheme may facilitate this process. The plan should address ‘after hours’ care to
help patients deal with exacerbations that may occur out of normal business hours. The patient’s GP and/or pain management
team should be informed of Emergency Department visits and locum consultations, especially where there is an increased
frequency of these presentations.
Progress should be evaluated at regular intervals. Where progress is less than satisfactory, the treatment/s may need adjustment.
The patient’s compliance with the plan may also need evaluation.
[back to top]
Treatment options for chronic pain
Management of chronic pain generally requires a multi-modal approach which emphasises the role of non-drug techniques. It
should not rely on pharmacological therapy alone. Non-pharmacotherapy options include patient education, behaviour therapy,
cognitive therapy, cognitive-behaviour therapy (CBT), physical therapy, family therapy, complementary and alternative therapy
(e.g. manipulative methods, acupuncture), and surgery and other invasive procedures.
Medication frequently forms part of a patient’s treatment. Selection of medication should take into account the patient’s medical
history, the nature of the pain (e.g. type, site, severity), and factors that may affect a patient’s compliance with the prescribed
regimen such as age, cognitive state, route of administration and tolerance. Useful guidelines and tools are available on
the Hunter Integrated Pain Service website.
[back to top]
Good practices in the pharmacological management of chronic

pain
Before starting patients on medication, it is important to review their medication history, including:
 Use of over-the-counter products (e.g. paracetamol, NSAIDs) or adjuvant agents, including information on dosage,
duration of treatment, and any adverse reactions
 Establish whether past treatment failures were the result of an inadequate therapeutic trial of medication, inappropriate
dosage adjustments, inadequate management of side effects, or patient misconceptions about the goals of therapy
 Use of alternate, herbal and complementary medicines
Regular dosing should be used rather than an ‘as required’ approach.
Maximal doses should be used before moving to the next line of medications.
Assess the patient’s response to medications after 2 to 3 weeks of use.
If the patient does not respond, review and explore the reasons for non-response. It may be that the medication is having little or
no effect on the patient’s pain, or it may be that the patient is underreporting their response (perhaps due to unrealistic
expectations) or they are not taking the medication as instructed (perhaps because of unpleasant side effects or forgetfulness, or
general concerns about taking medication).
Explain to the patient:
 Why analgesics are part of the treatment plan

 How and when to take the medication
 What side effects to expect and how to manage them
 How the effectiveness of the medication will be measured and progress monitored
 The doctor should be consulted before stopping or changing medication
Treatment of chronic pain should be reviewed regularly. Assessment should include:
 The patient’s level of comfort (or degree of analgesia)

 Medication-related side effects
 Physical and psychosocial functioning
 Review of pain diary entries, if being used
[back to top]
Using opioids to manage chronic pain

Existing evidence does not support the long term efficacy and safety of opioid therapy for chronic non-cancer pain.
Ideally, assessment by a pain clinic or consultation with a pain medicine specialist should precede the prescription of oral
opioids.
In NSW, if a patient is suspected or known to be drug dependent, authorisation to prescribe opioids for that patient must be
obtained from the NSW Ministry of Health prior to starting treatment. More information is available on Prescribing a Schedule 8
opioid or benzodiazepine.
Before initiating opioid therapy, the doctor should:
 Clearly explain the goals of opioid therapy (complete pain relief may not be achievable) and the time course over
which these goals should be attained
 Discuss the likelihood of developing physical dependence and tolerance, and any concerns about abuse or diversion
 Explain to the patient that opioids may at first affect their alertness and impair their thinking and that they should avoid
driving or similar activities until the effects dissipate
 Explain other side effects (e.g. constipation) and how they may be managed
 Explain that patients who receive opioids for a medical reason and who have no history of drug abuse or addiction are
unlikely to develop an addiction problem, but if there is reason to suspect that the patient is developing problems, referral to a
specialist in pain medicine, mental health or drug services may be necessary
 Document the patient’s informed consent to treatment in the medical record
It is important that the appropriate dose is prescribed. An appropriate dose is one which achieves satisfactory functioning with
adequate pain control and tolerable side effects. A common error is to use inadequate doses of opioid analgesics.
Injectable opioids are rarely necessary to treat chronic pain, and should be reserved for patients with acute pain.
Pethidine has a relatively short duration of action and is not recommended for the management of chronic pain.
[back to top]
Pain management and drug dependence

Some patients who are prescribed opioids engage in problematic drug-related behaviours. In NSW, clinical advice on the
management of a patient with problems related to opioid dependence is available from the NSW Drug and Alcohol Specialist
Advisory Services on 1800 023 687 or (02) 9361 8006.
If a doctor suspects a patient of seeing other doctors – ‘doctor shopping’ – to obtain opioids or other drugs liable to abuse such as
benzodiazepines, they can contactMedicare Australia's Prescription Shopping Program registered with the service, doctors can
obtain information on the amount and type of Pharmaceutical Benefits Scheme (PBS) medicine recently supplied to patients who
have been identified as obtaining medicine in excess of their medical needs.
Patients who are suspected or known to be drug dependent will inevitably require treatment for pain at some stage, and have a
right to have their pain managed in the same way as other patients.
Those who are on substitution therapies (e.g. methadone or buprenorphine maintenance), or those who are physically dependent
on prescribed or illicitly obtained opioids will need to have their baseline opioid requirements met in addition to pain treatment.
Because of their tolerance, they may require higher or more frequent doses for pain control. Pain management for such patients is
ideally carried out by specialists in drug and alcohol or pain medicine.
In NSW, for a patient who is drug dependent or for whom a doctor suspects is drug dependent, authorisation to prescribe opioids
( Schedule 8 drugs) must be obtained from the NSW Ministry of Health (Pharmaceutical Services) before treatment is initiated.
[back to top]
Do I need approval to prescribe pain medication?

To prescribe under the Pharmaceutical Benefits Scheme (PBS), you will need to obtain a Federal Government authority
from Medicare Australia for particular medications.
In addition to a Federal authority, you may require approval (in the form of a written authority) from your State or Territory
health authority (e.g. NSW Ministry of Health). It should be noted that different legal requirements exist between States and
Territories in Australia.
In NSW, a doctor must obtain an authority from the NSW Ministry of Health (Pharmaceutical Services), after 8 weeks of
continuous treatment with any of the following medications in order to continue prescribing:
 any injectable drug of addiction

 alprazolam (from 1 February 2014)
 buprenorphine (except transdermal preparations)
 flunitrazepam
 hydromorphone
 methadone
If a patient is suspected of being drug dependent, an authority must be obtained before starting treatment with any medication
classified as a drug of addiction (i.e. drugs listed under Schedule 8 of the NSW Poisons List.)
For details of requirements for an authority in NSW refer to Requirements for an Authority to Prescribe Drugs of Addiction
Under Section 28 of the Poisons and Therapeutic Goods Act (TG212) or contact the Duty Pharmaceutical Officer at
Pharmaceutical Services, NSW Ministry of Health, on (02) 9391 9944 if you have any queries about prescribing opioid treatment
in NSW. More information about prescribing opioid medication and to obtain an application form for authority to prescribe an
opioid is available on Prescribing a Schedule 8 Opioid or Benzodiazepine.

Pain Management Pharmachology and Non Pharmacology

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Abstract

Nonpharmacological analgesia therefore involves the inhibition of nociceptive input by

2. Transcutaneous Electrical Nerve Stimulation (TENS)

3. Acupuncture, Electroacupuncture, and Acupressure

4. Effect of Warming Interventions on Pain

4. Efek Intervensi Pemanasan pada Nyeri

We are happy to offer our clients non-pharmaceutical pain management therapies.

What Is the Benefit of Non-Pharmaceutical Pain

Non-pharmaceutical therapies decrease pain and can be used in addition to

What Are Some Non-Pharmaceutical Pain Control

Transcutaneous Electrical Nerve Stimulation: This procedure uses a battery-

Spinal Cord Stimulation: During this procedure, an electrode is implanted close to

Acupuncture: Acupuncture is a therapy that has been used for centuries to provide

Physical Therapy: Physical therapy teaches you how to heal yourself. It teaches

How We Can Help

Information for Medical Practitioners

About 1 in 5 Australians suffer from chronic pain.

The impact of chronic pain

The doctor-patient relationship

How to assess pain

Psychological, social and occupational functioning

What should a patient know about chronic pain and its

Developing a pain management plan

Good practices in the pharmacological management of chronic

Assess the patient’s response to medications after 2 to 3 weeks of use.

Explain to the patient:

 Why analgesics are part of the treatment plan

 The patient’s level of comfort (or degree of analgesia)

Using opioids to manage chronic pain

Pain management and drug dependence

Do I need approval to prescribe pain medication?

 any injectable drug of addiction

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