Multidisciplinary pain management rsuh dr. takdri

MULTIDISCIPLINARY PAIN MANAGEMENT:
INDONESIA PERSPECTIVE
A.M.TAKDIR MUSBA
o DEPARTMENT OF ANESTHESIOLOGY, INTENSIVE CARE AND PAIN
MANAGEMENT, FACULTY OF MEDICINE, HASANUDDIN UNIVERSITY
o INDONESIAN PAIN SOCIETY
o TASK FORCE OF PAIN MANAGEMENT GUIDELINE, INDONESIA MINISTRY
OF HEALTH

OUTLINE
 PAIN MANAGEMENT FACT IN INDONESIA
 MULTIDISCIPLINARY PAIN MANAGEMENT
 THE NEED OF MULTIDISCIPLINARY APPROACH
 REGULATION SUPPORT

Pain as a priority
 American Pain Society, 1996 :
 Pain as the 5th vital sign
 JCAHO, 2000 ( JCI ):
 Patient’s right to appropriate assessment and
management
 Montreal Declaration, 2010 :
 The right of all people access pain management
 All people with pain have assessment and treatment
by trained HCP
 Indonesia Hospital Accreditation :
 KARS
 SNARS1

Mengenang Ibu Endang ( Almh )
 "Sekarang kondisi saya masih belum sehat, karena masih
uber-uberan dengan penyakit saya. Artinya, setiap
diperiksa, kanker itu masih ada di dalam sana.Ternyata
kanker itu pintar, ditembak di sini, keluar di sana," ujar
Endang dalam diskusi buku Berdamai dengan Kanker di
RSCM (8/6/2011)
 Keberadaan kankernya tidak menyebabkan rasa sakit apa
pun. Justru terapi radiasi dan kemoterapi yang dijalaninya
selama lebih kurang dua tahun yang membuatnya
merasakan sakit yang luar biasa. Setiap kali pengobatan,
kita harus berfikir kita hidup di sini ada yang menunggu,
suami dan anak-anak. Ditanggung bersama rasanya jadi
enteng," katanya.
PAIN IN HOSPITAL , ITS REAL …………

INADEQUATE PAIN MANAGEMENT IN
INDONESIA
 Pain Survey in Outpatient Setting, 2011-2012, INDONESIA
 Interviewing patient using closed ended questionnaires
 14218 patients, 528 MDs
 Contributors specialist: Surgeon, Neurologist, Internal
Medicine, PM&R specialist, Rheumatologists, Orthopedic
Surgeon, Neurosurgeon, Urologist, GP, etc.
 Result
Source : UTOPIA Initiative, Pain Survey , 2011-2012
 87% of patients suffered pain
 61% suffer from pain more than 1 week
 currently consuming painkiller ( 61% of pts )
 consuming NSAID/COXIB (63% of pts )
 suffer moderate-severe pain (74% of pts )

Source : UTOPIA Initiative, Pain Survey, 2011-2012
74% of Patient suffer moderate-severe pain
but only 17% patient get ladder 2 & 3 painkiller
INADEQUATE PAINTREATMENT IN INDONESIAPain Complaint Vs Pain Treatment

Result
simple random sampling dari 1924 pasien
dengan keluhan nyeri , n=331
KARAKTERISTIK PASIEN RAWAT JALAN DENGAN
KELUHAN NYERI DI PUSKESMAS X KOTA Y
PADA BULAN FEBRUARI 2017
Hasbar AM, Musba AMT. 2017. unpublished

Low utilization OPIOID by Indonesia Physician
 Cross-sectional study was conducted in General Hospital Jakarta and Private
Hospital inTa ngerang with medical specialist who treating cancer pain.
 From a total of 146 distributed questionnaires, we received 103
questionnaires (70,5%).
 Result :
 The majority of respondents (69,9%) had inadequate knowledge
 The highest rate (70,55) was found in the choosing opioid section, the
lowest rate (49,5) was found in the opioid side effects section.
 There is no significant relationship between physician knowledge on
opioid usage and specialization (P= 0,355)
 Major obstacle to opioid use
 Government regulation
 Lack of training
 Drug availability
 Knowledge of side effects
Indrayani L, et al, Indonesian Journal of CancerVol. 11, No. 4, 2017
THE SURVEY RESULT

Multi-approach based on
pain conceptual model
Gatchel, 2004

Surgical
Approach
Multimodal Approach of PAIN
Psychological
Support
Strategies for
Managing Pain and
Associated Disability
Physical Medicine
and Rehabilitation
Lifestyle Change
Complementary and
Alternative Medicine
Pharmacotherapy
bio-psycho-social approach
Interventional
Approach
Schatman M.E., Interdisciplinary Chronic Pain Management.
Bonica’s Pain Management , 4th ed. 2010

Response Cortical
Response Suprasegmental
Response Segmental
Response Local
- anxiety
- fear
- apprehension
- neurohumoral response
- catecholamines
- cortisol
- dll.
- musclespasm
- vasospasm
- bronchospasm
-release pain substances
-inflammation
RESPONSES TO NOXIOUS STIMULI

The Impact of Inadequate
Pain treatment
INADEQUATE PAIN
TREATMENT
PHYSIOLOGIC, PSYCHOLOGIC
AND SOCIAL CONSEQUENCES
MORBIDITASAND MORTALITAS

Pain and its management
at the beginning of the 21st Century
 Significant advances in knowledge regarding the
biological, psychological and social aspects of the pain
 Advances in pharmacological, interventionalist and
psychological management
 Development across theWestern world of
 introduction of acute pain management teams into hospitals
 multi-professional pain clinics , than unimodal pain clinic
Bond, M. Pain Manage. (2011) 1(1), 3–5
Few of these advances were evident
in developing countries.

Multidisciplinary team
Pergolizzi J. TOWARDSA MULTIDISCIPLINARYTEAMAPPROACH
IN CHRONIC PAIN MANAGEMENT

Advantages of Multidisciplinary
Team (1)
 Allows a multidimensional diagnosis of chronic pain
 „Avoids duplication of investigations
 „Facilitates early and accurate diagnosis
 „Aids rapid initiation of treatment following diagnosis
 „Ensures the availability of a wide array of treatment options
(pharmacological and non-pharmacological)
 „Treatment plans are individualized
 „Care is delivered in a programmed and coordinated manner
 „Provides continuity of interaction and care
 „Treatment offered is up-to-date, evidence based and safe
Pergolizzi J et al.Towards a multidisciplinary pain team
approach in chronic pain. EFIC. CHANGEPAIN

 „Treatment failure can be recognized early on
 „Potential for improvement in patient’s quality of life, patient
optimism and mood state
 „Faster return to work
 „Patients greater confidence in treatment plan knowing that it
developed by collaboration between different specialties
 „Patients opportunity to discuss treatment options and ask
questions of the different specialists involved in their care
 „Opportunity for access to clinical trials and research program
within the pain clinic
 „Improved interdisciplinary knowledge
Advantages of Multidisciplinary
Team (2)
Pergolizzi J et al.Towards a multidisciplinary pain
team approach in chronic pain. EFIC. CHANGEPAIN

Without multidisciplinary approach
(An example)
Overtreating of Chronic Back Pain
 Overprescription of opioids and Analgesics
 Overutilization of interventional techniques
and spinal surgery
 Lack of access to interdisciplinary pain
management programs
Deyo RA, Mirza SK,Turner JA, Martin BI. Overtreating chronic back
pain: time to back off? J Am Board Fam Pract 2009;22:62–8.

47.849 Specialist
41.026 General Practitioner ( 16.565 in PKM )
12.740 Dentist ( 6.537 in PKM )
223.940 Nurse
Ministry of Health, Indonesia, 2015
2488 Hospital
9754 Public Health Centre
( 1 : 30.000 population )
255.461.686 Population
• ACUTE PAIN  CHRONIC PAIN
• LATE D/ & R/  CHRONIC PAIN SUFFERING
• PAIN PALLIATIVE CARE

PAIN MANAGEMENT development based
on our National Health System
• PRIMARY CARE CENTRE
• PAIN COMPETENCY of HCP
• AVAILABLE ANALGESIC DRUG
• NOT A PRIORITY IN PRIMARY CARE
• Secondary and tertier CARE CENTRE
• Less collaboration
• Less support

Pain Services Referral
I
N
D
O
N
E
S
A
n
o
w
f
u
t
u
r
e
Pergolizzi J. TOWARDSA MULTIDISCIPLINARYTEAM
APPROACH IN CHRONIC PAIN MANAGEMENT

Single Discipline out-patient
pain practice
Pergolizzi J. TOWARDSA MULTIDISCIPLINARY
TEAM APPROACH IN CHRONIC PAIN
MANAGEMENT
unidisciplinary pain practice :
- Has a good working knowledge of what other disciplines can offer
- Has the facility to consult as needed with healthcare workers from other specialities

PAIN MANAGEMENT IN HOSPITAL
 ACUTE PAIN SERVICES
 CHRONIC PAIN SERVICES
 CANCERAND PALLIATIVE SERVICES
Secondary andTertier Care
- COMPREHENSIVE
- INTEGRATED
- ADVANCE

OUR LOVELY INDONESIA
DEVELOPING COUNTRY BIG COUNTRY
BIG POPULATION VERY DIVERSE
UNIQUE LOCALLY OTONOMIC ERA
REGULATION

KELOMPOK KERJA PENYUSUNAN PEDOMAN
TATALAKSANA NYERI DI RUMAH SAKIT,
DIRJEN YANKES KEMKES, 2017

DRAFT PNPK TATALAKSANA NYERI
TERPADU KEMKES RI, 2018
PENGESAHAN FINAL DRAFT, 19 Feb 2019

Draft Panduan tatalaksana nyeri
KEMKES RI, 2018
 Modalitas penanganan nyeri
 Penanganan nyeri multidisiplin
 Alur pelayanan pasien nyeri
 Klinik nyeri unidisiplin/multidisiplin
 dll

Factors in PM development
PAIN
MANAGEMENT
Human resources
- Education,Competency and
Collaboration
Drug and
technique
available
- Opioid,Non-opioid
- PM facilities
- APS equipment
Patients perspective
- Belief
- Culture
- Fear of side effect
Health care
system
- Pain priority
- Cost and Reward
- Government and
Hospital policy
M. Size, et al. Anaesthesia, 2007, 62 (Suppl. 1), pages 38–43
Bond M. Pain Manage. (2011) 1(1), 3–5

SUMMARY
 INADEQUATE PAINTREATMENT STILL A FACT IN
INDONESIA HEALTH SERVICES
 PAIN AS A COMPLEX PROBLEM NEED
MULTIDISCIPLINARY APPROACH FOR BETTER RESULT
BASED INDIVIDUALLY PATIENT NEEDED
 THERE IS A BIG ROLE OF PHYSICIAN AND HOSPITAL
FOR BETTER PAIN MANAGEMENT
 CHANGE PARADIGMTO MULTIDISCIPLINARY PAIN
TREATMENT IS AN OBLIGATE FOR ALL PHYSICIAN

LEARNING TOGETHER
WORKING TOGETHER
SHARING EACH
OTHER
-AHT-

Multidisciplinary pain management rsuh dr. takdri

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