Download Cancer Pain - The Filipino Doctor

Cancer Pain
(2012)
Philippine Society of Oncology, Inc.
Room 803 North Tower Cathedral Heights Building Complex,
St. Luke's Medical Center, E. Rodriguez Sr. Ave., Quezon City
Telephone Nos.: 723- 0301 loc 5803; 724-5219
E-mail: [email protected]
Website: http://pso.ph
Cancer Pain
Philippine Society of Oncology, Inc.
Room 803 North Tower Cathedral Heights Building Complex,
St. Luke's Medical Center, E. Rodriguez Sr. Ave., Quezon City
Telephone Nos.: 723- 0301 loc 5803; 724-5219
E-mail: [email protected]
Website: http://pso.ph
Officers 2013
President
Vice President
Secretary
Treasurer
Immediate Past President
Executive Council Members
Roel S. Tolentino, MD, MBA
Ramon C. Severino, MD
Gonzalo C. Banuelos, Jr., MD
Luis P. Cruz, MD
Romulo S. de Villa, MD, PhD
Salvador E. Brodit, Jr., MD
Gil S. Gonzalez, MD
Charity V. Gorospe, MD
Jorge G. Ignacio, MD
Gil M. Vicente, MD
Pain Control and Palliative Care Section
Section Editor/Reader
Working Group
Francis O. Javier, MD
Luzviminda S. Kwong, MD
Ma. Lourdes Cabaluna, MD
Ma. Florizel del Prado-Marquez, MA
Merle F. dela Cruz-Odi, MD
Jose Ian M. Guevarra, MD
Francis O. Javier, MD
Catherine S. Krings, MD
Luzviminda S. Kwong, MD
Soledad Lim-Balete, MD
Isabel E. Melgar, PhD
Frank C. Nacario, MD
Angelo Poblete, MD
Leticia P. Ramos, MD
Amado San Luis, MD
Maria Elena B. Tiamzon, MD
Antonio N. B. Yap, MD
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29
Cancer Pain
Cancer Pain
*
Background
Pain is experienced by 30-60% of cancer patients during
active therapy, and more than two-thirds of those with
active disease. (Bonica, JJ, 1990) The World Health
Organization (WHO) conservatively estimates that 25%
of all cancer patients die with unrelieved pain. In 1986,
the WHO Analgesic Ladder was introduced with the
purpose of alleviating cancer pain worldwide. However,
cancer pain remains a problem worldwide.
In most cancer patients, pain can be relieved adequately
using the WHO Analgesic Ladder, and yet, cancer pain
remains untreated or even untreated. This is especially
true in poor developing countries. (University of Winconsin
Pain and Policy Studies Group).
The opioid use in the Philippines is very low. The International Narcotics Control Board (INCB) has allocated at
least 90 kg of morphine was just over 20 kg. The actual
morphine use is even lower since some of the morphine
tablets remain in the shelves of stock inventory of most
pharmacies (Dangerous Drugs Board of the Philippine
Annual Report). Likewise, fentanyl, both parenteral and
transdermal has very low usage. The INCB has allocated
100 grams annually to the Philippines, but importation
was pegged at around 7 grams only.
Pathophysiology
The classification of pain forms the basis for the pharma­
cologic treatment.
1.Pain states associated with the cancer itself like direct
tumor involvement and metastases.
2.Pain states associated with cancer treatment like
surgery, chemotheraphy and radiotherapy.
3.Pain states not falling under the first two causes like
pre-existing pain (arthritis, migraine, osteoporosis,
etc.) and pain of acute herpes zoster infectin, due to
the immunocompromised state of the patient.
morphine to big government hospitals, there are still
a lot of physicians who are not familiar and afraid of
its proper use.
2.Government regulations
A physician needs to apply for a narcotic license (S-2)
in order to prescribe opioids. Because of perceived
difficulties in applying for this license, very few
physicians acquire it.
3.Low priority given by the health care system to cancer
pain management.
a.Cure of the diseases is given priority; cancer pain
and palliative care are not included in major health
programs.
b.PHIC and HMO’s do not cover pain management.
4.Economic constraints
a.Since majority of Filipinos live in poverty, priority
is given to the basic needs (e.g., food, clothing,
shelter);
b.The cost of new pain medications is prohibitive.
5.False beliefs about opioid use
a.Generally, opioids are perceived as “addictive.”
b.Use of opioids connotes that a patient is dying or at
the terminal stage of the disease.
c.Belief that if patients use opioids, there will come
a time when no other analgesics can relieve their
pain.
d.Belief that use of opioids will make one bedridden.
6.Cultural resistance
a.Pain is perceived as an inevitable part of having
cancer.
b.Filipino patients are known for bearing the pain of
whatever cause (psychology of “tiis”).
c.Some patients are willing to bear pain as “atonement
for sins.”
Assessment of Cancer Pain
Assessment is an ongoing and dynamic process that
includes evaluation of presenting problems, elucidation
of pain syndrome and pathophysiology and formation of
a comprehensive plan for continuing care.
Types of Pain
Medical Evaluation
1.Nociceptive pain
Those associated with ongoing tissue damage have
nociceptive components. Pain of nociceptive type is
described as sharp and aching sensation.
1.Pain History
A thorough history of the patients disease, including
the character and intensity of pain, and the role it plays
in the overall suffering of the patients are vital in the
process.
2.Neuropathic pain
Those resulting from nervous system dysfunction in the
absence of ongoing tissue damage have neuropathic
components. Pain of the neuropathic type is described
as burning, or lancinating with numbness, itching or
crawling sensations.
2.Pain Rating Scales
This is used to establish a baseline against which the
success of the treatment may be assessed. Behavioral
observation may be used to assess patients who have
problems communicating.
Barriers to effective cancer pain management
1.Opioid availability and its maldistribution.
The miniscule opioid importation of the country visà-vis the cancer population is the major factor. The
bulk of the opioids are in Metro Manila and big urban
centers. While the government tries to distribute
30
*Source: Javier FO, Kwong LS, Cabaluna, ML, et al (2012).
Cancer Pain (Chapter 45). In The Philippine Handbook of Clinical
Oncology (3rd ed., pp. 619-625). Manila, Philippines: The Philippine Society of Oncology, Inc.
Cancer Pain
Examples of Scales
1. Visual Analog Scake (Simple descriptive pain scale)
2. 0-10 Numeric Pain Scale
3. Faces Scale (Happy-Sad faces)
4. Wong and Baker Faces Scale for Children
0
1
2
3
4
5
NO HURT HURTS
HURTS
HURTS
HURTS
HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST
Learn to access drug info on your cellphone. Send PPD to 2600 for Globe/Smart/Sun users.
31
Cancer Pain
Pharmacologic Treatment
The WHO has devised a three-step analgesic ladder outlining the use of non-opioid analgesics, opioid analgesic
and adjuvant medications for progressive severe pain.
This was designed for easy use by caregivers since the
drugs are basically given through the mouth, at regular
intervals and with the options for rescue doses.
According to this scheme, step 1, a nonopioid analgesic
with or without adjuvants is used for mild pain. If pain
persists, the patient should be switched to step 2, a
nonopioid analgesic plus a weak opioid, with or without
adjuvants. If pain persists, patient should be shifted to
step 3, the use of a nonopioid plus a strong opioid, with
or without adjuvants.
A.WHO Pain Relief Ladder
Step 1. Mild pain (nonopioid alone +/- adjuvant)
WHO’s Pain Relief Ladder
at any step of the WHO analgesic ladder, especially in
the presence of neuropathic pain
Note:Rescue doses of short acting opioids are
given for steps 2 & 3
Examples of adjuvant medications:
1. Anti-convulsants
a. Carbamazepine 200 mg/tab titrate to effect
b. Gabapentin 300-3,600 mg/day p.o.
c. Pregabalin 50 mg-600 mg/day p.o.
2. Antidepressants
a. Imipramine 25 mg/tab HS p.o.
b. Trimipramine 25 mg HS-TID p.o.
c. Duloxetine 30-120 mg HS p.o.
d. Sertraline 50 mg q HS p.o.
Other adjuvant drugs that may be used:
1.Steroids – If patient is with an acute inflammatory condition. These drugs also improve appetite and mood.
2. Bisphosphonates – for bone metastasis
a. Clodronic acid
b. Pamidronic acid
c. Ibandronic acid
d. Zoledronic acid
3. Muscle relaxants
a. Baclofen 10-30 mg/day
b. Tizanidine 2-6 mg/day
c. Eperisone 50 mg TID
d.Orphenadrine – usually in combination with Acetaminophen
4. Tranquilizers/Anti-psychotic
a. Haloperidol 1-4 mg/day
B.Newer Technologies
e.g. 1. Acetaminophen 500 mg p.o. q 4-6 hours
2. NSAIDs and COX-2 inhibitors
a. Diclofenac 50 mg p.o. TID
b. Naproxen 550 mg p.o. BID-TID
c. Mefenamic acid 250-500 mg P.O. TID
d. Celecoxib 100-400 mg BID p.o.
e. Etoricoxib 60-120 mg BID p.o.
Step 2. Moderate pain (nonopioid + weak opioid +/- adjuvant)
Tramadol up to 400 mg
Step 3. Severe pain (nonopioid + strong opioid
+/- adjuvant)
Morphine sulfate (immediate release)
10 mg q 4-6 hours p.o., titrate to effect
Long-acting or sustained release morphine
Oxycodone immediate release capsule and
sustained-release tablet
Transdermal Fentanyl
Adjuvant Medications
Adjuvant drugs were formerly used for purposes other
than pain control but were found to have analgesic
effects. The use of adjuvant medications maybe indicated
32
Newer drugs and technology have extended the cancer
pain management beyond the WHO Analgesic Ladder
1. Major neurolytic blocks – performed by experts
e.g., Celiac plexus block for pancreatic cancer
2. Use of PCA machine
The patient-controlled analgesia (PCA) machine
provides excellent relief of pain. It is a drug delivery
system for drugs like morphine, fentanyl and tramadol.
It can be brought anywhere. A systematic titration of the
medication is obtaine, achieving adequate relief with
the least probable side effects. The patient has control
over his pain without depending on others. Through the
PCA button, they have the liberty of giving the rescue
drug themselves, thus eliminating delay in delivery.
However, this is an expensive modality of treatment.
3. Transdermal fentanyl patch and transmucosal fentanyl
lozenge
The patch is applied to the skin and changed every
48-72 hours. For breakthrough pain, the lozenge is
convenient as a lollipop. (Currently not available in
the Philippines)
Cancer Pain
References:
1. Association American Hospital. A Patient’s Bill of Rights.
Revision was approved by the AHA Board of Trustees on
October 21, 1992.
2. Ballantyne JC. Opioid analgesia: perspectives of right use
and utility. Pain Physician. 2007. May; 10(3): 479-91.
3. Cancer Management: A Multidisciplinary Approach 2001.
Leoser JD. Bonica's Management of Pain, 3rd ed.
4. Development of the World Health Organizatin WHO QOLBREF quality of life assessment. The WHO QOL Group.
Psychol Med 1998 May; 28(3): 551-8.
5. Doyle D. Hanks GWC MacDonald N. Oxford Textbook of
Palliative Medicine, 2nd ed, Oxford University Press New
York 1998.
6. Evans BW, Clark WK, Moore DJ, Whorwell PJ. Tegasord
for the treatment of irritable bowel syndrome. Chocrane
Database Systs Rev 2004; (1): CD003960.
7. Hall S, Gallagher RM, Gracely E, Knowlton C, Wesclues
D. The terminal cancer patient: effects of age, gender,
and primary tumor site on opioid dose. Pain Med 2003 Ju;
4(2):125-34.
8. International Narcotics Control Board; UN Demograpics
Yearbook by Pain and Policy Studies Group; University of
Wisconsin/WHO Collaborating Center, 2005.
9. Jadad AR, Browman GP. The WHO analgesic ladder for
cancer pain management. JAMA 1995; 274(23): 18701873.
10. Javier FO, LA Magpantay, et al. Opioid use in Chronic Pain
Management in the Philippines, Asia Pacific Conference on
Pain Control, Jan 15-28, 2001. Sydney, Australia.
11. Maddocks I. Palliative Care Study Text. The International
Institute of Hospice Studies, Flinder Press, Australia,
1997.
12. Marg Venning (ed). Palliative Nursing Care: A Community
Perspective, South Australian Health Commission, Australia
Oxford Textbook in Palliative Medicine 2001.
13. Marinangeli F, Ciccozzi A, Leonardis M. et al. Use of strong
opioids in advanced cancer pain: a randomized trial. J Pain
Symptom Manage 2004; 27(5); 409-416.
14. McNicol E, Strassels SA, Goudas L, Lau J, Carr DB. NSAIDS
or paracetamol, alone or combined with opioids, for cancer
pain. Chocrane Database Systs Rev (1):CD005180, 2005.
15. Meldrum M. The ladder and the clock: cancer pain and public
policy at the end of the twentieth century. J Pain Symptom
Manage 2005; 29(1):41-54.
16. Oxford Textbook of Palliative Medicine.
17. Prager J et al. The Illustation. Cancer Pain Management
Continuum: A Flexible Approach. Clinical Journal of Pain
2001; 206-214
18. Sloan PA, Moulin DE, Hays H. A Clinical evaluation of
transdermal therapeutic system fentanyl for the treatment of
cancer pain. J Pain Symptom Manage 1998 Aug; 16(2):10211.
19. Till JE. Quality of Life Measurements in Cancer Treatment/
In Devite, VT, Hellmon S, Rosenberg SA (eds): Important
Advances in Oncology. Philadelphia: JB Lippincott 2:1992.
20. Twycross. Pain in Advanced Cancer. 1994.
21. Wong D, Baker C. Pain in children: comparison of
assessment scles, Pediatr Nurs 14(1):9017, 1988.
22. Woodruff R. Palliative Medicine. Asperula PTY Ltd, Australia
1993.
23. World Health Organization, Constitution of the World Health
Organization, WHO Chronicles 1947; 1:29.
24. World Health Organization (WHO) Step Pain Relief Ladder.
Retrieved from: http://www.who.int/cancer/palliative/
painladder/en.
25. Yeo W, Lam KK, Chan AT, Leung TW, Nip Sy, Johnson PJ.
Transdermal fentanyl for severe cancer-related pain. Alliat
Med 1997 May; 11(3):233-9.
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Cancer Pain
Index of Drugs Mentioned in the Guideline
This index is not part of the guideline. It lists the products and/or their therapeutic classes as mentioned in the guideline. For
the doctor's convenience, brands available in the PPD references are listed under each of the classes. For drug information,
refer to the PPD references (PPD, PPD Pocket Version, PPD Text, PPD Tabs, and www.TheFilipinoDoctor.com).
Analgesics
Coxibs
Celecoxib
Celebrex
Coxid
Etoricoxib
Arcoxia/Arcoxia AC
Parecoxib
Dynastat
Rofecoxib
NSAIDS
Diclofenac
Abicfen
Acloren
Cataflam
Denkoran
Diclowal/Diclowal Retard
Difenax
Dolfastad
Doloflam
Neo-Pyrazon/Neo-Pyrazon SR
UL Diclofenac Na
VCP Diclofenac Na
Voltaren
Voren/Voren Forte/Voren SR
Mefenamic Acid
Abicfen
Acidan
Analcid
Aprostal
Biogenerics Mefenamic Acid
C&M Mefenamic Acid
Calibral
DLI Mefenamic Acid
Dolfenal
Dolmetine
Drugmaker's Biotech Mefenamic Acid
Escandar
Fendal
Fenexan
Gardan
Gisfen
Harpinac
Isagesic
Istan
Medianon
Pacimic
Penomor
Pharex Mefenamic Acid
Ponstan
Proxyl
Ralgec
Revalan
RiteMED Mefenamic Acid
Selmac
Sensomef
Spegic
Totagesic
Tynostan
Zapan
Naproxen
Flanax/Flanax Forte
Lefaine
Naprelan
Naprosyn LLE/Naprosyn LLE Forte
Non-Opioid Analgesics
Paracetamol
Aeknil
Afebrin
Aldep
Aminofebrin
34
Baropyrine
Biogenerics Paracetamol
Biogesic
Calpol/Calpol Six Plus
Carpacet
Crocin
Delgin
DLI Paracetamol
Dolexpel
Drugmaker's Biotech Paracetamol
Europharma Paracetamol
Franciphen
Gendol Susp/Tab
Genpyra
Gifaril-P
Lenor
Medgenol
Medicol-A
Metagesic
Myremol
Naprex
Naprinol
Neo-Aspilets
Nopain Forte
Norgesic
Octagesic/Octagesic Forte
Opigesic
Pacigesic
Pharex Paracetamol
Pynal
Rexidol
Reximed
RiteMED Paracetamol
Rufenal
Saridon
Tempain Syr/Forte Tab/
Forte Syr/Drops
Temperal
Tempra/Tempra Forte
Tylenol
Paracetamol/Vitamin B-Complex
Dolo-Neurobion
Opiates & Antagonists
Fentanyl
Durogesic
Sublimaze
Morphine sulfate
Hizon Morphine Sulfate
Relimal CR
Oxycodone
Oxycontin
Oxynorm
Oxynorm Injection
Oxycodone/Naloxone
Targin
Tramadol
Dolotral
Siverol
TDL
Tradonal
Tramal
Adjuvants
Anticonvulsants
Carbamazepine
Tegretol
Gabapentin
Neurontin
Antidepressants
Imipramine
Tofranil
Sertraline
Zoloft
Trimipramine
Surmontil
Bisphosphonates
Disodium Clodronate
Bonefos
Zoledronic Acid
Zometa
Steroids
Betamethasone
Betnelan
Celestone
Diprospan
Dexamethasone
Decilone
Drenex
Inflam
Oradexon
Oradexon Forte
RiteMED Dexamethasone
Scancortin 4
Scancortin 5
Hydrocortisone
Hydrocort
Hydrotopic Inj
Pharmacort
Phoenix Hydrocortisone
Sodium Succinate
Solu-Cortef
Methylprednisolone
Depo-Medrol
Medrol
Solu-Medrol
Prednisone
Drazone
Drugmaker's Biotech Prednisone
GXI Prednisone
Orasone 5/Orasone 20
Organon Prednisone
Pred 5/10/30
Roidrenal
Prednisolone
Liquipred
RiteMED Prednisolone
Triamcinolone
Kenacort
Kenacort-A Intra-articular/
Intradermal
Muscle Relaxants
Baclofen
Lioresal
Onelaxant-R
Trilaxant
Tizanidine
Sirdalud
Eperisone
Myonal
Perispa
Orphenadrine
Norgesic Forte
Tranquilizers/Anti-psychotic
Haloperidol
Haldol Decanoas
Serenace
Zuredel