Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 www.TheFilipinoDoctor.com l Sign up and open your clinic to the world. 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. www.TheFilipinoDoctor.com l Sign up and open your clinic to the world. 33 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