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Cancer Pain management Hesam modin hariri,MD Palliative & supportive care center به نام خداوند جان و خرد Definition of pain “Pain is an unpleasant sensory and emotional experience associated with actual and potential tissue damage or described in terms of such damage” Physical Social TOTAL PAIN Spiritual Psychological Prevalence 64% in patients with metastatic or advanced stage disease 59% in patients on anticancer treatment 33% in patients after curative treatment The experience of pain can Induce depression Exacerbate anxiety Interfere with social performance and impair the quality of relationships. Negatively impact on physical capability. Prevent work & reduce income. Challenge existential beliefs. Constantly impact on the patient’s experience of pain. Causes Cancer itself (this is by far the most common): • • • • • • Extension into soft tissues Visceral involvement Bone involvement Nerve compression Nerve injury Raising intracranial pressure Causes Related to the cancer • e.g. muscle spasm, lymphoedema, constipation, bedsores Related to anticancer treatment • e.g. chronic postsurgical scar pain, chemotherapy-induced mucositis Concurrent disorder • e.g. spondylosis, osteoarthritis Evaluation 1. 2. 3. 4. 5. 6. 7. 8. 9. Believe the patient’s report of pain Initiate discussions about pain Evaluate the severity of the pain Take a detailed history of the pain Evaluate the psychological state of the patient Perform a careful physical examination Order & personally review any necessary investigations Consider alternative methods of pain control Monitor the results of treatment Approaches to pain management in cancer patients Psychological approaches: Modification of pathological process: Understanding Companionship Cognitive behavioural therapies Radiotherapy Hormone therapy Chemotherapy Surgery Drugs: Analgesics Antidepressants Anticonvulsants Anxiolytics Neuroleptics Interruption of pain pathways: Local anaesthetics Neurolytic agents Neurosurgery Immobilization: Modification of daily activities Rest Cervical collar or corset Plastic splints or slings Orthopedic surgery “Drug treatment is the mainstay of cancer pain management” WHO guidelines for analgesics use to control cancer pain ̶ ̶ ̶ ̶ ̶ By mouth By the clock By the ladder For the individual Attention to detail World Health Organization. Cancer pain relief. PRN Analgesic 1 4 8 12 16 20 Analgesic given on PRN basis 24 By the clock analgesic Breakthrough pain Baseline pain 1 4 8 12 16 Analgesic given by the clock 20 24 PRN analgesic By the clock analgesic Breakthrough pain Baseline pain 1 4 8 12 16 Analgesic given by the clock 20 24 3 Strong opioid ± Non-opioid ± Adjuvant Pain persisting or increasing 2 Weak opioid ± Non-opioid ± Adjuvant Pain persisting or increasing 1 Pain Non-opioid ± Adjuvant WHO. Cancer Pain Relief. 1996. The risk of respiratory depression from opioid analgesic is more myth than fact” مرکز جامع مراقبتهای حمایتی و تسکینی بیمارستان حضرت سید الشهدا (ع) به زودی