Download Pain and its management - Botswana Medical Association

Cancer pain and its management
Dr.Vincent Appathurai M.B.B.S.
D.T.M.
Principal Medical officer, BLH
Presented at Annual
Conference, BMA
28th Oct 2007
“Pain is a greater Lord of mankind
than even death itself”
- Albert Schewitzer
Introduction
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Cancer accounts for 12.5% deaths worldwide
more than HIV/AIDS,TB, Malaria put together
By 2020, 15 million new cases will occur each yr
in the world, 1 million of them in African
countries
An estimated 80% of people with cancer present
to heath services with late stage cancer when
pain relief and palliation is the only option
Hence cancer pain management is an integral
part of primary care
Definition of pain
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An unpleasant sensory and emotional
experience associated with actual or
potential tissue injury or described in terms of
such damage (International Association for
the Study of Pain ) IASP.
The intensity of pain varies with the degree
of injury, disease or emotional impact.
Pain is a psychosomatic phenomenon
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Pain is what the patient says it is.
Pain is a self reported subjective experience
involving sensory neural transmission of the
afferent noxious stimulation that has an
expression of the person’s reaction to the
pain
Pain is a psychosomatic phenomenon
modulated by mood, morale and meaning (
Dr.Robert Twycross )
Concept of Total Pain
PHYSICAL
PSYCHOLOGICAL
TOTAL PAIN
SPIRITUAL
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SOCIAL
Physiology of pain
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It is important to understand the underlying
patho-physiological factors before attempting
to treat pain in a logical and systematic way.
Peripheral receptors and pathways
Central pathways
Modulatory mechanisms
Physiology of pain
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Neurotransmitters and receptors
Prostaglandins and bradykinin
Opioid receptors
Glutamate and NMDA receptors
The role of sympathetic nervous system
Neuropathic pain
Nerve compression pain
Sympathetic mediated pain
Pain in Cancer
May not have pain !!!
 Most do have pain- 2/3rd with advanced
cancer
Number of pains
 1/5th have one pain
 4/5th have 2 or 3 pains
 1/3rd have 4 or more pains
 Not all pain in cancer is caused by cancer
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Top 10 cancer pains
Directly related to the cancer ( 4 of them)
 Bone
 Visceral
 Neuropathic
 Soft tissue
( All constitute 30-40% of pains )
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Top 10 cancer pains
Cancer pain with debility ( 6 of them )
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Immobility, Constipation
Myo- fascial, Cramps
Oesophagitis
Degeneration of spines ( All constitute 1020% )
Pain associated with chemotherapy,
radiotherapy, surgical intervention.
Others- Difficult pains – complex 10%
Aetiology of cancer pain
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Infiltration of the viscera
Bony metastases
Smooth muscle spasms
Muskulo- skeletal pains
Infection
Nerve compression pain
Unrelated pains
Assessment of pain
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Good history taking - Pain is the fifth vital
sign
Site
Duration
Onset
Quality of pain
Aggravating factors
Relieving factors
Assessment of pain
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Temporal pattern (acute, chronic, sub acute,
breakthrough pain, incident pain)
Interference with daily living
Sleep
Psychological status
Response to current and previous therapy
A systematic approach
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Evaluation
Explanation
Management
Monitoring
Attention to detail
Tools used in assessment of pain
Numerical scale
0 1 2 3 4 5 6 7 8 9 10
No pain
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Worst pain
Categorical scale
None (0)
Mild (1-3)
Moderate ( 4-6 )
Severe ( 7-10 )
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Visual Analogue scale
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No pain
(mark)
worst pain
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Pain faces scale
used in children - Wong - Baker
0 - very happy, no hurt
2 - hurts just a little bit
4 - hurts a little more
6- hurts even more
8 – hurts a whole lot
10 – hurts as much as it can ( crying )
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Management of pain
- Pharmacological
- Non - pharmacological
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Pharmacological Management
WHO Analgesic Ladder 1980’s
Three steps
Mild pain = Non- opioid + or – Adjuvant
Mod.pain = Weak opioids + or – Non-opioid
+ or – Adjuvant
Severe pain = Strong opioids + or – Non-opioid
+ or - Adjuvant
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WHO Analgesic Ladder
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Principles are Five
- By mouth
- By the clock
- By the ladder
- For the individual
- Attention to detail
WHO Analgesic Ladder
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Outcome (WHO analgesic ladder)
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Relieves pain effectively in 80-90% of
cancer patients
10-20% of pains are difficult pains
Good relief of pain in 75% of terminally ill
patients
Consider adding non-opioids and adjuvant
for effective control
Principles in use of morphine
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Administer in simple aqueous solution
10mg/5ml
Begin with 5-10mg every 4 hrs orally
Adjust after 24hrs- titrate dosage.
No ceiling effect Dosage is usually 100-500mg
Principles in use of morphine
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A double dosage at bedtime 22.00hrs
Calculate LA twice daily dosage after
assessment e.g 120mg total = 60mg b.d
Antiemetic for nausea-Haloperidol 1-2.5mg is
best, but often metoclopramide is used.
Laxative-senna or bisacodyl or liquid paraffin
Principles in use of morphine
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One sixth of original dose for breakthrough
pains
If unable to take oral morphine use
parenteral s.c or i.m – 1:3 or 1:2 or rectal
Use syringe driver under supervision
Addiction does not occur
Tolerance does occur
Some physical dependence may occur
Side effects of morphine
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Nausea and vomiting
Confusion
Sedation
Constipation
Hallucinations
Constricted pupils
Biliary colic
Side effects of morphine
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Itching
Sweating
Myoclonus
Convulsions
Dry mouth
Histamine release ( broncho-constriction )
Pulmonary oedema
Treatment of side effects
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Opioids used according to guidelines rarely
cause severe toxicity or addiction particularly
morphine
Reduction of dosage is all that is necessary e.g
myoclonus
Antidote treatment is indicated only, if severe
respiratory depression is present
Naloxone o.4mg dil in 10ml N.saline given as
0.5ml/ 2mt intervals until resp. normal
Non-opioids
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Aspirin 600mg p.o every 4 hours
Paracetamol 1g p.o every 4hours
NSAID’s
–
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Ibuprofen 400mg p.o tds
Indomethacin 50mg p.o tds
Diclofenac 50mg p.o tds
Other Adjuvants
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Antidepressants- Amitriptyline
Anticonvulsants-carbamazepine, Sodium
Valproate
Corticosteroids- Prednisolone,
Dexamethasone, methyl prednisolone
Muscle relaxants-Diazepam or Baclofen
Bisphosphonates- Disodum pamidronate
Weak opioids
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Codeine
Hydrocodone
Propoxyphene
Tramadol
Used in step 2 for mild to moderate pain
Add non opioid and adj. to optimize effect
Strong opioids
Short half life
-Morphine
-Hydromorphone
Oxycodone
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Meperidine
Fentanyl
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Long half life
- Methadone
- Levorphanol
- Transdermal
fentanyl
Corticosteroids in cancer pain
management
Use only in specific indications
 Spinal cord compression, Nerve
compression pain and weakness
 Lymphangitis carcinomatosis
 Raised intracranial pressure
 Superior vena cava syndrome
 Capsular stretching of internal organs
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Dosage of corticosteroids
Large dosage regimen
Dexamethasone 100mg stat followed by
96mg/day in divided doses, reduced over
weeks, supplemented by other analgesic
approach such as radiotherapy
 Low dosage regimen
Dexamethasone 1-2mg once or twice daily
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Anaesthetist’s role
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In intractable, opioid non responsive
advanced cancer pain, consider
Brachial plexus block
Intercostal block
Coeliac plexus block
Lumbar plexus block
Perineal and saddle block
Intrathecal morphine
Non-pharmacological methods
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Distraction, Music therapy
Relaxation therapy- yoga, meditation
Cutaneous stimulation –TENS
Acupuncture
Psychotherapy and counselling
Hypnosis
Mechanical therapies – massage, exercise,
immobilization, orthopaedic aids and mobility
devices
Barriers to pain management
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Inadequate pain assessment
Inadequate knowledge about cancer pain
and its treatment
Patient and physician’s attitudes and fears
about pain and opioids – opiod phobia
Poorly accessible and unavailable pain
management services ( anaesthetists )
Lack of pain clinics services
Why pain relief ?
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Despite all available methods of pain control, too
many people are suffering from unrelieved pain
particularly those affected by Cancer and
HIV/AIDS
The quality of life in these pts depends on
effective pain relief
Africans die in pain because of fears of opiate
addiction – opiophobia ( APCA, 2nd conf 2007 )
Pain is under diagnosed and under treated
Why pain relief?
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It is a basic human right -- Declaration at APCA, 2nd
African palliative conference - Sept 2007, Nairobi
Home based care patients especially those with advanced
cancer and HIV/AIDS need morphine regularly
We must make sure that supply of all essential analgesics,
particularly morphine is made available in district, primary
hospitals and clinics in our country – Essentially Liquid
morphine and oral preps
Appropriate legislation must be in force e.g. Uganda
Botswana must make an effort to procure liquid morphine (
NASCOD, MOH, CMS initiative)
References
1) Twycross R, Wilcock A. Symptom management
in advanced cancer (3e),Abingdon, Oxon:
Radcliff medical press, 2001,pp 51-58
2) Dr. Ian Back, Topics in palliative care, Pain,1997
3) Eduardo Bruera et al, Palliative care in the
developing world: Cancer pain, pp 107-124,
IAHPC, 2004
4) Marie Fallon, Bill O’Neill, ABC of Palliative care,
Pages 2-4,BMJ Books, 1998
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References
5) Cancer pain relief, edn 2. Geneva: World
Health Organization, 1996
6) International Association for the study of
pain. Pain 6:249-252, 1979
7) Palliative Care Training Manual, MOH,
Botswana. 3rd draft, April 2007
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KEALEBOGA
Thank you
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