cancer pain
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Cancer Pain Concept
A. HUSNI TANRA
Department of Anesthesiology & ICU and Pain Management
Faculty of MedicineHASANUDDIN UNIVERSITY
MAKASSAR
Palliative CarePalliative CarePalliative Care is comprehensive, interdisciplinary
care for patients whose disease is chronic and progressive, or unresponsive to curative treatment. It includes pain and symptom management as well as psychological, emotional and spiritual care. The goal of palliative care is to achieve the best quality of life for patients and their families, regardless of life expectancy
Center for Health Workforce Studies
School of Public Health, University of AlbanySeptember 2002
CurativeCurative vs. Palliative vs. Palliative Model of CareModel of Care
Disease Progression
DEATH
Curative Palliative
BEREAVEMENT
Disease Progression
DEATH
Curative Palliative
BEREAVEMENT
The Continuum of Palliative CareThe Continuum of Palliative Care
PersonPerson
FamilyFamily
DDIISSEEAASSEE
DDIISSCCOOMMFFOORRTT
DDYYIINNGG
ILLNESS TRAJECTORYILLNESS TRAJECTORY BEREAVEMENTBEREAVEMENTSSYYMMPPTTOOMMSS
DDXX
DDEEAATTHH
Disease Specific RxDisease Specific Rx
Comfort, Supportive RxComfort, Supportive Rx(Palliative Care)(Palliative Care)
Bereavement Bereavement SupportSupport
(Palliative Care)(Palliative Care)
DDIISSTTRREESSSS
DDYYSSFFUUNNCCTTIIOONN
Caregivers and Service providersCaregivers and Service providers
Cancer Pain?
Pain
Unpleasant sensory and emotional experience
-Associated with actual or potential tissue damage
-or described in terms of such damage
International Association for the Study of Pain (1979)
What the textbooks would have you believe
about pain
Noxious (painfull) stimulus to the body
What PAIN is?What PAIN is?
Pain has two dimensions
1. Unpleasant sensory (Physical dimension)
2. Emotional experience (Psychological dimension)
J. Loeser (1980)
Concept of nociception, pain, suffering and pain behavior
PERILAKU NYERI(PAIN BEHAVIOUR)
PENDERITAAN(SUFFERING)
NYERI(PAIN)
BIOPSIKOSOSIAL(BIOPSYCHOSOCIAL)
NOSISEPSI(NOCICEPTION)
PENGERTIAN MODEL NYERI
BYERS AND BONICA, 2001MODIFIKASI PENULIS
•Terapi kognitif•Restorasi fungsional
•Opioid•Tramadol
•Oxcarbazepine•Gabapentin
•Eperisone HCL•Paracetamol
•OAINS
•Antidepresan•Psikotropika•Relaksasi•Spiritual
•Blok Lokal•Diklofenak•Etodolac•Dexketoprofen•Celecoxib
•Modalitas fisik
•steroid
Cancer Pain Conceptby Dr. Cicely Saunders 1967, founder of first Hospice in
London.
‘TOTAL PAIN’ is the sum of 4 components:
1. Physical noxious stimuli
2. Emotional discomfort
3. Interpersonal conflicts
4. Nonacceptance
4 Components of “total pain” by Cicely Saundres using concept Da Vinci’s Vitruvian Man representing person.
Physical PainPhysical Pain
NonacceptanceNonacceptance
InterpersonalInterpersonalConflictsConflicts
EmotionalEmotional discomfortdiscomfort
Aspects of “total pain”.
TOTAL PAIN TOTAL PAIN
Interpersonal Interactions
Individual Fear of isolation from others Fear of loss of career or job status Fear of substance abuse
Interpersonal Interactions Marital discord Estrangement from family Isolation from spouse and children Conflicts with coworkers Mounting financial stress
Inadequate Pain Control Verification patient is receiving
pain medication. Assessment for new physical
cause of pain Altered Metabolic States
Medical conditions such, hypocalcaemia, hypoglycemia, hypoxia, delirium and sepsis
Hormone-Secreting Tumors Pheochromocytoma ACTH-producing tumors Thyroid tumors
Anxiety From Medications Rapid tapering of prednisone. Alcohol withdrawal Akathisia associated with
metoclopramide hydrochloride Preexisting Anxiety
Supportive therapy or medication (or both) helpful
Spirituality Personal values of life, what
death mean for him/her. Fear of dying alaone.
Three-Stage Model A guide to anticipate
difficulties with greater sensitivity:� Initial stage: the patient
faces the threat of death;� Middle stage: a universal
depression that the patient now knows the disease will cause death;
� Third stage: the patient’s acceptance of imminence of own death
Anxiety Nonacceptance
TOTAL
PAIN
ORGANIC PAIN
ANXIETY
ANGERDEPRESSION
Non-cancer pathology
Cancer Symptoms of debility
Side-effects of theraphy
Loss of social position
Loss of job prestige and income
Loss of role in family
Chronic fatigue and insomnia
Sense of helpessness
Disfigurement
Bureaucratic prosedure
Friends do not visit
Delay in diagnosis
Unavailable doctors
Irritability
Therapeutic failure
Fear of hospital or nursing home
Worry about family
Fear of death
Spiritual unrest
Fear of pain
Family finances
Loss of dignity and bodily control
Uncertainty about future
WHO 1986
Pain
Somatic or Visceral
pain
Neuropathic Pain
Psychological
Disturbances
SufferingPsychological State and
Traits
Loss of Work
Physical Disability
FearOf Death
FinancialConcerns
Social/ Familial
Functioning
AMERICAN CANCER SOCIETY 1988
Magnitude of Cancer Pain
WHO 1986
4,5 million people suffering from cancer pain with or without satisfactory treatment every day
More than 9 million cancer deaths will occur in 2015 70 – 80 % of these patients will experience moderate to
severe pain Most of them will die in pain
For many patients pain is the first sign of cancer.
30 – 50 % of all cancer patients will experience moderate to severe pain.
75 – 95 % of patients with advanced stages will experience severe pain.
45 % of cancer patients have inadequate pain control.
25 % Will die in pain. Nature Reviews Cancer March 2002
Pain is extremely a major problem in cancer patients
Pain is the most disruptive on Q of L of cancer patients
Pain is one of the most feared aspect in cancer patients
Unrelieved severe pain may associated with• Disturbed sleep• Reduced appetite• Unrepaired concentration• Irritability and depression, etc.
69 % of severe cancer pain patient to cause consideration of suicide.
(Wisconsin 1985)
Problem of Pain in Cancer Patient
As a doctor, our task is:
*To cure is sometime *To treat is often, but …
*To comfort is always A. Pare (1598)
The “Total” Pain Concept
Spiritual
Emotional
Financial
Physical
•Guilt
•Why me?
•Life closure issues
•From disease•From treatment
•Direct costs
•Indirect costs
•Loss of function
•Coping abilities
PAIN
Types of pain based on neurophysiologic mechanism.
Physical PainPhysical Pain
Neurophysiologic MechanismsNeurophysiologic Mechanisms
Visceral Pain Difficult to localize. Felt as “deep
pressure,” “spasms” associated with nausea, diaphoresis, and emesis.
Somatic Pain Nociceptor stimulation
of skin and deep musculoskeletal tissues.
Well localized as “deep, aching feeling,” tender to palpation.
Neuropathic Pain Damage to the peripheral or the
central nervous tissue. Peripheral nerve described as
“sharp,” “electric,” “burning” pain.
Central pain is “throbbing”; the headache is “dull” and “never relenting”
CAUSE OF CANCER PAIN Can be classified into 3 categories:
1. Pain associated with direct tumor (tumour infiltration, bone metastases)2. Pain associated with cancer therapy (chemotherapy, surgery or radiation)3. Pain unrelated to cancer (RA, OA, headache or herpes zoster)* Due to cancer debility (decubitus)
Types of Cancer Pain
1. Somatic Pain 2. Visceral Pain 3. Neurophatic Pain
Mostly in combine form
Somatic Pain
• Constant pain• May be dull or sharp• Well localized• Often worse with movement
Eg/– Bone & soft tissue– chest wall
Visceral Pain
• Constant or crampy• Poorly localized• Usually with Nausea & Vomit• Often referred
Eg/– CA pancreas– Liver capsule distension– Bowel obstruction
Neuropathic Pain
Damage to the nerve pathways
There can be an abnormal response to a normal stimulus
May be peripheral or central nerve damage
COMPONENT DESCRIPTORS EXAMPLES
Steady, Dysesthetic
• Burning, Freezing
• Constant-aching
• Squeezing, Itching
• Allodynia
• Hyperalgesia
• Diabetic neuropathy
• Post-herpetic neuropathy
Paroxysmal, Neuralgic
• Stabbing
• Lancinating
• Shock-like, electric
• Shooting
• trigeminal neuralgia
• may be a component of any neuropathic pain
FEATURES OF NEUROPATHIC PAIN
Burning, feeling like the feet are on fire
Stabbing, like sharp knives Lancinating, like electric shocks
Freezing, like the feet are on ice, although they feel warm to touch
Modified by Meliala 2006
Breakthrough PainBreakthrough Pain
An intermittent increase in pain that occurs spontaneously and is usually associated with an increase in activity or stress. If
breakthrough pain becomes continuous, it is usually a sign that opioid dose needs to be
increased
Chronic Cancer Pain Chronic Cancer Pain Effectively treating chronic pain poses a great challenge for physicians. This type of pain often
affects a person’s life in many ways. It can change someone’s personality, ability to
function, and quality of life.
According to the American Cancer Society, chronic cancer pain may involve persistent pain
and breakthrough pain. Persistent pain is continuous and may last all day.
Breakthrough PainBreakthrough Pain
BTP is a brief flare-up of severe pain that occurs even while the patient is regularly
taking pain medication. It usually comes on quickly and may last from a few minutes to an hour. Many patients experience a number of episodes of breakthrough pain each day.
Breakthrough PainBreakthrough PainBreakthrough cancer pain can result from the
cancer or cancer treatmen, or it may occur during a certain activity (e.g., walking, dressing, coughing). It also can occur
unexpectedly, without a preceding incident or clear cause. Breakthrough pain usually is
treated with strong, short-acting pain medications that work faster than persistent
pain medications.
Causes of Cancer painDIRECT TUMOR ITSELF
Causes of Cancer pain
Causes of Cancer pain
Cancer painFROM CHEMOTHERAPY
Causes of Cancer painRELATED TO THERAPY
COBALT RADIATION BURN
Cancer painOther Factors
Acute Herpes Zoster
Cancer pain
OTHER FACTORS-Immunocompromised state
Cancer pain
Mucositis
Nociceptor is stimulated by the tumor Peripheral sensitization Enzyme Cox-2
Inflammation. Tumor induced acidosis. ( massive apoptosis) Tumor induced distension of sensory fibers
neurophatic pain Centra sensitization Chronic pain
Cancer cells + macrophage + inflammation cells produce high level of Cox-2 enzyme high level of prostaglandins.
Cancer cells induced acidosis due to that inflammatory cells invade neoplastic tissue release H+ and massive apoptosis also contribute release H+ increase acidosis.
Two ascending pathway are activated. ( STT and PSDCT)
Three Step Ladder WHO, 1986
5 essential concepts By mouth By the clock By the ladder By individual With attention to
detail
By this modality ± 90% of cancer pain can be relieved
Gold Standard of Pain Management
Is constant pain assessment. Pain is whatever the patient says it is.Pain in cancer never purely physical.Nonphysical pain describe as ‘discomfort’Take a careful history of the pain complaintAssess characteristics of each pain; site, type
pattern of referral, aggravating & relieving factors etc.
Assessment of Painusing VAS is !
0 3 421 5 6 7 8 9 10
No distress Unbearable distress
a 10-cm baseline is recommended for VAS
( Visual Analogue and Numeric Scale )
Assessment of Pain Intensity
No Mild Moderate Severe Very Worstpain pain pain pain severe possible
pain pain
Verbal Pain Intensity Scale
No
pain
Visual Analog Scale
Wong-Baker FACES Pain Scale
0 1 2 3 4 5
0–10 Numeric Pain Intensity Scale
No Mild Moderate Worstpain pain pain possible pain
0 1 2 3 4 5 6 7 8 9 10
Worstpossible
pain
29
Types of Cancer Pain 1. Nociceptive Pain
Somatic Pain
Visceral Pain 2. Neurophatic Pain (Mostly in combine form)
3. BreakThrough Pain (BTP)
Somatic Pain
• Constant pain• May be dull or sharp• Well localized• Often worse with movement
Eg/– Bone & soft tissue– chest wall
Visceral Pain
• Constant or crampy• Poorly localized• Usually with Nausea & Vomit• Often referred
Eg/– CA pancreas– Liver capsule distension– Bowel obstruction
Neuropathic Pain
Damage to the nerve pathways
There can be an abnormal response to a normal stimulus
May be peripheral or central nerve damage
COMPONENT DESCRIPTORS EXAMPLES
Steady, Dysesthetic
• Burning, Freezing
• Constant-aching
• Squeezing, Itching
• Allodynia
• Hyperalgesia
• Diabetic neuropathy
• Post-herpetic neuropathy
Paroxysmal, Neuralgic
• Stabbing
• Lancinating
• Shock-like, electric
• Shooting
• trigeminal neuralgia
• may be a component of any neuropathic pain
FEATURES OF NEUROPATHIC PAIN
Burning, feeling like the feet are on fire
Stabbing, like sharp knives Lancinating, like electric shocks
Freezing, like the feet are on ice, although they feel warm to touch
Modified by Meliala 2006
Chronic Cancer Pain Chronic Cancer Pain Effectively treating chronic pain poses a great challenge for physicians. This type of pain often
affects a person’s life in many ways. It can change someone’s personality, ability to
function, and quality of life.
According to the American Cancer Society, chronic cancer pain may involve persistent pain
and breakthrough pain. Persistent pain is continuous and may last all day.
Breakthrough PainBreakthrough Pain
BTP is a brief flare-up of severe pain that occurs even while the patient is regularly
taking pain medication. It usually comes on quickly and may last from a few minutes to an hour. Many patients experience a number of episodes of breakthrough pain each day.
Breakthrough PainBreakthrough PainBreakthrough cancer pain can result from the
cancer or cancer treatmen, or it may occur during a certain activity (e.g., walking, dressing, coughing). It also can occur
unexpectedly, without a preceding incident or clear cause. Breakthrough pain usually is
treated with strong, short-acting pain medications that work faster than persistent
pain medications.
CAUSE OF CANCER PAIN Can be classified into 3 categories:
1. Pain associated with direct tumor (tumour infiltration, bone metastases)2. Pain associated with cancer therapy (chemotherapy, surgery or radiation)3. Pain unrelated to cancer (RA, OA, headache or herpes zoster)* Due to cancer debility (decubitus)
Causes of Cancer painDIRECT TUMOR ITSELF
Causes of Cancer pain
Causes of Cancer pain
Cancer painFROM CHEMOTHERAPY
Causes of Cancer painRELATED TO THERAPY
COBALT RADIATION BURN
Cancer painOther Factors
Acute Herpes Zoster
Cancer pain
OTHER FACTORS-Immunocompromised state
Cancer pain
Mucositis
WHO 3-step Analgesic WHO 3-step Analgesic LadderLadderWHO 3-step Analgesic WHO 3-step Analgesic LadderLadder
1 1 MildMild
22 Moderate Moderate
3 3 SevereSevere
Morphine
Hydromorphone
Methadone
Fentanyl
Oxycodone
± Adjuvants
A/Codeine
A/Hydrocodone
A/Oxycodone
Tramadol
± Adjuvants
ASA
Acetaminophen
NSAIDs
± AdjuvantsAdapted from the EPEC Project
Gold Standard of Pain Management
Is constant pain assessment. Pain is whatever the patient says it is.Pain in cancer never purely physical.Nonphysical pain describe as ‘discomfort’Take a careful history of the pain complaintAssess characteristics of each pain; site, type
pattern of referral, aggravating & relieving factors etc.
The Phenomenon of CANCER PAIN
COMPLEX and COMPLICATED is the cumulative among :• PHYSICAL PAIN
• PSYCHOLOGICAL PAIN• socioeconomic,cultural and
spiritual
TOTAL PAIN
BIOPSYCHOSOCIOCULTUROSPIRITUAL
Paracetamol adjuvants
Weak Opioid for mild to moderate
pain Paracetamol adjuvants
Strong Opioid for severe pain(Morphine)
Celecoxib adjuvants
Increasing painIncreasing pain
WHO three step ladderWHO three step ladder
It’s important to more understanding PAIN, type and characteristic of pain..
Because…
In many parts of Indonesia : Many people may die in pain, but Many more people dying with pain, Even many more people living in pain
This is our task to help them as a Doctor
Take Home Message
San Diego, 2002
Total Pain – Osteopathic Medical Total Pain – Osteopathic Medical Care.Care.
Osteopathic Medical Care is based on osteopathic philosophy; the four components being:
1.The body is a unit.2.The body has self-regulatory
mechanisms.3.Structure and functions are reciprocally
interrelated.4.Rational therapy is based on these
principles.
Structure andStructure andFuntion Funtion ReciprocallyReciprocallyInterrelatedInterrelated
Self-RegulatorySelf-RegulatoryMechanismMechanism
Elisabeth K.Ross (1969) “on death and deying”.
BEHAVIOR CHARES IN CANCER PATIENT
1. DENY
2. ANGER
3. BARGENING
4. DEPRESSION
5. ACCEPTANCE
A Patient’s perspective
“ One of the worst aspect of cancer pain is that it`s a constant reminder of the disease and of death ..
My dreams is for a medication that can relieve my pain while leaving me alert and with no side effects “
Jeanne Stover, 1992
Role of COXIB in cancer painRole of COXIB in cancer painCelecoxib is the rational use for the cancer pain management,
particularly in advance stage, because celecoxib is:
* Strong antiinflammation
* Analgesic * Antipyretic * Carcinoprotective (prevent angiogenesis, tumor
growth and metastasis)
* simple administeration
Non-opioid adjuvants
Weak Opioid for mild to moderate
pain non-opioid adjuvants
Strong Opioid for severe pain
non-opioid adjuvants
Increasing painIncreasing pain
WHO three step ladderWHO three step ladder
84
WHO ANALGESIC LADDER CANCER PAINWHO ANALGESIC LADDER CANCER PAIN
Aspirin&
NSAID+
Adjuvants
Add weak Opioid(if pain
unrelived)+
Adjuvants
Add strong Opioids
+ Adjuvants
PSYCHOLOGICAL & SOCIAL SUPPORT
Nociceptive painNociceptive painA NOCICEPTION has at least 4 components
1. TRANSDUCTION2. CONDUCTION/ TRANSMISSION
3. MODULATION 4. PERCEPTION
SpinothalamicSpinothalamictracttract
PeripheralPeripheralnervenerve
Dorsal HornDorsal Horn
Dorsal root Dorsal root ganglionganglion
PainPain
MedulationMedulation
TransductionTransduction
AscendingAscendinginputinput
DescendingDescendingmodulationmodulation
PeripheralPeripheralnociceptorsnociceptors
TraumaTrauma
Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
PerceptionPerception
transmissiontransmission
ConductionConductionConduction/Conduction/TransmissionTransmission
Modified by AHT
88
Poisons
Mechanical, thermal, chemical, electrical
Tissue damage
Release of mediators
Hydrogen and potassium ions, neurotransmitters, kinins, prostaglandins
Stimulation of nociceptors
Transmission to CNS
via afferent pathways
What is pain?
A NOCICEPTION has at least 4 components
1. TRANSDUCTION2. CONDUCTION/
TRANSMISSION 3. MODULATION
4. PERCEPTION
ACUTE (NOCICEPTIVE) PAIN PATHWAY
Figure 10-13: Referred pain
Allodynia: Nerve Injury Leads to Central Reorganization in the Spinal Dorsal HornAllodynia: Nerve Injury Leads to Central Reorganization in the Spinal Dorsal Horn
Normal terminations of primary afferents in the dorsal hornNormal terminations of primary afferents in the dorsal horn
After Nerve InjuryAfter Nerve Injury
Dorsal Horn
Dorsal rootganglion
Peripheral sensoryNerve fibers
A
A
C
Largefibers
Smallfibers
Two sensory afferent neurons1. Large myelinated A fibers, very fast conduction velocity.
Respond to innocuous stimuli 2. Small myelinated A & C unmyelinated fibers, have slow
conduction velocity. Respond to noxious stimuli
Modified by AHT
Although in normal condition AAlthough in normal condition A fiber does not fiber does not response to noxious stimuli, but it plays a big response to noxious stimuli, but it plays a big role in role in NORMAL SENSATION.NORMAL SENSATION.
The Role of AThe Role of A fiber fiber
Without A fiber fiber, any noxious stimuli will perceive as BURNING PAIN (TN, HZ)
A
A
A
CLateral
Nucleusproprius
Marginal layerSubstantiagelatinosa
Medial
Afferent Synaptic in DHN
Ascending spinomesencephalic and spinothalamic axons
Dorsal Root Ganglion
C Fiber
A delta Fiber
Second Order Sensory Neuron
Lateral horn cell and sympathetic axon
Ventra horn motor neuron
Anterior Lateral Spinal Thalamic Tract
Modified by AHT
Pain
Somatic or Visceral
Pain
Neuropathic Pain
Psychological Pain
SufferingPsychological State and
Traits
Loss of Work
Physical Disability
FearOf Death
FinancialConcerns
Social/ Familial
Functioning
Nature of Cancer Pain
Three Step Ladder WHO, 1986
5 essential concepts By mouth By the clock By the ladder By individual With attention to
detail
By this modality ± 90% of cancer pain can be relieved
Three Step Ladder WHO, 1986
5 essential concepts By mouth By the clock By the ladder By individual With attention to
detail
By this modality ± 90% of cancer pain can be relieved
Step I for MILD PAIN
NSAIDs may delay the need of opioid. About 20% of patients were taking NSAIDs
in the last week of life. Caution is needed when using NSAIDs for
long periods GI bleeding and renal failure are the most
common. It has ceiling effect.
Use paracetamol, aspirin or NSAID
Step Il for MODERATE PAIN Combine Paracetamol, NSAIDs + Codein Formula
Constipation is the most common side effect of codein
Acetominophen 500 mgCodein 10 mgDulcolax ¼ tab
mf pulv dtd XXX6 dd I cap
+ adjuvant06.00 18.0010.00 22.0014.00 02.00 prn
– It is a new multimodal analgesic tablet.– Contains
• 325 mg Acetominophen• 37.5 mg Tramadol
– Doses were selected based on golden ratio synergic effect.
– Decreased side effect, while maintaining efficacy
– Approved in over 25 countries including US, Europe, for moderate to severe pain
TRAMADOL peak = 2-3 hrs T1/2 = 6 hrs
TIME
Dru
g E
ffec
t
APAP peak = 30 min T1/2 = 2 hrs
In combination, T1/2 extends to 7-9 hours
Result of combination:
–Fast onset of action
–Prolonged action
Step lll for SEVERE PAIN
Oral morphine is the mainstay of severe cancer pain.
Strong pain needs strong analgesic. It is a very safe drugs as long as given properly Morphine immediate release is not available MS contin is one of choice
– Sustained release– Long acting
Why Cancer Pain Undertreated
For Step 1 & 2- doses are too low- intervals are too long- not individualized, by titration
For step 3 (strong opioid = morphine)- morphine is underused
STEP 1Nonopioid
STEP 2Weak opioid+ nonopioid
STEP 3Strong opioid+ nonopioid+ adjuvant
Why Morphine is Underused?
Morphin is underused due to:
The Myths and prejudice orInsufficient knowledge
Which is in clinical experience do not show to be true.
MYTHS & PREJUDICE of OPOID
When mention about opioids negative side Our textbooks are filled with a side effects.
– Mostly respiratory depression , addiction,
tolerance , physical dependence,
sedation, nausea/vomiting; etc.
Not the benefit of potential analgesic
In clinical experience those myths & prejudice, do not show to be true.
Myth and Prejudice of Morphine
2. Fear of addiction Addiction is the most feared side effects. When we say morphine addiction is the first
answer, not the analgesic
Large survey, 12.000 patients only 4 patients (0.03%) were considered addict
(Boston Collaborative Drug Surveillance Program) All studies chronic opioid treatment demonstrate
a lack of addiction
No evidence of addiction as long as given properly
Opiophobia
“failure to administer morphin analgesics because of a fear of these drugs to
produce addiction”
ConsequenceDue to those myth and prejudice, most cancer pain patients do not get inappropriate treatment, and failure to get the benefit of opioid.
Tragedy of Needless PainTragedy of Needless Pain
Underused of opioid in Indonesia it might be due that?
PAIN MANAGEMENT IN INDONESIA IS NOT THE PRIORITY.
Where University also should play a big role.
Adjuvant Drugs
Corticosteroids : Dexamethasone, Prednison Anticonvulsant : Carbamazepine, Gabapentin, etc Antidepressant : Amytriptiline, Doxepine Neuroleptics : Methotrimeprazine Antihistamines : Hydroxyzine Local anesthetic/antiarrhytmics : Lidocaine Psycho-stimulans : Dextroamphetamine Laxatives : Bisacodyl, Lactulose, etc Antiemetics : Droperidol, Metoclopropamide, etc
New and Alternative Pain Treatment Options
Tramadol Ultracet Clonidine Calcitonin Accupuncture Magnetic-field therapy Duragesic ( transdermal fentanyl) TENS DepoMorphine etc
Some Invasive Modalities For Cancer Pain Relief
1. Neurolitic Block- Alcohol 100 %
- Phenol glycerin 15 %
2. Epidural / Spinal opioid
3. Celiac Ganglion Block
4. Neural blockade
5. SC Morphine / Pethidine continuous infusion
6. Etc.
ConclusionAbout 90% of cancer pain patients can be
relieved by three step ladder of WHOMorphine such is very safe drug when use
properlyUnderuse morphine due to the myths and
which cannot be verified in clinical practiceMany cancer patients could die free from
pain and with dignity if a few of those myths died
In many parts of Indonesia
*Many people may die due to pain
*Many more people dying with pain
* Even many more people living in pain, particularly cancer patients.
This is our task as a doctor
NATURE OF INDONESIA
MAGNITUDE OF CANCER MAGNITUDE OF CANCER PAINPAIN Bonica 1985
– 50 % of patient of all stage reported pain– > 70 % with advanced cancer
Faley 1985– 50 % of patient with non metastatic cancer had significant pain– 60-90 % of patient with advanced cancer reported debilitating
pain WHO 1986
– 70 % of patient with advanced cancer has pain– 3,5 million people suffering from cancer pain with or without
satisfactory treatment every day Paice, 2006
– 20-75% have pain at first diagnosis – 23- 100% report pain in advance stage
CANCER PAIN
FACTS ABOUT CANCER PAIN
90% of patients with advanced cancer experience severe pain;
Pain occurs in 30% of all cancer patients, regardless of the stage of the disease.
FACTS ABOUT CANCER PAIN
More than 50% of cancer patients may be undertreated for their pain
Pain usually increases as cancer progresses.
Pain Assessment
Treat patient’s pain and regularly reassess response to therapy.
Discuss care plan with patient and family.
Causes of Cancer Pain
Pain secondary to the tumor itselfPain secondary to cancer therapyOther factors
Nociceptive PainSOMATIC PAIN
Nociceptive PainVISCERAL PAIN
Barriers to Cancer Pain Management
1. Inadequate knowledge of pain management.
2. Low priority given to cancer pain treatment.
3. Restrictive regulations, availability of nonopioid and opioid analgesic.
4. Inadequate reimbursement.
5. Fear of patient’s addiction, tolerance, and side effects of opioids; patient’s reluctance to take pain medication.
Mercadante S. WHO Guidelines – Problem Areas in Cancer Pain Management
+/- adjuvantNon-opioid
Weak opioid
Strong opioid
Pain persist
s or in
creases
By the
Clock
W.H.O. ANALGESIC LADDER
+/- adjuvant
+/- adjuvant
1
2
3
COMBINE DRUGS MAY HAVE 3 EFFECTS
1. Synergetic ............. 2+2>4
2. Additive ................ 2+2=4
3. Subadditive ........... 2+2=3
Statistical Test for a Range of Synergy
ACETAMINOPHEN
TR
AM
AD
OL Line of
Additivity
• Tramodal & Acetaminophen has different action
• Synergistic analghesia
• Reduced adverse effect
• Faster onset longer action
‘‘Isobologram’ for analgesic interaction between acetaminophen and tramadolIsobologram’ for analgesic interaction between acetaminophen and tramadol
Ultracet
Is not an NSAID (not Cox1 or Cox2 inhibitor ) Not associated with
prostaglandin-mediated side effects
Cardiovascular side effects
Not associated with GI bleeding or ulcer formation in clinical trials
No effect on platelet aggregation No risk for NSAID-induced nephrotoxicity
Myth and Prejudice of Morphine
3. Sedation• Drowsiness may occur at the beginning
but this usually disappears after a few days
• Drowsiness due to the fact that the patient has first good sleep.
• No patient would accept pain free with sedation.
WHO ANALGESIC LADDER
Physicaldimention
ORGANIC PAIN• Motivational affective• Cognitive evaluation• The meaning of pain
• unpleasant sensory• emotional experienced
“ an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in term of such damage”
PAIN is defined (by IASP 1979) as :
PAINPsycologicaldimention
Definition of Pain
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage,
or described in terms of such damage”
“Suatu perasaan dan pengalaman emosional yang tidak menyenangkan akibat kerusakan jaringan
yang nyata atau yang berpotensi rusak, atau sesuatu yang tergambarkan seperti itu”
IASP, 1979
Byock’s five key points:
“I forgive you.” “Forgive me.” “Thank you.” “I love you.” “Goodbye.”
Structure andStructure andFuntion Funtion ReciprocallyReciprocallyInterrelatedInterrelated
Self-RegulatorySelf-RegulatoryMechanismMechanism
TYPES OF PAINNEUROPATHICNOCICEPTIVE
Deafferentation Sympathetic Maintained
Peripheral
Somatic• bones, joints• connective tissues• muscles
Visceral• Organs –
heart, liver, pancreas, gut, etc.
J.Loeser (1980)
Concept of nociception, pain, suffering and pain behaviour
Pain behaviour
Suffering
Pain
Nociception
A-Alpha MotorEfferent
SympatheticEfferent
Delta SensoryAfferent
C-Fiber SensoryAfferent
PeripheralNociceptor
Spinal Cord
NSST
PSST
NRMBrainstem
Midbrain
Hypothalamusand Pituitary
Cortex andThalamus
LC
PAG
MTVPL
SSC FLC
AscendingPathaways
DescendingPathaways
SympatheticOutflow
Hypothalamic-Pituitary Outflow
Visceral pain Poorly localized, constant, aching and commonly
referred to cutaneous sites Results from injury to the organs that are
sympathetically innervated Referred pain
Pain and hyperalgesia localized to deep or superficial tissues and often found distant from the source
One proposed mechanism to explain this occurrence is central convergence of afferent impulses
Acute Pain
constant sharp aching well localized
constant dull aching poorly localized usually with nausea and
vomit occasional colicky or cramp often referred to cutaneous sites
Somatic pain Visceral pain
Somatic Pain vs Visceral Pain