cancer pain and its management dr.vincent appathurai m.b.b.s. d.t.m. principal medical officer, blh...
TRANSCRIPT
Cancer pain and its management
Dr.Vincent Appathurai M.B.B.S. D.T.M.Principal Medical officer, BLHPresented at Annual Conference, BMA28th Oct 2007
“Pain is a greater Lord of mankind than even death itself”
- Albert Schewitzer
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Introduction
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
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Definition of pain
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.
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Pain is a psychosomatic phenomenon
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 )
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Concept of Total Pain
TOTAL PAIN
PHYSICAL
SOCIALPSYCHOLOGICAL
SPIRITUAL
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Physiology of pain
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
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Physiology of pain
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
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Pain in Cancer
May not have pain !!! Most do have pain- 2/3rd with advanced
cancerNumber 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 painsCancer pain with debility ( 6 of them )
Immobility, Constipation Myo- fascial, Cramps Oesophagitis Degeneration of spines ( All constitute 10-20%
) Pain associated with chemotherapy,
radiotherapy, surgical intervention. Others- Difficult pains – complex 10%
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Aetiology of cancer pain
Infiltration of the viscera Bony metastases Smooth muscle spasms Muskulo- skeletal pains Infection Nerve compression pain Unrelated pains
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Assessment of pain
Good history taking - Pain is the fifth vital sign
Site Duration Onset Quality of pain Aggravating factors Relieving factors
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Assessment of pain
Temporal pattern (acute, chronic, sub acute, breakthrough pain, incident pain)
Interference with daily living Sleep Psychological status Response to current and previous therapy
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A systematic approach
Evaluation ExplanationManagementMonitoringAttention to detail
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Tools used in assessment of pain
Numerical scale
0 1 2 3 4 5 6 7 8 9 10
No pain Worst pain
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Categorical scale
None (0)
Mild (1-3)
Moderate ( 4-6 )
Severe ( 7-10 )
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Visual Analogue scale
_________________________________
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’sThree steps Mild pain = Non- opioid + or – AdjuvantMod.pain = Weak opioids + or – Non-opioid
+ or – AdjuvantSevere pain = Strong opioids + or – Non-opioid
+ or - Adjuvant
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WHO Analgesic Ladder
Principles are Five - By mouth
- By the clock - By the ladder
- For the individual - Attention to detail
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WHO Analgesic Ladder
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Outcome (WHO analgesic ladder)
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
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Principles in use of morphine
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
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Principles in use of morphine
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
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Principles in use of morphine
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
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Side effects of morphine
Nausea and vomiting Confusion Sedation Constipation Hallucinations Constricted pupils Biliary colic
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Side effects of morphine
Itching Sweating Myoclonus Convulsions Dry mouth Histamine release ( broncho-constriction ) Pulmonary oedema
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Treatment of side effects
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
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Non-opioids
Aspirin 600mg p.o every 4 hours Paracetamol 1g p.o every 4hours NSAID’s
– Ibuprofen 400mg p.o tds– Indomethacin 50mg p.o tds– Diclofenac 50mg p.o tds
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Other Adjuvants
Antidepressants- Amitriptyline Anticonvulsants-carbamazepine, Sodium
Valproate Corticosteroids- Prednisolone,
Dexamethasone, methyl prednisolone Muscle relaxants-Diazepam or Baclofen Bisphosphonates- Disodum pamidronate
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Weak opioids
Codeine Hydrocodone Propoxyphene Tramadol Used in step 2 for mild to moderate pain Add non opioid and adj. to optimize effect
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Strong opioids
Short half life Long half life
-Morphine - Methadone
-Hydromorphone - Levorphanol
Oxycodone - Transdermal fentanyl
Meperidine
Fentanyl
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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
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
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Non-pharmacological methods
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
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Barriers to pain management
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
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Why pain relief ?
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
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Why pain relief?
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)
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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