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