View
213
Download
0
Embed Size (px)
Citation preview
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 1/51
A Husni Tanra
Department of Anesthesiology, Intensive Care andPain Management
Faculty of Medicine Hasanuddin University
MAKASSAR
CANCER PAIN
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 2/51
A Patients perspective
“ One of the worst aspect of cancer pain is thatit`s a constant reminder of the disease and ofdeath ..
My dreams is for a medication that can relievemy pain while leaving me alert and with noside effects “
Jeanne Stover, 1992
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 3/51
Physicaldimension
Organic Pain
• unpleasant sensory• emotional experienced
Pain is “an unpleasant sensory and
emotional experience associated withactual or potential tissue damage ordescribed in term of such damage”
Definition of Pain (IASP 1979)
PAINhas 2 dimensions
Psycologicaldimention
PsychologicalPain
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 4/51
• Pain is extremely a major problem in 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 Cancer Pain
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 5/51
Prevalence of Cancer Pain
Bonica 1985
• + 50 % of patients of all stage reported pain• > 70 % with advanced cancer
Faley 1985
• 15 % of patients with non metastatic cancer hadsignificant pain
• 60-90 % of patient with advanced cancer reporteddebilitating pain
• 25% of all patients with cancer die in pain.WHO 1986
• 70 % of patient with advanced cancer had pain
• 3,5 million people suffering from cancer pain with or
without satisfacttory treatment every day
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 6/51
The Phenomena of Cancer Pain
COMPLEX and COMPLICATED
• ORGANIC PAIN
• PSYCHOLOGICAL PAIN• SUFFERING FROM PAIN
TOTAL PAIN
BIOPSYCHOSOCIOCULTUROSPIRITUAL
is the cumulative among :
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 7/51
TOTAL
PAIN
SOMATIC SOURCE
(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 bungling
Friends who 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
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 8/51
Elisabeth K.Ross (1969) “on death
and dying”. BEHAVIOUR CHANGES IN CANCER PATIENTS
1. DENY2. ANGER
3. BARGAINING
4. DEPRESSION5. ACCEPTANCE
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 9/51
Pain
Somatic or
VisceralNociception
NeuropathicMechanisms
PsychologicalDisturbances
SufferingPsychologicalState and
Traits
Loss ofWork
PhysicalDisability
FearOf Death
FinancialConcerns
Social/Familial
Functioning
Pain In Cancer Patient
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 10/51
Mechanism of Cancer Pain
Can be divided into 2 catagories
1. ORGANIC PAIN
2. PSYCHOLOGICAL PAIN
ORGANIC PAINA. Nociceptive pain
1. Somatic pain(skin, muscle, bone, connective tissue)
2. Visceral pain
(thoracic and abdominal viscera)
B. Non nociceptive pain3. Neuropathic pain (deafferentiation pain) damage
of peripheral or central n.s.
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 11/51
Nociceptive Pain
Nociceptive pain means, pain with nociception
Nociceptive means, activity of afferent neurons
induced by a noxious stimulus
• TRANSDUCTION
• TRANSMISSION
• MODULATION
• PERCEPTION
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 12/51
Process whereby
noxious stimuli are
translated into
electrical activity at
the sensory endings
of nerves.
Heat
Chemical
TRANSDUCTION
Pressure
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 13/51
TRANSMISSION
Refers to the propagation
of impulses throughoutthe sensory nervous
system.
Transmission
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 14/51
MODULATION Process whereby endogenous
analgesic systems can modifynociceptive transmission. Theseendogenous systems (opioid,seretonergic, and noradrenergic)exhibit their inhibitory influenceat the dorsal horn.
Plays important role to the
individual perception.
Modulation
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 15/51
Pain
PerceptionBrain
PerceptionFinal process wherebytransduction,
transmission, andmodulation interact withthe uniqueness of theindividual to create the
final subjective feelingthat we call pain.
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 16/51
Organic pain in cancer
patients can be devided intothree types:
1. SOMATIC PAIN
2. VISCERAL PAIN
3. NEUROPHATICPAIN
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 17/51
Characteristic of Somatic Pain
• Example :
• Mechanisms :
• Management :
• Continous activation of nociceptors may producesensitization of N.S. (peripherally & centrally)
constant
aching, gnawing well localized
activation of nociceptors release algesic substances
(spesially prostaglandins)
bone metastasis. tumor of the soft tissue
Aspirin
Acetaminophen NSAID
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 18/51
Characteristic of Visceral Pain
• Mechanisms :
• Example :
• Management :
constant
deep or dull aching poorly localized usually with nausea and vomit often referred to cuttaneous sites
occational colicky or cramp
activation of nociceptors
pancreatic cancer
liver/lung metastasis with shoulder pain
Opioid (MS confine ®) Nerve block (e.g celiac plexus block)
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 19/51
Stimuli Sufficient To Cause
Visceral Pain Are:
1. Irritation of mucosal and serosal surfaces
2. Torsion and traction of mesentery
3. Distension or contraction of hollow viscus
4. Impaction of visceral organs
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 20/51
Characteristic of Neuropathic Pain(Deafferentiation Pain)
• Mechanisms :
• Example :
• Management :
burning pain paroxysmal shooting or electricalshock-like pain
spontaneus discharges of
peripheral or central n.s. loss of central inhibition
metastasis brachial or lumbosacralplexopathies
post herpetic neuralgia antidepressant or anticonvulsant nerve block etc
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 21/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 22/51
Classification of Cancer Pain
1. TEMPORAL2. TOPOGRAPHIC
3. ETIOLOGIC and
4. PATHOPHYSIOLOGIC
1. Pain associated with direct tumor
2. Pain associated with cancer therapy
3. Pain unrelated to cancer
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 23/51
1. Pain associated with direct tumor
Due to invasion of bone
• Base of skullOrbital syndromeParasellar sinus syndromeSphenoid sinus syndromeClivus syndrome
Jugular foramen syndromeOccipital condyle syndrome
• Vertebral body Atlantoaxial syndromeC7-T1 syndrome
L1 syndromeSacral syndrome
• Generalized bone painMultiple metastase
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 24/51
1. Pain associated with direct tumor
Due to invasion of nerves
Peripheral nerve syndromeParaspinal massChest wall massRetroperitoneal mass
Painful polynueropathyBrachial, lumbal, sacral plexopathiesLeptomeningeal metastaseEpidural spinal cord compression
Due to invasion of visceral Due to invasion of blood vessels
Due to invasion of mucous membranes
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 25/51
2. Pain associated with cancer therapy Surgery
Postthoracotomy syndrome
Postmastectomy syndromePostradical neck dissection syndrome
Postamputation syndromes
Chemotherapy
Painful polyneuropathyAseptic necrosis of bone
Steroid pseudorheumatism
Mucositis
Radiation
Radiation fibrosis of brachial or lumbosacral plexus
Radiation myelophaty
Radiation-induced peripheral nerve tumors
Mucositis
Radiation necrosis of bone
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 26/51
3.Pain indirectly related or
unrelated to cancer
Myofascial pains
Osteoporosis Postherpetic neuralgia
Debiliting (decubitus ulcer)
Etc
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 27/51
ABCDE Mnemonic for Pain
Assessment and Management
Ask about pain regularly
Believe the patient reports of pain
Choose pain control appropriately
Deliver in a timely, logical and coordinated
Empower patients and family
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 28/51
Three Step Ladder WHO, 1986
5 essential concepts
By mouth
By the clock
By the ladder
For individual
With attention to
detail
By this modality±
90% of cancer pain can be relieved
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 29/51
Pharmacologic Management of
Cancer Pain Individualize cancer pain management to the
patient
Use the simplest dosage schedules and theleast invasive means
An NSAIDs or acetaminophen should be usedin the pharmacologic management of mild tomodertae peripheral cancer pain, unless thereis a contraindication
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 30/51
Step I for MILD PAIN
NSAIDs may delay the need for escalatingopioid.
About 20% of patients were still taking NSAIDsin the last week of life.
NSAIDs have a potential opioid-sparing effect.
Caution is needed when using NSAIDs for
prolonged periods Risk factors such as aging, renal or GI diseases
should be considered.
It has ceiling effect.
Use paracetamol, aspirin or NSAID
f
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 31/51
Step Il for MODERATE PAIN
Combine Paracetamol/Aspirin/ NSAIDs + Codein
Formula
Constipation is the most common side effect ofcodein
Acetaminophen/
Aspirin 500 mg
Codein 10 mg
Dulcolax ¼ tab
mf pulv dtd XXX6 dd I cap
+ adjuvant
06.00 18.00
10.00 22.00
14.00 02.00 prn
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 32/51
Step lll for SEVERE PAIN
Oral morphine is the mainstay of severe cancerpain.
Strong pain needs strong analgesic.
It is a very safe drugs as long as given properly Morphine immediate release is not available in
Makassar.
MS contin is one of choice Sustained release
Long acting (twice a day)
Strong opioid
WHO A l i L dd
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 33/51
WHO Analgesic Ladder
Consider other treatment modalities when possible andappropriate
Radiotherapy, hormonal therapy, palliative chemotherapy, surgery
Consider nonpharmacologic modalities
Physiotherapy, psychotherapy, TENS, Accupucture, etc.
Address all aspects of suffering
Physical, psychosocial, cultural, and/or spiritual
STEP 1
Nonopioid
STEP 2
Weak opioid
+ nonopioid
STEP 3
Strong opioid
+ nonopioid
+ adjuvant
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 34/51
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
O F l i RSWS
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 35/51
Ours Formula in RSWS
Acetaminophen/Aspirin 500mg
Codein 20 mg
Dulcolax ¼ tab
mf pulv dtd XXX
6 dd I cap
+ adjuvant
06.00 18.00
10.00 22.00
14.00 02.00 prn
Moderate pain Severe pain
MST 5 - 10 mg
2 dd I tab
Celebrex 100 – 200 mg
2 dd I cap
+ adjuvant
06.00
18.00
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 36/51
If we could notable to cure the cancer patients,
never deny cancer pain, and let them die freeof pain and with IMAN
As a doctor, one should keep in mind :
To cure is sometimeTo treat is often, but…
To comfort is always
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 37/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 38/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 39/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 40/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 41/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 42/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 43/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 44/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 45/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 46/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 47/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 48/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 49/51
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 50/51
CONCLUSION1. Pain is a common problem and a major symptom
of cancer patients.
2. Pain is one of the most feared aspect and cancause to suicide
3. Cancer pain can be organic or psychological pain
4. Organic pain may be somatic, visceral orneuropathic pain or combined.
5. Total pain is aBIOPSYCHOSOCIOCULTUROSPIRITUALproblem.
6. CANCER PAIN management should be treated
integrated and comprehensive by multidisiplinedoctors.
8/21/2019 Cancer Pain2
http://slidepdf.com/reader/full/cancer-pain2 51/51