Cancer pain and its management

Dr.Vincent Appathurai M.B.B.S. D.T.M.

Principal Medical officer, BLH Presented at Annual Conference, BMA 28 th Oct 2007

“Pain is a greater Lord of mankind than even death itself”

- Albert Schewitzer

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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

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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.

5 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

PHYSICAL PSYCHOLOGICAL TOTAL PAIN SOCIAL 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

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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

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Pain in Cancer

  May not have pain !!!

Most do have pain- 2/3 rd cancer with advanced Number of pains  1/5 th have one pain   4/5 th have 2 or 3 pains 1/3 rd 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 )

Top 10 cancer pains Cancer pain with debility ( 6 of them ) 11

 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

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Evaluation

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Explanation

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Management

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Monitoring

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Attention to detail

16 Tools used in assessment of pain Numerical scale 0 1 2 3 4 5 6 7 8 9 10 No pain Worst pain

Categorical scale

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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

Pharmacological Management

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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

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WHO Analgesic Ladder

24 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

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

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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

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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 –

Ibuprofen 400mg p.o tds

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Indomethacin 50mg p.o tds

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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 -Hydromorphone Oxycodone - Methadone - Levorphanol - Transdermal fentanyl Meperidine Fentanyl

35 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

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

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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, 2 nd conf 2007 ) Pain is under diagnosed and under treated

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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)

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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. 3 rd draft, April 2007

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KEALEBOGA Thank you