แนวทางเวชปฏบตการดแลรกษาผปวยปวดจากมะเรง

พญ.ฉนทนา หมอกเจรญพงศ

กลมงานเวชศาสตรประคบประคอง

สถาบนมะเรงแหงชาต

กรมการแพทย กระทรวงสาธารณสข

ความปวด ***** PAIN

An unpleasant sensory and

emotional experience associated with

actual or potential tissue damage, or described in terms of such damage

ประสบการณทไมสบายกาย ไมสบายใจ ทเกดจากการบาดเจบของเนอเยอหรอศกยภาพทจะท าใหมการบาดเจบของเนอเยอ หรอประหนงวามการบาดเจบ

Facts about cancer pain

Frequency of occurrence varies with ;

• stage of the disease• primary site of the tumor

Frequency of occurrence varies with ;

• stage of the disease• primary site of the tumor

Moderate or severe pain occurs in 30 - 40%

of the patients at the time of diagnosis and 60 - 100% with advanced cancer

Moderate or severe pain occurs in 30 - 40%

of the patients at the time of diagnosis and 60 - 100% with advanced cancer

Most cancer patients have more than one painMost cancer patients have more than one pain

ความปวดทพบในผปวยมะเรงเกดจากหลายสาเหต

Causes of Pain

1. Due to tumor involvement 78%

• bone, nerve, soft tissue, viscera

2. Associated with treatment 19%

• diagnosis and staging procedures

• surgery

• chemotherapy; mucositis, phlebitis,

tissue necrosis, myalgia, arthralagia

• radiotherapy; mucositis, neuropathy,

myelopathy

3. Due to general illness but not cancer (10%)

• constipation

• pressure

• gastric distention

• reflux esophagitis

• bladder spasm (with catheterization)

• musculoskeletal pain

• thrombosis and embolism

• mucositis

• post herpetic neuralgia

4. Unrelated to cancer or its treatment(10%)

Causes of Pain

ความปวดจากมะเรงมผลเสยทางดานความเปนอย จตใจ อารมณ สงคม ของผปวยและผใกลชด

Assessment: Review of the systems

1. Systemic/constitutional– anorexia เบออาหาร– weight loss น าหนกลด– cachectic ผอมหนงหมกระดก– fatigue/weakness ความลา / ออนแรง– insomnia นอนไมหลบ

2. Neurologic– sedation งวงซม– confusion มนงง สบสน– hallucination ประสาทหลอน– headache ปวดศรษะ– motor weakness กลามเนอออนแรง– altered sensation การรบความรสกเปลยนแปลง– incontinence กลนไมอย

Assessment: Review of the systems

3. Respiratory– dyspnea, cough, hiccough

4. Gastrointestinal– dysphagia - dehydration

– nausea/vomiting - constipation/diarrhea

5. Psychological– irritability - depression

– anxiety - dementia

6. Integument– decubitus

– dry, sore mouth

Physical

well-beingPsychological

well-being

Social

well-beingSpiritual

well-being

Quality of life for cancer patients in pain

Pain

Total suffering

Psychological problems

Physical symptoms

Spiritual concerns

Cultural factors

Social difficulties

การประเมนความปวด

Pain Assessment

• Location of all the pain

• How the pain feels

• Intensity of the pain

• When, frequency, duration

• What ease the pain, what worsen

the pain

• Medications taking

• Side effects of pain medications

• Quality of life issues

• Pain diary!

Pain Assessment

• Chronicity: Acute vs Chronic pain

• Pain intensity

• Pathophysiology:

somatic vs. visceral

nociceptive vs. neuropathic

• Course of the disease: continuous,

breakthrough, incident pain.

• Pain syndrome: brain metastasis,

bone pain

ChronicityChronicity

Acute pain Chronic pain

Onset well-defined ill-defined

Cause acute injury or illness

chronic progress

Duration days/weeks

predictable

months/years

unpredictable

Physiological

sympathetic over activity

no sympathetic over activity

Acute pain Chronic pain

Affective anxiety depression

Cognitive meaningful meaningless

Behavioral inactivity until recovery

changes in life style

changes in functional ability

withdrawn

Treatment cause

temporary analgesics

supportive

regular analgesics

Categoral scales

• Verbal rating scale (VRS)

(verbal descriptor scale)

• 2 – 7 words

None Mild Moderate Severe

• Pain relief

None Slight Moderate Good Complete

Numerical rating scale (NRS)No pain 0 1 2 3 4 5 6 7 8 9 10 Worse pain

imaginable

Visual analog scale (VAS)

No pain ____________________ Worse pain

imaginable

Happy/sad faces.

Pain Assessment

• Chronicity: Acute vs Chronic pain

• Pain intensity

• Pathophysiology:

somatic vs. visceral

nociceptive vs. neuropathic

• Course of the disease: continuous,

breakthrough, incident pain.

• Pain syndrome: brain metastasis,

bone pain

Pathophysiology

• Nociceptive ( somatic and visceral )– constant and well localized

– aching, throbbing, gnawing

– vague in distribution and quality, deep, dull,

aching, dragging, squeezing, pressure-like

• Neuropathic– may be constant, steady, and spontaneously

maintained, intermittent, shock-like, shooting,

lancinating, electrical, burning, tingling, numbing,

pressing, squeezing, and itching

– dysesthesia, hyperalgesia, allodynia,

hyperesthesia, hyperpathia

Neuropathic Pain

• Hardest mechanism to treat

• Diagnose straightforward: nerve or

dermatome distribution, no local tenderness

but referred

• Two types

– Mixed: nociceptive/neuropathic due to tumor

invasion or compression of nerve pathway;

brachial, lumbosacral plexus, chest wall invasion,

spinal cord compression

– Pure (Deafferentation): no nociceptive element;

PHN, post-thoracotomy syndrome, phantom pain

Bone Pain

• Most common cause of pain in advanced

cancer

• Most common malignancies metastasize to

bone: breast, prostate, lung, kidney, thyroid

• Common problems: chronic bone pain,

pathologic fracture, hypercalcemia

• Treatment includes: NSAIDs, opioids,

radiotherapy, Strontium-89, bisphosphonate,

corticosteroids, calcitonin.

• Early Orthopedic consultation and treatment

is important

Pattern of pain

Constant pain

Breakthrough and

incident pain

Intermittent pain

หลกการระงบปวดในผปวยมะเรง

Principle of Analgesic Use

• Define the nature of pain

• Maximize the current regimen

• Understand the drug Pharmacology

– Speed of onset and duration of action

– Management of side effects

– Beware of the drug interactions

• Emphasize patient education

Cancer Pain Management

• Pharmacologic

treatment

• Non-

Pharmacologic treatment

WHO Analgesic Ladder (1992--)

Non-opioid+ Adjuvants

Opioid for mild to moderate pain

+ Non-opioid + Adjuvants

Opioid for Moderate to severe pain

+ Non-opioid + Adjuvants

Pain

Pain persist

Pain persist

Freedom from

cancer pain

Morphine เปนยาแกปวดรนแรงทดทสดในปจจบน

ใชกนไดสะดวกบรหารไดหลายวธ

Essential concepts in the WHO approach to drug therapy

• By the mouth

• By the clock

• By the ladder

• For the individual

• With attention to detail

Principles of analgesic used

• Administer on strict schedule to

prevent pain, not PRN

• Give instructions for treatment of

breakthrough pain

• Following analgesic ladder

• Review & assess

GENERAL RECOMMENDATIONS

• Oral medications should be used as the first line approach.

• Any proposed systemic regimen must be individualized.

• There is no predetermined maximum dose of an opioid.

• Dose titration may be required periodically.

Adverse drug effects from opioid therapy

• Tolerance

• Physical dependence

• Addiction

• Constipation

• Sedation

• Nausea-vomiting

• Mental clouding

• Myoclonus, pruritus, urinary retention

• respiratory depression

Nausea

• Moderate to severe 8.3 – 18.3%

• Direct effect of opioids on CTZ

• Decrease quality of life, limit food

intake

• Other underlying conditions; electrolyte imbalance, dehydration, brain metastasis, intestinal obstruction, ileus, chemotherapy, tumor of the GI, constipation, infection, blood poisoning, kidney problems, anxiety, etc.

Nausea

• Usually subside within few days

• Treatment; – Metoclopramide ( block in GI tract and CTZ)

– Butyrophenones (haloperidol, droperidol) (at CTZ)

– Phenothiazine (CTZ, GI, vestibular)

– Antihistamine (dramamine,hydroxyzine) (H1 blockade and VC)

– Hyoscine, scopolamine (VC and GI)

– Ondansetron (5HT3 in GI and CTZ)– Benzodiazepine (lorazepam) GABA agonist

Constipation

• The most troublesome, almost

everyone is involved, will not develop

tolerance

Treatment of Constipation

• Stimulant laxatives• Senokot 1 tab hs – 4 tab tid orally

• Dulcolax 1 tab hs – 3 tab tid orally

• Bulk-forming laxatives• Metamucil 1 tsp in 8 oz water OD – tid

• Bran

• Saline or osmotic cathartics• MOM 15 – 40 ml OD – bid

• Magnesium citrate solution 240 ml OD

CNS effects

• Aggravating factors;

– High doses opioid

– Psychoactive drugs

– Renal failure

• Slow down of cognitive function, sedation,

hallucination and delirium, fluctuation of

consciousness, change in sleep-wake cycle,

agitation, myoclonus.

• Improve spontaneously

CNS effects

• Role of M-3-G

• Management;

– Opioid rotation

– Dose reduction

– Circadian modulation

– Hydration

– Psychostimulants

– Other drugs; haloperidol, midazolam, baclofen, clonazepam,clonidine

Adjuvants

• Antidepressants : tricyclic antidepressant (amitriptyline), SSRI (Fluoxitine)

• Anticonvulsants : Carbamazepine (tegretol), Hydantion (dilantin), Gabapentin (Neurontin)

• Sedatives, hypnotics, tranquilizers

• Steriod

• Muscle relaxants

ADJUVANTS

DRUGS

- Anticonvulsants

- Antidepressants

- Local anesthetics

- Corticosteroids

- Antihistaminics

- Muscle relaxants

- Psychostimulants

- Drug action on bone

INDICATIONS

- neuropathic pain

- neuropathic pain

- neuropathic pain

- multiple

- coanalgesic, antiemetic

- muscle spasm

- opioid sedation

- bone pain

Antidepressants

• Used in neuropathic pain ; several studies in

Diabetic neuropathy, Post-herpetic neuralgia,

phantom limb pain, migraine headache

• Reduce insomnia and anxiety

• 1-2 weeks lag time for clinical effects

• Start 10-20 mg hs

• Escalated 4-5 day intervals to doses 100- 150

mg

• Abrupt escalation not recommended

TCA Uses Limited by Side Effects

• Anticholinergic : dry mouth, visual

changes, constipation, tachycardia, urinary

retention, reduced gastric motility, worsen

narrow angle glaucoma

• Antihistamine : sedation

• Alpha adrenergic blockade :orthoststic hypotension

• Sodium channel blockade :prolonged QT and QRS

สรปแนวทางการระงบปวดผปวยโรคมะเรง

• มะเรงเปนโรคทมผลรายตอชวต มะเรงระยะทายท าใหผปวยจ านวนมากมความปวด

• ความปวดทพบในผปวยมะเรงมหลายสาเหต รกษาตามความเหมาะสมของแตละสาเหต

• การประเมนความปวดมทงทางกายและทางใจ

• ปรมาณความปวดดไดจาก VAS ฯ

สรปแนวทางการระงบปวดผปวยโรคมะเรง

• การระงบปวดใชยาเปนหลก

• ใหยาระงบปวดตามความรนแรง ตามเวลาอยางตอเนอง เสรมเมอตองการเพม และประเมนผลการรกษาบอยๆ

• ยงมการระงบปวดโดยไมใชยาอกหลายวธ

• ดแลคณภาพชวตของผปวย

Thank you