Dr U.Kamariah binti U.Ahmad

Pain Specialist and Anaesthesiologist

Hospital Sultan Ismail,

Johor Bahru , Johor.

10th Malaysian Hospice Congress

Introduction

How can we

maximized the

pain management. WHO standard

treatment

Assessment of

patient

Cancer Prevalence in Malaysia Epidemiology of cancer pain Studies on global impact of pain in Ca pt Studies on impact of mood & psychology function

A total of 21,773 cancer

cases were diagnosed

among Malaysians in

Peninsular Malaysia in the

year 2006 and registered

in the National Cancer

Registry. It comprises of

9,974 males and 11,799

females.

Incidence Rate (ASR) for

all cancers in the year

2006 regardless of sex

was 131.3 per 100,000.

the five most common

cancer among

population of Peninsular

Malaysia in 2006 were

breast, colorectal, lung,

cervix and nasopharynx

A total of 18,219 new

cancer cases were

diagnosed in 2007 and

registered at the National

Cancer Registry. It

comprises of 8,123

(44.6%) males and 10,096

(55.4%) females.

The age-standardised

incidence rates (ASR)

were 85.1/100.000 males

and 94.4/100,000

females while the

The five most frequent

cancers among

Malaysian males in 2007

were lung, colorectal,

nasopharynx, prostate

and

lymphoma, while the

five most common

cancers in females were

breast, colorectal,

cervix, ovary and lung

(Table 9,

National Cancer Registry’s Malaysian Cancer Statistics:

Data and Figures, Peninsular Malaysia 2006

Cancer Incidence per 100,000

population by age - Females %

Cancer Incidence per 100,000

population by age - Males %

pain occurs in 30% of all cancer patients, regardless of the stage of the disease.

not all cancer patients feel pain, and pain is rarely a sign of early cancer.

30% - 40% of patients suffers with pain while on active Rx 90% of patients with advanced cancer experience severe pain

Pain usually increases as cancer progresses..

As many as 50% of patients may be under treated for cancer pain

The second most common

cancer pain is caused by

tumors infiltrating the

nerve and hollow viscus.

– Tumors near neural

structures may cause the

most severe pain.

The most common

cancer pain is from

tumors that metastasize

to the bone.

As many as 60-80% of

cancer patients with

bone metastasis

experience pain. The third most common

pain associated with

cancer occurs as a result

of chemotherapy,

radiation, or surgery

WHO standard

treatment

Assessment of

patient

Treatment

Neuroablative techniques

Intraspinal opioids / local anaesthetics

Regional catheters

S/C opioids / adjuvants / ketamine

Oral opioids / adjuvants.

Psychological therapies

Acupuncture; TENS

Simple analgesics; NSAIDs.

Anti-neoplastic drugs; XRT

WHO CANCER PAIN

GUIDELINES.

Three principles of

analgesic use2

By the mouth

By the clock

By the ladder

The three critical components of cancer pain management occur on a cyclical basis:

Cleary JF. Cancer Control 2000;7(2):120-131.

Therapeutic

Opioid Regimen

Integration with

other therapies

Pain

Assessment

History

Examination

Investigation

Look for new

symptoms

Type of pain:

Neuropathic

Nociceptive

Many

cancer

patients

experience

pain from

more than

one source

What cause cancer pain?

Caused by cancer treatment (chemotherapy, radiotherapy @ surgery)

Neuropathic pain:

This pain may occur if treatment damages the nerves.

Burning, sharp, or shooting.

The cancer itself causes burning itself can also cause this kind of pain.

Phantom pain.

may still feel pain or other discomfort coming from a body part that has been removed by surgery.

Important to :

listen and believe the

patient

Take a pain history :

“Tell me about your pain…”

5th Vital Sign: Doctors’ training module: Pain Assessment

P : Place or site of pain “Where does it hurt?”

(a body chart might help describe

their pain)

A : Aggravating factors “What makes the pain worse?”

I : Intensity “How bad is the pain?”

N : Nature and neutralizing

factors “What does it feel like” “What makes the pain

better?”

5th Vital Sign: Doctors’ training module: Pain Assessment

•Xray

•Ultrasound

•Bone scan

•? MRI or CTscan

0-3

4-6

Regular

Higher dose of

weak opioid

Or

IV/SC Morphine

5-10mg 4 hrly

OR

Aqueous

morphine 10-20

mg

± PCM 1gm QID

oral / rectal

± NSAID /

COX2 inhibitor

MILD

MODERATE

SEVERE

Regular

No

medication

or PCM

1gm 6hrly

Regular

Weak Opioid

± PCM 1gm QID

oral

± NSAID /

COX2 inhibitor

PRN

PCM &/or

NSAID /

COX2

inhibitor

7-10

PRN

IV/SC

Morphine

5-10mg

OR

Aqueous

morphine

*Oral or SC

Morphine may

be safely

given at hourly

intervals

PRN

Additional

weak opioid

UNCONTROLLED

To refer to APS for:

PCA or Epidural or

other form of analgesia

Analgesic Ladder for Acute

Pain Management

The Adult Analgesic Ladder for Acute Pain:– pain as 5th vital sign Doctor’s training module KKM guideline :

adopted with modification from West Hertfordshire Hospitals acute pain guideline

Pseudo-resistant • underdosing

• poor absorption

• poor intake

• ignoring psychological

aspects of care

Semi-resistant • Bone metastases

• Neuropathic (Some)

• RICP

• Activity related

Resistant Neuropathic (some)

Muscle spasm

From Melzack and Wall Textbook of Pain 3rd ed 1995

Nociceptive Neuropathic

Superficial

somatic

Deep

somatic

Skeletal

muscle

Visceral

colicky

Visceral

constant • Anti-arrhythmic

• Antiepileptic

• Capsaicin

• Corticosteroid

• Intraspinal

clonidine, opioid

• Nerve block

• Opioid

• Parenteral

ketamine

• TCA

• Heat or cold

• Irrigation

• Local

anaesthetic

• Opioid

• Paracetamol

• Radiotherapy

• Topical

NSAID

• Corticosteroid

• Heat or cold

• Immobilisation

• NSAID

• Opioid

• APAP

• Radiotherapy

• Baclofen

• Clonazepam

• Dantrolene

• Diazepam

• Heat or cold

• Immobilisation

• Massage

• NSAID

• Opioid

• Anti-

spasmodic

• Heat or cold

• Ketorolac

• Nifedipine

• Opioid

• Corticosteroid

• Opioid

• APAP

Adapted from: Mashford ML, et al. Therapeutic Guidelines: Analgesic. 2002.

WHO

recommendation:

Oral route

Types of opioids

Other routes:

patches

Subcutaneous

Intravenous

Intrathecal

Oral Opioids Pharmacology of morphine

slow release and regular

interval How to give:

Dose : calculated

Dosing times: regular

To reduce side

effects / better

compliance:

Slow released opioid

Less sedation

Breakthrough dose:

1/3 – full dose

Slow release drug

Regular interval drug

Patient pre morbid

condition

Dose requirement

Side effects

Availability

Acceptable or

permissible route

Drug interaction

Patients compliance

and acceptability

Sublingual

tablets

Rectal

suppositories

Transdermal

patch

Continuous

subcutaneous

infusion

Subcutaneous

injection

Spinal delivery

Tablet

Liquid

suspensions

Liquid

solutions

Sprinkling on

solid foods

The wide variety of formulation of opioid analgesia increases their clinical utility

Adopted from: Twycross, Wilcock A, symptom management in advance cancer 3rd edition. Abingdon,UK, Redellife Medical Press 2001.

What is the

Maximum dose for

opioids?

No limits

To take as much as

needed till

development od side

effect.

How do you monitor

safety of giving opioid?

Vital sign esp.

respiratory rate, Blood

Pressure. Pulse rate,

Pain score

Conscious level

Comfort score

Definition:

is a physiological

phenomenon where

increasing doses of a

drug are required to

produce the same

pharmacological effect,

or where the same dose

produces less effect.

Patient will escalate

(increased dose

requirement) within

few weeks

But pain relief is still

not satisfactory and not

maintain

Started to developed

side effect

Clinical presentation:

Changing opioid

type:

Opioid rotation

Calculate the

equivalent dose of

the chosen drug

Changing the

mode of giving:

Patch

Subcutaneous

PCA etc

Type of Pain Response to Opioid Drug Treatment

Visceral Totally Responsive Opioid

Soft tissue Partially Responsive Non-opioid/NSAID +

opioid

Bone Partially Responsive NSAID + opioid

Nerve compression Partially Responsive Opioid + corticosteroid,

anticonvulsant

Nerve destruction Partially Responsive

Tricyclic antidepressant,

anticonvulsant, local

anaesthetic

Muscle pain (spasm) Non Responsive Muscle relaxant

Nociceptive Neuropathic

Superficial

somatic

Deep

somatic

Skeletal

muscle

Visceral

colicky

Visceral

constant • Anti-arrhythmic

• Antiepileptic

• Capsaicin

• Corticosteroid

• Intraspinal

clonidine, opioid

• Nerve block

• Opioid

• Parenteral

ketamine

• TCA

• Heat or cold

• Irrigation

• Local

anaesthetic

• Opioid

• Paracetamol

• Radiotherapy

• Topical

NSAID

• Corticosteroid

• Heat or cold

• Immobilisation

• NSAID

• Opioid

• APAP

• Radiotherapy

• Baclofen

• Clonazepam

• Dantrolene

• Diazepam

• Heat or cold

• Immobilisation

• Massage

• NSAID

• Opioid

• Anti-

spasmodic

• Heat or cold

• Ketorolac

• Nifedipine

• Opioid

• Corticosteroid

• Opioid

• APAP

Adapted from: Mashford ML, et al. Therapeutic Guidelines: Analgesic. 2002.

• Antiepileptic:

• Carbamazepine

• Phenytoin

• Gabapentine

• Antidepressent:

• Amitriptyline

• Nortriptyline

• Anti-arrhythmic

• mexilitine

• Capsaicin

Canadian Family Physician June 2010 vol. 56 no. 6

Dr U.Kamariah binti U.Ahmad

Pain Specialist and Anaesthesiologist

Hospital Sultan Ismail,

Johor Bahru , Johor.

10th Malaysian Hospice Congress