PAIN CONTROL

What can we do when one’s cancer is not curable?

Medhat Faris

M Far is 12/04/2010

Outcome of Cancer Treatment

Diagnosis of Cancer

45%Curative Treatment 30% Cure

55%Palliative Treatment

15%

70%TerminalCare

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Quality of Life

• Symptoms from cancer,

• Side effects of treatment,

• Level of physical functioning (PS),

• Social, psychological, and sexual status as well as sense of well-being.

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Palliative TreatmentIs the active, total care of patient whose

disease is not responsive to curativetreatment.

Control of pain, other symptoms and ofpsychological, social and spiritualproblems is paramount.

The goal of palliative care is achievementof the best possible quality of life forpatients and their families M Far is 12/04/2010

PAIN• “ An unpleasant sensory and emotional

experience, associated with actual or potentialtissue damage, or described in terms of suchdamage”

(International Assoc.for the Study of Pain, 1994)• “ Pain is what the patient says hurts”.

• “ It is what the patient describes and not whatothers think it ought to be”.

M Far is 12/04/2010

More than 70% of patients with cancerdevelop significant pain during the course oftheir illness.

Data shows that most cancer pain can bewell controlled without parentral analgesics.

with supplemental therapeutic modalities,approximately 95% of patients can be free ofsignificant pain.

PAIN FACTS

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PAIN FACTSOnly 50% of cancer pain is controlled in mostdeveloping countries.

Despite the publication and widespreaddistribution of guidelines for pain management,many patients with cancer receive inadequateanalgesia.

Studies have documented that many patients donot report pain unless specifically asked.

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Barriers to Effective Pain Management

1- Reluctance to report pain:* fear of distracting the physician; * fear that increased pain means disease progression; * concern with complaining about symptoms for fear

of not being seen as a "good" patient

2- Fears of addiction.

3- Fears of tolerance.

4- Fears of side-effects to medications.M Far is 12/04/2010

Six Myths About Opioids Usage

M #1 "Addiction to opioids is a sign of depravity andshould be avoided at all costs.“

M #2 "If I give you morphine now, no strong pain medicinewill be available later when you need it.“

M #3 "Oral medications don't work for cancer painInjections are always required."

M #4 "Totally relieving cancer pain produces dopedzombies unable to think or function normally."

M #5 "Pain medicine should be given as needed (P.R.N.).“M #6 "High doses of opioids act as a form of euthanasia."

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Impediments to cancer pain relief

Absence of national policies on cancer pain relief andpalliative care.

Lack of recognition by health care workers, policymakers, administrators, and the public that most cancerpain can be relieved.

Lack of financial resources and limitations in health caredelivery system and personnel.

Concern that medical use of opioids will produceaddiction and drug abuse.

Legal restrictions on the use and availability of opioidanalgesics.

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Principles of Cancer Pain Management

• Understand the natural history of cancer typeand the principles of pain management.

• Selecting a drug appropriate for the type of pain.

• Medications taken by mouth when possible.

• Medications taken by the clock.

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Principles of Cancer Pain Management

• Medications are escalated according to theRating of pain from mild, moderate to severe.

• Medications are tailored to individual needs.

• Pain is monitored and re-assessed regularly.

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Totalpain

Anger•Bureaucratic bunging•Delays in diagnosis•Unavailable physicians•Uncommunicative physician•Failure of therapy•Friends who do not visit

Physical pain• Other symptoms• Adverse treatment effects

Depression•Loss of social position•Loss of job•Loss of role in family•Chronic fatigue &insomnia•Sense of helplessness•Disfigurement

Anxiety•Fears of hospitals•Fear of pain•Fear of death•Worry about family& finances•Spiritual unrest, uncertainty about future

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CAUSES OF PAIN* Tumour pressing on nerves, bone

and/or various organs :Visceral e.g. liver.Somatic e.g. bone.Neuropathic.

* Procedures used for evaluation and/or treatment, and/or pre-existing conditions.

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Associated with investigationsDiagnostic and staging Procedures

Surgery Neuropathy after thoracotomyNeck dissectionmastectomy

Chemotherapy Phlebitis ,extravasationMucositisMyalgia, arthralgia

Radiotherapy

CAUSES OF PAIN

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Pain due to debilitating diseasePressure soresGastric distensionReflux oesphagitisPost herpetic neuralgiaThrombosis and embolismConstipation

Musculoskeletal painSecondary to inactivity

CAUSES OF PAIN

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Clinical Guideline For Patient AssessmentMedical Assessment

Psychological Assessment

Group Meeting with Patient

Treatment Pathway

Review Meeting with Patient

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Assessment of Pain1- The initial evaluation.2- The "ABCDE":

* Ask about the pain regularly.* Assess pain systematically. * Believe the patient and family. * Choose appropriate pain control options * Deliver interventions in a logical fashion. *Enable patients to control their life.

(The Agency for Health Care Policy and Research1994)

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Methods of Pain Assessment1- Visual Analogue Scale :

One end from "No Pain" to the other end, "Pain" as bad as it could possibly be.

2- Numerical Intensity Scale 0-10:0 reflecting "No Pain" and 10 reflecting the "Worst Pain Possible.

3- Simple Descriptive Pain Intensity Scale:* No Pain. * Mild Pain.* Moderate Pain. * Severe Pain. * Worst Possible Pain.

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Numerical Scale

0 2 3 4 5 6 7 8 9 10

No pain Worst Pain

0 2 4 6 8 10VeryHappy

Hurts justa little bit

Hurts alittle more

Hurts evenmore

Hurts awhole lot

Hurts as muchas you canimagine

VISUAL PAIN SCALE

WHO Analgesic Ladder

CANCER PAIN

NSAIDCorticosteroids

Antidepressants

Anyxiolytics

Muscle Relaxants

AnticonvulsantsPalliative

RadiotherapyPsychological supportof the patient and family

Analgesic Drugs

MorphineCodineParacetamol

Adj.

Nerve Block

Epidural Morphine

Intrathecal Phenol

Cordotomy

Hypophysectomy

Bisphosphonates

Tramadol Fentanyl Patches

Chemotherapy

Morphine

There is no standard dose of morphine forthe treatment of cancer related pain

The correct dose of morphine is that whichcontrols the pain with tolerable side effect

The dose must be individualizesMorphine should be given with caution to

patients with:– Renal impairment– Severe hepatic dysfunction– CNS depression from any cause

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Administration of Morphine

Oral morphine is the preparation of choicefor patients with moderate or severe painwho are able to take oral medications.Oral morphine mixture (Short acting)

– Morphine mixture is commercially available in2mg/ml, 5mg/ml, 10mg/ml strengths

– Cheap, well absorbed, well tolerated– Effective in 85% of patients– Easy to take (30-100ml/24h)

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• Initial dose– Patients on Tramal, 20% of total dose/day– Patients receiving oxycodone, same dose (mg/d) – Patients not previously receiving opioids, start with

10mg PO q4h, if frail, elderly or with renal impairment, start 5mg PO q4h.

• Frequency– 4-hourly, 2 am dose should be given unless patient

sleeps through and does not wake with pain which is difficult to control. May be avoided by giving increased dose at 10pm.

– Breakthrough pain is treated with an extra dose, as often as required. The dose is the same as the 4-hourly dose.

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Long Acting Morphine (MST)

• Same total dose of short acting Morphine

• Twice a day

• The parental Morphine dose= 1/3 of the oral dose

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Fentanyl• A synthetic primary µ-opoid agonist and

a potent narcotic analgesic with a shortduration of action and rapid onset

• Fentanyl is approximately 100 timesmore potent than Morphine

• 100 micrograms of Fentanyl equivalentto 10 mg of Morphine and 75 mg ofPethidine M Far is 12/04/2010

Fentanyl Transdermal Patch (Durogesic/Duragesic/Matrifen)

• The patches work by releasing fentanyl intobody fats, which then slowly release thedrug into the bloodstream over 48 to 72hours, allowing for long-lasting pain relief

• Manufactured in five patch sizes: 12.5 µg/hour,25 µg/h, 50 µg/h, 75 µg/h, and 100 µg/h.

• Dosage is based on the size of the patchM Far is 12/04/2010

Durogesic® D-TRANS• The novel D-TRANS® drug-in-adhesive

matrix combines improved adhesion,with reliable and sustained fentanyldelivery

• D-TRANS® is smaller, thinner, moreflexible and easier to apply, (improvingwear ability)

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Durogesic® D-TRANS

• The new D-TRANS® drug-in-adhesivematrix provide:– improved adhesion,– ease of use, and– a reliable and sustained fentanyl profile,

which combined with its proven efficacyand tolerability offers improvedmanagement of chronic pain

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CONCLUSIONS

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• Improving control of pain is a clinical challenge.

• Pain assessment must be a routine.

* Pain relief must be a cardinal goal of cancertherapy.

* Assurance that pain control will not be at theexpense of cancer control

* Continuity of care requires proper monitoringand responds quickly, flexibly, and expertly tothe changing needs of the patient.

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“Freedom from pain should be seen as a right for every

cancer patient”

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THANK YOU