Optimising Pain Management in Cancer treatment
Esther Cege Munyoro
Gladys Nduku
KNH-Pain and Palliative care unit.
What is Pain?
“An unpleasant sensory or emotional experience associated with actual or potential tissue damage”.
( IASP, 1979)
WELLS, M., DRYDEN, H., GUILD, P., LEVACK, P., FARRER, K. AND MOWAT, P. 2001, The knowledge and attitudes of surgical staff towards the use of opioids in cancer pain management: can the Hospital Palliative Care Team make a difference? European Journal of Cancer Care, 10: 201–211.
• Wells et al 2001 noted the existence of myths and misconceptions about the use of opioids in surgical wards in the United Kingdom. The study found misunderstandings and anxieties about addiction, tolerance and side effects, especially respiratory depression. Even with education that saw improvement in awareness about the properties of opioids, the study found minimal change in attitude and concluded that attitudes may be more difficult to influence than knowledge.
What is pain??• Pain is whatever the person
experiencing says it is
and exists where he
says it does.
( McCaffery & Pasero, 1999)
Defining “Total Pain”
• Dame Cicely Saunders defined the concept of total pain as the suffering that encompasses all of a person's physical, psychological, social, spiritual, and practical struggles.
DEFINING TOTAL PAIN
……………a diagnosis of a life threatening illness
jars open a door of awareness, for most of our
lives we keep this door locked and it comfortably
allows us to keep thoughts about death in the
background.
7Coyle N. The existential slap—a crisis of disclosure. International Journal Palliative Nursing 2004;10: 520. [PubMed]
Why treat pain?
In low-resource countries, pain is the most common indication for visiting a health care practitioner
• Improves compliance to curative treatment
• Extends survival for some patients
• Improves quality of life
• Improves patient – physician relationship
• Reduces unnecessary prolonged admission
• Reduces chances of litigation
IASP: Treatment of pain in low-resource settings (2010) Temel et al- NEJM (2010)
8
Zaza C, Baine N. Cancer pain and psychosocial factors: a critical review of the literature. J Pain Symptom Manage 2002;24:526–42
OPTIMISING
Make pain visible in our practice
1. Documentation
2. Protocols for pain and other symptoms
3. Education programs for Patients
4. Pain diaries
5. Learn to individualize pain treatment.
6. Multidisciplinary pain management
7. Increased collaboration at End of Life.
DOCUMENTATION
– Assessment charts at clinics must have pain scales for pain scores, body charts.
– Sheets for vital signs must provide a space to pain scores, more importantly healthcare workers must respond appropriately to the reported pain score.
PCAU 13
Body charts
Use the body chart to indicate areas of pain and annotate descriptions such as burning, throbbing, or aching
throbbing
tingling
Clinical Practice Guidelines: Pain Management
• The goals of protocols is to help the primary care provider manage patients with chronic or persistent pain by providing guidance about how to manage pain and guidance about when to refer for specialized pain management services
15
WHO STEPWISE THERAPY
Non-Opioid-
Analgesics+/-Adjuvant
Low potent Opioids
+non-opioids+/-
Adjuvants
I
II
III
IV
High potent
Opioids + non opioids+/-
Adjuvants
INVASIVE
THERAPY
STEP 1
Paracetamol
Non steroidal anti-inflammatory
drugs
STEP 2
Codeine
Dihydrocodeine
Tramadol
STEP 3
MorphineMethadone, Oxycodone
Fentanyl
Pethidine
STEP 4
Spinal opiates
Nerve blocks
PATIENT EDUCATION/ Pain Diary
• An accurate record of
your pain
–Pains interference
with activities like
sleep, work or
walking.
–Drugs side effects
–Other treatments herbal etc used
Multidisciplinary Pain teams
• Multidisciplinary pain treatment provides patients with an opportunity to achieve both adequate pain relief and improved physical, behavioral and psychological functioning.
• Physiotherapists, Occupational therapists, Psychologists and Nurses are important team members.
• An important factor in improving psychosocial well-being of patients with chronic pain is to enhance their self-efficacy and perceived ability to control or manage their pain.
It is every health worker’s responsibility
The advent of effective treatment algorithms means that all nurses and physicians can provide effective, high-quality pain treatment
• Pain assessment and treatment in the uncomplicated patient should be integrated into service delivery in all departments
• Specialists in palliative care or anaesthesiologycan be called on for complex cases
18
Pain at the End of life
• Pain relief should always be a top priority. If the primary focus is on treating disease, even when the prognosis is poor, get somebody else to provide pain management.
• We are a Death denying society so patients tend to suffer in our hands at the end. Pain medication is reduced as the end gets closer and sometimes stopped so that ? Death does not occur.
• We need to talk about death and reap the benefits.
WHO pain Relief Program
WHO PAIN
RELIEF
PROGRAMME
Multidimensional assessment
Appropriate ladder Level
Oral drugs
Regular medication
Drugs for breakthrough pain
Consider adjuvant drugs
Morphine/ strong opioid of choice
PAIN ASSESSMENT
Description
Location
Duration
Characteristics
Mechanism Cause
Pathological Cancer
nociceptive (tissue) Non- cancer
Neuropathic (nerve) Debility
Functional Treatment
Somatic muscle (e.g. cramp) Concurrent disorder
Visceral Muscle ( e.g. colic)
Non-Physical factors
Psychological
Social
Spiritual
PAIN
History taking
• Is the pain limiting activity?
• What does the patient feel about the pain?
• What are the expectations of treatment?
• What are the patient’s fears?
• What are the patient’s previous experience of pain and illness?
Pain score-Numeric pain rating scale
• Pain levels 0-10, explained verbally to the patient in which 0 is no pain and 10 is the worst possible pain.
• Patients are asked to rate their pain.
• Record the pain level to make treatment decisions and follow-up.
Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training
Curriculum: Harvard Medical School, Centre for Palliative Care (2007)
26
Assessment of pain in cognitively impaired patients
Use the following pointers:
Vocalization e.g. groaning, crying.
Changing body language e.g. fidgeting, guarding of a body part
Physiological changes, e.g.. Increased pulse rate, high temperature and blood pressure.
Behavioural changes e.g. confusion, refusing to eat, anxiety.
Physical changes e.g. skin tears, pressure areas sores andcontractures.
How to treat pain?
In 1986,WHO developed a 3 step simple algorithm as a guide to treat pain in cancer patients. The WHO Analgesic Ladder
• It incorporates opioids, non- opioids and adjuvant medicines.
• It is extremely effective.
• When the ladder is optimised,85-90% of patients report excellent pain control.
IASP: Treatment of pain in low-resource settings (2010) 30
WHO 3-step Ladder
1 mild
2 moderate
3 severe
Morphine
Methadone
Fentanyl
Oxycodone
± Adjuvants±NSAIDs/
paracetamol
Codeine
Dihydrocodeine
Tramadol
Betapyn
± Adjuvants±NSAIDs/
paracetamol
ASA
Paracetamol /
Acetaminophen
NSAID’s
± Adjuvants
WHO. Geneva, 2008.
The big question is…..
How effective is the ladder even after modification over years???
………First is to question about
your practice!!!
MorphineOral morphine is the gold standard in the treatment
of severe pain in cancer patients (Gordon et al, 1999).
WHO has placed oral morphine on the essential drug list.
Due to its established effectiveness, availability, familiarity to physicians, simplicity of administration and relative cost.
Its short-half-life characteristic generally favour its use because it is easy to titrate.
Morphine
Rectal morphine bio-availability is similar to the oral route.
Reassure the patient about the safety and efficacy.
Constipation occurs at least to 90% of patients and 2/3 develop N/V, Prescribe prophylactic laxatives and antiemetics.
(Europian Journal of pain.vol 11,issue 8, November 2007,p.gs823-830.)
Initiating morphineStarting dose 5-10mg 4hrly.
For opioid naive and elderly patients, or those with renal impairment use smaller doses e.g. 2.5mg 4hrly with close monitoring.
– if pain is not controlled, titrate dose by 25–50% every 24-48 hrs.
Reassess pain daily; this can be done over the phone.
Once pain is controlled, either continue regular immediate relese dose or convert to a 12hrly modified-release preparation.
Rescue dose
All patients on around-the-clock opioid regime should be offered a “rescue dose” (supplemental dose) given on “as-needed basis” to treat pain that breaks through a regular schedule= BTP
Break through pain:
• A transient flare-up of pain of moderate or severe intensity arising on a background of a well controlled pain.
Indications of Fentanyl patches
• Second line opioid for moderate to severe responsive pain.
• Pain that is stable.
• Patients unable to tolerate morphine/ diamorphine due to persited side effects.
• Poor compliance but supervised patch application is possible.
http://www.palliativedrugs.com.
Adjuvant analgesics. Opioids are not the only “magic bullets” in pain management.
Adjuvant drugs not primarily designed to control pain but they do control pain.
Have independent analgesic activity for certain pain types like neuropathic pain and pain syndromes e.g. fibromyalgia.
E.g. anticonvulsant, antidepressants, steroids
Beating Pain, 2nd Ed. APCA (2012); Using Opioids to Manage Pain, APCA (2010)
42
Golden Rules
43
WHO Genf (1986)
by the mouth
by the clock
by the ladder
for the individual
Make it simple !
Invasive analgesic techniques;
• Despite appropriate use of analgesia and non-drug therapies, 8-10% of patients will still have uncontrolled pain or unacceptable side effects or both.
• Such patients should be considered for some invasive analgesic techniques e.g. a simple nerve block or a regional or neuro destructive blocks.
• Hanks GW,Conn F,Chemy N,Hanna M,Kalso E,Mcquary HJ,et al.Morphine and alternative opioid in cancer patients:The EAPC RECOMMENDATIONS.Br J. Cancer 2001:84:587-93
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