Oncological Pain Management Evidence Based PracticeWORK PREPARED: LAURYNA SIDLAUSKAITE, TADAS JACKUS OF KLAIPEDA STATE COLLEGE, LITHUANIA 2013.

THE AIM OF WORK: to discuss about the oncological pain managementWork tasks:Review primary causes of cancer-related pain.Recognize effects of pain on cancer patients.View pain conception.

Pain is whatever the experiencing person says it is, and exists whenever he/she says it does.

An unpleasant sensory and emotionalexperience in associational with actual orpotential tissue damage, or described interms of such damage.

Cancer statistics One in eight deaths worldwide is due to cancer worldwide. Cancer causes more deaths than AIDS, tuberculosis, and malaria combined. There were more than 12 million new cancer cases in 2007 worldwide By 2050, the global burden is expected to grow to 27 million new cancer cases and 17.5 million cancer deaths due to cancer .

Types of pain:

Neuropathic pain Nociceptive pain Cancer pain

Neuropathic painCompressing or infiltrating nerves/nerve roots/blood supply to nerveNerve damage from treatmentsShooting, sharp, burning, pins & needlesCranial neuropathiesPost-herpetic neuropathiesBrachial plexus neuropathiesPost-radiationpain Neuropathic pain can be a sharp, intense, shocking, or shooting pain.

Nociceptive painNociceptive pain is the type of pain you feel when you burn yourself, twist your ankle, or stub your toe. It is a dull or sharp aching pain, and it can be mild to severe. This type of pain can usually be controlled. Nociceptive pain can be a temporary condition, such as when you have a sprained ankle, but it can also be a chronic condition. Cancer pain and arthritis pain are common types of chronic nociceptive pain.

Cancer painPain in cancer may arise from tumor compression or infiltration of tissue; from treatments and diagnostic procedures; or from skin, nerve and other changes caused by the body's immune response or hormones released by the tumor. Most acute (short-term) pain is caused by treatment or diagnostic procedures, though radiotherapy and chemotherapy may produce painful conditions that persist long after treatment has ended.

Physiological effects of PainIncreased catabolic demands: poor wound healing, weakness, muscle breakdownDecreased limb movement: increased risk of DVT/PERespiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasisIncreased sodium and water retention (renal)Decreased gastrointestinal mobilityTachycardia and elevated blood pressure

What can we do ?

To Give Better Quality Of Life

Patients should have the opportunity to express their emotions, thoughts, fears and expectations regarding their pain.

SPECIAL GROUPS( Sau pasirasyti: Certain groups of individuals may be at a higher risk of under treatment for cancer pain. )These groups include:older people.the cognitively impaired.people whose first language is not English.known or suspected substance abusers.patients at the end of their lives..Sau pasirasyti: People who are being treated for cancer may also be at risk of developing pain syndromes as a direct result of cancer treatment strategies. Pain assessment tools to assess cancer pain in special groups should be made available.

Psychosocial factors

Negative emotions: anxiety, depressionSleep deprivationExistential suffering

An assessment of the psychosocial factors influencing the experience of pain will include:the patients understanding of their condition.what the pain means to the individual and their family.how the pain may impact upon relationships within the patients family.whether the pain influences the patients mood.changes in mood.coping strategies adopted by the patient.the patients sleep pattern.any economic impact.

What Pain Rating Scales Do We Know??

Descriptive pain rating scales

Numeric pain rating scale

Verbal Pain Scale

Wong-Baker faces pain rating scale

Visual Analog Scale

Sympathy is not enough

WHO ladder system

Non opioid adjuvantsWeak opioids Strong opioids

WHO ladder systemThe WHO ladder states that non-opioids (Paracetamol & NSAIDs) should be administered first,followed by weak opioids (Codeine) and then, if required, strong opioids (Morphine).It also recommends the use of adjuvant drugs to calm fears and anxieties.

Medicines used to relieve pain

The type of medicine and the way the medicine is given depend on the type and cause of pain. For example, chronic pain is best relieved by methods that deliver a steady dose of pain medicine over a long period of time, such as a patch that releases medicine through the skin or slow-release pills. On the other hand, breakthrough pain is best treated with medicines that work fast (quick release), but stay in the system only for a short time. Below is an overview of the types of medicines used to relieve pain.

For mild to moderate pain

Non-opioid analgesics are pain medications for mild to moderate pain. Non-opioid analgesics include NSAIDs, such as ibuprofen, as well as other analgesics such as acetaminophen and aspirin. These medications also include adjuvant analgesics, which are those that relieve pain even though pain relief is not their primary purpose. Examples include antidepressants and anticonvulsants, both regularly used to treat certain types of chronic pain.

Non-opioid analgesics may be short-acting or long-acting pain medications. They may be taken alone for pain management, though they may also be taken in combination with opioids to relieve moderate to severe pain.

For moderate to severe pain

Opioids have long been used to treat severe pain, though their use in the management of chronic pain remains somewhat controversial. Some people are able to tolerate opioids for years without any adverse effects, while others may become physically dependent or even develop a tolerance with regular use. Like most medications, opioids work differently for everyone.

Opioids are a type of analgesic, or medication used to control pain sensations. Because they are classified as narcotics, they are available by prescription only. Opioids work by attaching to certain receptors in the nervous system and changing the way the brain perceives and interprets pain.

For breakthrough pain

Rapid-onset opioids: Fast-acting oral morphine; fentanyl in a lozenge or "sucker" form (These forms of fentanyl are absorbed from your mouth as you suck on them -- they are not swallowed.)A short-acting opioid, which relieves breakthrough pain quickly, is often used with a long-acting opioid for chronic pain.

For tingling and burning pain

Antidepressants: Amitriptyline, nortriptyline, and desipramineAntidepressants are prescribed to relieve certain types of pain. Taking an antidepressant does not mean that you are depressed or have a mental illness.Anti-convulsants (anti-seizure medicines): Carbamazepine, gabapentin, and phenytoinDespite the name, anti-convulsants are not only used for convulsions (seizures), but also to control burning and tingling (nerve) pain.

Complementary and alternative medicineThere is a weak evidence base for the effectiveness of complementary therapies in terms of pain control, but theymay improve well-being. Safety issues are also a consideration.

IntroductionComplementary and alternative medicine (CAM) refers to a diverse array of treatment modalities and diagnostic techniques. It has been defined as, diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole. A large proportion of cancer pain patients use CAM. The reasons for this include dissatisfaction with conventional medicine, desperation, compatibility between the philosophy of CAM and the patients own beliefs and the wish for more control over ones own health. CAM therapies have the potential to increase wellbeing and thus influence pain. They are often employed in addition to conventional treatments in palliative and supportive cancer care.

AcupunctureThis is the insertion of needles into the skin and underlying tissues for therapeutic or preventive purposes at specific sites, known as acupuncture points.A systematic review identified two randomized clinical trials (RCTs) and found no compelling evidence that acupuncture controls cancer pain, which was confirmed by other reviewers. Subsequent RCTs did not produce convincing evidence of effectiveness. However, it is effective in alleviating chemotherapy-related nausea and vomiting and may hence contribute to pain control.

AromatherapyThis is the controlled use of plant essences, applied either to the skin through massage, added to baths or inhaledwith steaming water. A Cochrane systematic review concluded that aromatherapy and/or massage have beneficial short-term effects on well-being in cancer patients. However, it has not been convincingly demonstrated whether it is associated with clinically relevant analgesic effects.

Herbal medicineThe medical use of preparations, which contain exclusively plant material.There is no convincing evidence for any herbal medicine to suggest effectiveness for treating cancer pain (Ernst, 2007).

HomeopathyThis is where the diluted preparations of substances are taken whose effects when administered to healthy subjects correspond to the symptoms and clinical signs of the disorder in patients.A systematic review of 6 RCTs found no convincing evidence that homeopathic remedies have analgesic effects in cancer patients.

HypnotherapyThis is the induction of a trance-like state to facilitate relaxation and enhance suggestibility for treating conditions and introduce behavioural changes.Studies have suggested the usefulness of hypnotherapy in palliative cancer care. A systematic review found encouraging evidence that hypnotherapy can alleviate cancer pain. Due to the often poor methodology of the primary data, this evidence was deemed inconclusive. Similar conclusions were reached in two systematic reviews for procedural pain in paediatric cancer patients.

MassageThis is the manipulation of the bodies soft tissue using various manual techniques and the application of pressure and traction. Massage seems to increase well-being through the reduction of stress and anxiety levels, and thus may contribute to pain control. The evidence for analgesic effects in cancer patients is encouraging but not convincing.

Music therapyThe use of receptive (passive) and/or active music therapy, most commonly based on psychoanalytical, humanistic, cognitive behavioural or developmental theory. There is no convincing evidence from RCT data to suggest effectiveness for pain control in cancer patients (Ernst, 2007).

ReflexologyThe use of manual pressure applied to specific areas, or zones, of the feet (and sometimes the hands or ears) that are believed to correspond to other body areas or organs.A few small RCTs generated no convincing evidence that reflexology improves quality of life or pain of cancer patients (Stephenson, 2000).

RelaxationThis involves techniques for eliciting a relaxation response of the autonomic nervous system, resulting in thenormalizing of blood supply to the muscles and a decrease in oxygen consumption, heart rate, respiration andskeletal muscle activity. Most commonly, progressive muscle relaxation is used. Relaxation techniques have the potential to increase well-being and thus may contribute tocontrolling pain. Whether these techniques have direct analgesic effects remains, however,unknown.

SupplementsOral medical use of preparations of herbal or non-herbal origin.A systematic review of nine RCTs that tested cannabinoids concluded that they are not superior to codeine in controlling cancer pain. As cannabinoids cause central nervous depression, their introduction into routine care was deemed undesirable (Campbell, 2001).

ConclusionCancer pain can be from the cancer itself, or from cancer-related treatmentsCan be nociceptive, visceral, or neuropathic Choose non-opioid / adjuvants carefully paying close attention to side effect profile

ConclusionUse WHO ladder guidelines when titrating pain medications.Use long-acting opioids for chronic cancer pain.Ask the patient about pain and REASSESS!

Can we offer this ?

Thank you for attention!

ReferencesEuropean Pain in Cancer (EPIC) survey (2007). Cited in www.EPICsurvey.com.Cancer Pain Management (2013).The British Pain Society's. Ahmedzai SH, Walsh TD. Palliative medicine and modern cancer care. (2001). Seminars Oncology