Cancer pain

CANCER PAIN AND THE

MANAGEMENT

SYAFRUDDIN GAUS

DEPARTMENT OF ANESTHESIOLOGY, INTENSIVE CARE AND PAIN MANAGEMENT

FACULTY OF MEDICINE, HASANUDDIN UNIVERSITY

CPD Perioperative IDSAI, Medan Juli 2010

OBJECTIVE

Magnitude of Cancer Pain

Etiology of Cancer Pain

Pathophysiologic of Cancer Pain

Clinical Characteristic of Cancer

Pain

Evaluation of Cancer Pain

Management of Cancer Pain


MAGNITUDE OF CANCER PAIN Bonica 1985

50 % of patient of all stage reported pain > 70 % with advanced cancer

Faley 1985 50 % of patient with non metastatic cancer had significant pain 60-90 % of patient with advanced cancer reported debilitating

pain WHO 1986

70 % of patient with advanced cancer has pain 3,5 million people suffering from cancer pain with or without

satisfactory treatment every day Paice, 2006

20-75% have pain at first diagnosis 23- 100% report pain in advance stage


TOTAL

PAIN

SOMATIC SOURCE

ANXIETY

ANGERDEPRESSION

Non-cancer pathology

Cancer

Symptoms of debility

Side-effects of theraphy

Loss of social position

Loss of job prestige and income

Loss of role in family

Chronic fatigue and insomnia

Sense of helpessness

Disfigurement

Bureaucratic bungling

Friends who do not visit

Delay in diagnosis

Unavailable doctors

Irritability

Therapeutic failure

Fear of hospital or nursing homeWorry about familyFear of deathSpiritual unrest

Fear of pain

Family finances

Loss of dignity and bodily control

Uncertainty about future

WHO 1986


ETIOLOGY OF CANCER PAIN TUMOR-RELATED PAIN TREATMENT-RELATED PAIN DEBILITY-RELATED PAIN NON-MALIGNANT CONCURRENT

DISEASE


TREATMENT-RELATED PAIN Surgical procedures Chemotherapy

Immediate acute pain : iv infusion painPainful sequelae : arthralgia, headache,

mucositis Radiotherapy

Soft tissue injury : mucositis, proctitis, peripheral neurophaty, ets


PATHOPHYSIOLOGIC CLASSIFICATION OF CANCER PAIN NOCICEPTIVE PAIN

SOMATIC PAIN VISCERAL PAIN

NEUROPHATIC PAINNERVE COMPRESSIONDEAFFERENTATION NERVE INJURY SYMPATHETICALLY MEDIATED

PSYCHOGENIC PAIN


CLINICAL CHARACTERISTIC (1) 1. Nociceptive pain

Somatic pain : aching, stabbing, throbbing Well localized

Visceral pain : obstruction : gnawing, cramping Organ capsule : aching, sharp, throbbing Diffuse and difficult localize May referred to somatic structure


CLINICAL CHARACTERISTIC (2) 2. Neuropathic pain

Nerve compressions Burning, prickling, electric like Area innervated nerve Malignancy compression

Deafferentation nerve injury Same nerve compressions + shooting,stabbing allodynia Often loss afferent sensory function Superficial burning pain


CLINICAL CHARACTERISTIC (3)

Sympathetically mediated Cutaneous vasodilatation, increased skin

temperature, abnormal sweating, tropic cahanges and allodynia

Nondermatomal pattern pain Diagnostic sympathetic block

3. Psychogenic pain- after pathology pain generating excluded

- can contribute but pure psychogenic etiology is rare


SEVERITY-BASED CLASSIFICATION OF CANCER PAIN REFLECT

TUMOR SIZELOCATIONEXTENT TISSUE DESTRUCTIONMECHANISM OF PAIN

PAIN INTENSITY USED TO GUIDE ANALGESIC THERAPY


EVALUATION OF CANCER PAIN MEDICAL HISTORY PAIN HISTORY PAIN ASSESSMENT :

LOCATION CHARACTER SEVERITY ONSET DURATION TEMPORAL PATTERN RELIEVING AND EXACERBATION FACTOR ASSOCIATED SYMPTOMS PREVIOUS ANALGESIC THERAPY SPECIFIC CANCER TREATMENT


THE WHO CANCER PAIN STEP LADDER ORIGINALLY INTRODUCED IN 1986

SIMPLETHREE STEPWIDELY AVAILABLE AND INEXPENSIVE

ANALGESIC GLOBALLY DISTRIBUTED AND

CURRENTLY CONSIDERED AS STANDARD FOR MANAGEMENT CANCER PAIN



OPIOID Mainstay of cancer pain Multiple routes

EnteralParenteral ( iv, sc )Spinal deliveryTransdermalTransmucosal

Several formulation : sustained release eg. MS Contin, Kadian,

Avinza. Rapid release : not available in Indonesia


OPIOIDS COMPARATIVE

Opioid Half live Equipotent IV dose ( mg/kg)

Equipotent PO dose ( mg/kg )

Duration ( hr )

MorphineFentanyl

PethidineAlfentanylSufentanylCodeine Oxycodone

2-4 hrs1 – 7 min

3 – 4 hrs1.4 min1.4 min3 hrs2 – 6 hrs

0.10.001

10.050.00011.2N/A

0.3 – 0.50.001-0.005 transmucosal1.5 – 2N/AN/A20.1

3-50.75 – 1

2 – 30.514 - 6 4 – 6


MORPHINE Least lipid soluble Metabolites M6G and M3G ( longer half

lifes ) M6G more potent than morphine M3G ( no analgesic effect ) role in

tolerance Slow release ( controlled release or

sustained release ) use for chronic and cancer pain

Slow onset, prolonged duration fast titration its impossible


FENTANYL AND ITS ANALOGS Highly lipid soluble synthetic opioid Rapid onset and short duration Metabolite inactive (safe for renal

impairment) Suitable for transdermal administration


PETHIDINE Synthetized as a potential substitute for

atropine ( atropine like effect ) Weak affinity for NMDA receptor Pethidine superior in renal and biliary

colic but evidenced show that all opioids are equally effective

Metabolite is norphetidine ( normeperidine ) with long half-life ( 15-20 hrs ) analgesia ( µ receptors ) but neurotoxicity ( CNS excitation : anxiety, mood changes, tremors, twitching, myoclonic , convulsion )


NORPETHIDINE TOXICITY Treatment

Discontinue pethidine Substitue to alternative opioidSymptomatic treatment DO NOT administer naloxone

Suggest Dose limit : 1000 mg in first 24 hrs and 600-

700 mg/day thereafter, Reduced in elderlyShould be avoided in renal impairment


TRAMADOL Centrally acting synthetic analgesia µ receptors activity ( by main metabolite

M1 ( O-desmethyl-tramadol )) Inhibit reuptake NE and serotonine (5HT )

in nerve terminal Advantages of equianalgesic dose opioid

Less sedation Less repiratory depression Less constipation Nausea and vomiting similar Not a controlled drug


Epilepsy was relatively contra indication Seizure have been reported but

probably similar with other opioid Accumulation M1 in renal failure can

cause respiratory depression Total daily dose : 600 mg


CODEINE Naturally alkaloid like morphine Metabolized in liver by CYP 2D6

converted to morphine (2-10%) analgesic effect of Codeine

( ineffective prodrug of morphine ) Usually for mild to moderate pain Combine with non-opioid agents like

acetominophen or aspirin increased analgesic efficacy but also decreased opioid relate adverse effect


EQUIANALGESIC DOSES OPIOIDS

Oral dose ( mg )

Opioid Parenteral iv/sc/im( mg )

400 Meperidine 100

100 Tramadol 100

200 Codeine 130

30 Morphine 10

- Fentanyl 0.15 – 0.20

- Sufentanyl 0.02

Morphine 50 mg PO in 24 hrs = fentanyl patch 25 mcg/hr


PARACETAMOL Analgesic antipyretic Used in all steps in Stepladder WHO Recommend dose 4000 mg/d Dose adjustment in hepatic dysfunction


NSAIDS Analgesic, antipyretic and anti-

inflammatory Nonselective agents and selective COX-

2 inhibitors Effective component in multimodal

therapy Carefully selected patients due to

adverse effect COX-2 inhibitors proveide protection

adverse effect but concern in Cardiovascular effect


ADJUVANT ANALGESICS Antidepressant

Inhibition NE and serotonin reuptake For neurophatic pain Delays onset day to week Mood elevating and sleep enhancing effect Adverse effect on cardiac , glaucoma n prostatic Amitriptyline, Nortryptiline and Despiramine

Anticonvulsant For neurophatic pain eg. Chemotherapy Na channel blocker : Carbamazepine and

clonazepam Gabapentin : Ca Channel and can act as NMDA

antagonist . 900 – 3600 mg/d


ADJUVANT ANALGESIC Corticosteroids

Inhibit prostaglandin synthesis and reduce edema

For neuropathic pain syndromeBone pain , malignant intestinal obstructionDexamethasone 12 – 24 mg once daily

NMDA antagonistBind EAA glutamat For severe neuropathic painRoutine use limited due to cognitive

changes


ADJUVANT ANALGESIC Local anesthetic

Inhibiting ions across neural membrane Relieving neuropathic painOrally, topically, intravenously,

subcutaneously, spinallyFor Intractable neuropathic pain :

Lidocaine intravenous 1 – 2 mg/kg ( max 500 mg ) over 1 hour then 1 -2 mg/kg/h continuous infusion


OTHER TECHNIQUE FOR CANCER PAIN Nerve block Sympathetic nerve block Myofacial trigger point Neurolytic block : celiac plexus block Epidural or intratechal drugs


NONPHARMACOLOGIC THERAPIES Physical therapy

TENSAccupunctureCounterirritation

Psychological approachDepression and anxiety most oftenCognitive intervention : relaxation


Thank You

Health & Medicine

Cancer pain