Cancer Pain Management

dr. Tommy Nugroho Tanumihardja, Sp.An

 Cancer Pain ?
• Cancer pain ?
– Result from the cancer
– Result from treatment for cancer

• Cancer pain depends :

– type of cancer
– stage (extent) of the disease
– pain threshold (tolerance for pain) of the patient
with cancer.
 Epidemiology
• Cancer pain is still one of the most feared
• Cancer pain prevalence :
– 64% with metastatic, advanced or terminal phase
– 59% on anticancer treatment
– 33% after curative treatment

• In malaysia :
– Third most common cause of death in MOH Hospital
– 2000 estimate 90.000 patient suffered from cancer
 Causes of Severity

• Direct tumor invasion of local tissue

• Metastatic bone pain
• Osteoporotic bone and degenerative joint pain in older people
• Visceral obstruction
• Nerve compression and plexus invasion
• Ischaemia
• Inflamation
• Chemotherapy induced neuropathy, paraneoplastic neuropathy,
and arthropathy
• Post surgical pain and radionecrosis
Type of Pain
Pathophysiology
Reason for under treatment of cancer pain

• Poor resources in developing countries

• Unavailability of morphine
• Unconquered barriers
• Physicians opiophobia
• Problem with communication
• Regulation and policy
 Factors affecting the pain threshold
Effect on Effect on Patient’
’s
Threshold Perception of Pain Factors

Lower Increased severity Poor pain control

Depression
Anxiety
Sleeplessness
Anger
Fear
Fright
Isolation
loneliness

Raise Decreased severity Empathy

Sympathy
 Clinical Assessment of Pain
• History
• Physical Examination
• Investigations
– Radiological investigation
– Blood investigation
• Pain Assessment Tools
• Psychosocial Assessment
 Clinical Assessment of Pain
• History • Physical Examination
– Characteristics of – To confirm the
pain clinical diagnosis.
– Cancer history – Patient who
– Medication suspected
– Co-morbidities neuropathic pain ,
neurological
– psychosocial assessment must be
included.
 Pain Assessment Tools
• Evaluate the pain : PQRST - ABCD
• Pain assessment measures
– Uni-dimensional
– Multi- dimensional
Uni-dimensional
 Multi-dimensional
• McGill Pain Questionnaire (MPQ)
• The Brief Pain (BPI)
• Memorial Pain Assessment Card
• Pain diary
Pain Assessment in Advanced Dementia (PAINAD) Scale

Mild Pain : 1-3

Moderate Pain : 4-6
Severe Pain : 7-10
Phycosocial Assessment
Approaches to pain management in cancer
patients

• Phychological approach
• Modification of daily activities
• Modification of pathological process
• Pharmacological
• Interventional Technique
 Acetaminophen
• Step 1 analgesic, coanalgesic
• Minimal anti-inflammatory effect
• Hepatic toxicity if > 4 grams/24 hours
 NSAIDs
• Step 1 analgesic, coanalgesic
• Inhibit COX
• Highest incidence of adverse event
– Renal failure
– Hepatic disfunction
– Bleeding
– Gastropathy
– Inhibition of platelet aggregation
 Opioid
Full Agonist
Morphine - Binds at μ, κ, and δ receptors
Meperidine - Inhibition of transmission of
Hydromorphone nociceptive impulses
Fentanyl
Codein
Hydrocodone
Oxycodone
Partial Agonists
Buprenorphine - Binds at μ-receptors

Mixed Agonist-
Agonist-Antagonist
Nalbuphine - Antagonist or weak agonist
Butorphanol effects at μ-receptors
- Agonist effects at κ-receptors
 Adjuvant Drugs
• Treat adverse effect of analgesic medication
• Enhance pain relief
• Treat concomitant psychological disturbance
 Pharmacological management :
essential principal
• 1. by Mouth
• 2. by the Clock
• 3. by the ladder
• 4. for individual
• 5. with attention to detail
• Phycosocial intervention
– Education
– Cognitive behavioral intervention
– Attention-Diversion Strategies

• Physical therapy
– Exercise
– Massage and aromatherapy
– Acupuncture
– TENS
• Interventional Tecniques
– Neurolytic sympathetic plexus blocks
– Neuraxial opioid therapy
– Other surgical intervention
 Breakthrough Pain (BTP)
• temporary severe pain flare occurring in
patients with relatively well-managed baseline
pain.
• Incidence
– Predictable
– Unpredictable
Management of acute pain in cancer patients

• Therapy with WHO step 3 strong opioids

• After that : reduce opioids with non-opioids
analgesic drugs or with local anesthetics
 Evaluation
• Evaluate the pain
• Evaluate drug dose
• Effective
• Drug tolerance
• Side effect
 Evaluate the Patient
• the temporal aspects of the pain (Acute,
chronic, breakthrough pain)
• quality (Somatic , visceral, or neuropathic)
• Similarity to pain syndromes typically seen in
cancer patients
 Evaluate the pain
• Look for :
– Red flag
• Serious acute condition
– Yellow flag
• Psychosocial risk factor
– Orange flag
• Distress
– Blue and Black flag
• Related to workplace
Red Flags
Yellow Flags
Prevalence and severity of opioids
related side effects

Prevalence and severity of opioids related side effects

o Sedation - Rapid tolerance developes
- Treat by dosage, addition of adjuvant

- Eliminating contributory factors

non--essential drugs, metabolic disturbance

non
o Nausea/vomiting - Treat with anti-
anti-emetics

o Constipation - Most common AE

- Treat aggressively and prophylactically

o Respiratory depression - Most serious AE

- Rapid tolerance develops
o Mental clouding - ≈ sedation
- Low dose haloperidol

o Myoclonus - dosage, opioid switching

- Clonazepam

o Pruritus - Rarely a problem in chonic

administration
- Antihistamine : Diphenhydramine

o Urinary retention
- Rarely a problem in chonic
administration
- Treated by a direct cholinomimetic

Bethanechol
Goal of Pain Management
 case
• You are treating a patient with advance lung
cancer.
• Your patient undergone 2 rounds of
chemotherapy and radiation
• Your patient has deep pleural pain from the
source of the cancer.
– VAS 6 out of 10
• Has intercostal burning-electric pain at the site of
thoracotomy
– VAS 5 out of 10
• He has thoracic back pain from T9 fracture
compression cause by metastatic
– VAS 7 out to 10
– Describe : duly, deep,achy and constant
• He has some numbness mixed with burning pain
in his feet since chemotherapy
– VAS 3 out to 10
• He has long-standing OA at right knee
• Therapy : prococet 5/325 one tabs every 6 hours
• Metastatic bone pain
– Use NSAID for ex : celebrex 100 po bid
– This should help his periosteum pain
• Burning neuropathic pain
– Antiseizure or antidepressant medication
– Cymbalta 30 mg one a day and titrate it 60 mg one
a day in one week
• Compression fracture
– Kyphoplasty procedure
• The patient taking a short acting opioid but
still In pain
– Increase his opioid
– Prococet 5/325 10/325
– Add : laxative to prevent constipation
• A month later
– The patient returns stating that the medication very
helpful for his pain
• 1 month later , he is still stable
• 2 month later
– Pleuritic pain increased as well his tumor burden
– Therapy:
• oxyConton 10 mg every 8 hous
• Celebrex, cymbalta and percocet on going
• Hospice contacted, the patient dies in hospice