CANCER PAIN

(2003)

PAIN MANAGEMENT CENTER

ST. LUKE’S MEDICAL CENTER
Pain Management Center
St. Luke's Medical Center
Tel# 727-5416, 723-0301, 723-0101 ext. 4403/5416 Fax# 723-1023
Website: www.stluke.com.ph

Officers & Board of Trustees

Director Emeritus Cenon R. Cruz, M.D.

Director Francis O. Javier, M.D.
Training Officer Antonio N. B. Yap, M.D.

Active Consultants Visiting consultants

Ma. Victoria M. Abesamis, M.D.
Pediatric Oncology
Erlinda T. Arambulo, M.D.
Merlina L. Cabrera, M.D.
Luzviminda A. Salomon-Kwong, M.D.
Anesthesiology/Pain Medicine
Agnes C. Bueno, M.D.
Psychiatry
Rafael S. Claudio, M.D.
Orthopedic Oncology
Agnes M. del Rosario, M.D.
Pulmonary Medicine
Luisito O. Llido, M.D.
Nutrition Support Service
Gloria C. Luna, M.D.
Medical Oncology
Lyde A. Magpantay, M.D.
Reynaldo Rey-Matias, M.D.
Rehabilitation Medicine
Amado M. San Luis, M.D.
Edmundo G. Saniel, M.D.
Neurology
Miguel A. Ramos, M.D.
Geriatric Medicine
Ricardo B. Boncan, D.M.D.
Oral Surgery/TMJ Specialist Anesthesiology
Romulo S. De Villa, M.D.
Molecular Biology
Roberto O. Bolinas, M.D.
Medical Oncology
Eric C. Legaspi, M.D.
Neurosurgery
Juan Javier T. Lichauco, M.D.
Rheumatoogy
Randy S. Mercado, M.D.
Gastroenterology
Jose M. Paiso, M.D.
Orthopedic/Spine Surgeon
Florizel Del Prado, M.A.
Psychology
Antonio C. Sison, M.D.
Psychiatry
Honorary Consultants
Mayvelyn D. Gose, M.D.
Neurology
Leonor F. Rivera, M.D.

Fellows
Salvador E. Brodit, Jr., M.D.
Laarni P. Remorque, M.D.
Jefferson R. Castillo Lee, M.D.
Ma. Patria C. Flores, M.D.

57
CPM 6TH EDITION cancer pain

Algorithm for Cancer Pain Management

Notes:
1. A. Somatic Pain
2.B.Neuropathic pain- use of adjuvants (anticonvulsants,
1
antidepressants, anxiolytics, etc).
Cancer 3. C. Visceral - use of other adjuvants (antiemetics, proki-
Pain netics, antispasmodics, antacids, H2-blockers, proton pump
inhibitors, etc.)
4. 1. Blocks - peripheral or field blocks
2 - diagnostic/ palliative/ neurolytic


- continuous or single injection techniques

Evaluation - e.g.celiac plexus block for pancreatic cancer, sup. hypogastric
of pain block for rectal cancer
5. I. Oral
Opioids: Morphine - oral
NSAIDS (non-steroidal anti-inflammatory drugs)
3 Adjuvants


• Somatic Ia. Transdermal/ Transmucosal Pharmacotherapy

Fentanyl - transdermal (Durogesic), transmucosal (Actiq)
• Neuropathic
6.II. Parenteral (Intravenous/Intramuscular/Subcutaneous)
• Visceral Opioids: a. morphine
b. fentanyl
4 NSAIDS - diclofenac, ketorolac


Adjuvants
Use WHO Ladder 7.III. Epidural analgesia - continuous/single injection tech-
accordingly
 See Figure 1c niques alone or in combination with opioids (bupivacaine/
ropivacaine)
- use of implantable devices
8. IV. Intrathecal analgesia - continuous/single injection
techniques
- use of opioids/local anesthetics or combinations
- use of implantable devices
9.V. Surgical interventions - neurotomy, rhizotomy, my-
elotomy, cordotomy

6
5


Use:
Oral treatment Y • Opioids
effective?
 • NSAIDs
• Adjuvants
7 N
8


Blocks effective? Y • Peripheral or field blocks

 • Diagnostic/palliative/neurolytic
• Continuous or single injection techniques, e.g.
celiac plexus block for Pancreatic Ca; sup.
N hypogastric block for Rectal Ca
9 10


10 Use:
Transdermal/trans- Y • Fentanyl
mucosal Pharma-  (transdermal or
cotherapy effective? transmucosal)
11 N


Parenteral Y
treatment  See Figure 1a
effective?
N


See Figure 1b Figure 1

59
cancer pain cpm 6TH eDITION

1
Parenteral
treatment

3 5
2


Y Use PCA/PCEA May transfer to I-Ia

Titration?  for titration and  Rescue doses apply
pain control

N
4 6 7




Y
Continue Continue
Pain Relief?  management
management

N
8


Re-evaluate
patient

Figure 1a

Figure 1

1


Epidural analgesia Y
 See Figure 1a
effective?

N
2 3


Y Use:
Intrathecal analgesia  • Continuous/single injection techniques
effective? • Opioids/local anesthetics or
combinations
• Implantable devices
• Other complementary interventions
N (Radiotherapy, Chemotherapy, etc)

4


Surgical Interventions
(Palliative/Ablative)

Figure 1b

60
CPM 6TH EDITION cancer pain

1
WHO
Ladder


Analgesic drug ladder
steps 1 and 2

3


Pain due to:

Anticancer therapy
such as:
• Surgery
• Radiation
• Chemotherapy

4


Use Analgesic
drug ladder steps
1 and 2

5


6


Pain persists
Severe persistent
pain
7


Adequate pain 8


control
Use Analgesic drug
ladder
steps 2 and 3

9 10


Failed primary Switch to alternative

modalities, side effects opioid, change route/
 timing of administration,
unacceptable
use of adjuvant analgesics

11


Localized regional pain

• Neurolytic nerve blocks
(e.g. intercoastal block, celiac
plexus block)
• Neurosurgical procedures
(e.g. cordotomy)

Figure 1c

61
cancer pain cpm 6TH eDITION

Cancer Pain
The Pain Management Center of St. Luke's Medical The PCA allows for a faster drug titration and the drugs
Center follows the WHO three-step analgesic ladder computed based on patient's demands. An equivalent
for managing cancer-related pain. Pain not amenable oral opioid is prescribed once pain control has been
to oral route, or if fast opioid titration is necessary, the stabilized.
use of the PCA (Patient-Controlled-Analgesia Machine)
The use of transdermal fentanyl (Durogesic) is another
is mandatory.
option in providing pain relief of cancer patients. For
More than 65% of referrals to the Center are pain rescue doses, oral morphine is used. The transmucosal
secondary to cancer. (See WHO Three-Step Analgesic fentanyl citrate lozenge (ACTIQ) is only available as
Ladder.) "compassionate prescription".
For patients who are in need of a faster titration of The introduction of the sustained-release oxycodone
opioid, steps 2-3 may be done using the IV PCA (Oxycontin) has made it easier for patients to begin
technique. opioid therapy as it does not have the "morphine
stigma". This drug may be used from step 2 onwards.
WHO Three-Step Analgesic Ladder The limitation of the sustained-release oxycodone is
the unavailability of the immediate-release preparation
for rescue dose purposes. Morphine tablet (immediate-
release) may be substituted for this.
STEP 3
Severe Cancer Pain Census (Top 10)
A lot of cancer patients seen by medical oncologists are
STEP 2 in advanced stages. This is basically economic in nature
Moderate as people tend to postpone consultation to the doctor.
By the time the patient is seen at the Pain Management
STEP 1 Center, majority have difficult cancer pain syndromes
Mild Pain that require multidisciplinary management.
Pain secondary to metastatic lung cancer accounts for
the most number of pain patients followed by metastatic
Step 1 breast cancer.
ASA, NSAIDS (if no contraindications)
COX-2 inhibitors January 2000-December 2002
Used in combination with adjuvant drugs
(TCA, antihistamine, benzodiazepam, anticonvul-
sants, steroid, laxatives, phenothiazine)
Step 2
Non-opioid + mild opioid + adjuvant drugs
Tramadol is the Step 2 drug in the Philippines
Rescue medications apply.
Step 3
Non-opioid + strong opioid + adjuvants
Morphine is the drug of choice
Rescue medication apply.
Adjuvant drugs like TCA's, anticonvulsants,
steroids, bisphosphonates etc, maybe added in
all steps.

62
CPM 6TH EDITION cancer pain

Drugs Mentioned in the Treatment Guideline

This index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing information of these
drugs can be found in PPD reference systems.

Analgesics Muskelax Selmac

Coxibs Relaxid Sensomef
Celecoxib Selxan Spegic
Celebrex Indomethacin Totagesic
Coxid Indocid Tynostan
Etoricoxib Indomethacin farnesil Zapan
Arcoxia/Arcoxia AC Infree Meloxicam
Parecoxib Ketoprofen Mobic
Dynastat Ketofen Naproxen
Rofecoxib Orudis EC Flanax/ Flanax Forte
Vioxx Orudis IV Lefaine
NSAIDS Ketorolac Naprelan
Acemetacin Toradol Naprosyn LLE/ Naprosyn LLE
Rantudil Leflunomide Forte
Aspirin Arava Nimesulide
Bayer Aspirin Lonazolac Aulin
Cortal Exflame/ Exflame AR Piroxicam
Diclofenac Mefenamic Acid Drugmaker's Biotech Piroxicam
Abicfen Abicfen Feldene/ Feldene Flash
Acloren Acidan Flaxine
Cataflam Analcid Macroxam
Denkoran Aprostal Maxipin
Diclowal/Diclowal Retard Biogenerics Mefenamic Acid Parixam
Difenax C&M Mefenamic Acid Pirostad
Dolfastad Calibral Troxiflam
Doloflam DLI Mefenamic Acid Proglumetacin
Neo-Pyrazon/ Neo-Pyrazon SR Dolfenal Afloxan
UL Diclofenac Na Dolmetine Sulindac
VCP Diclofenac Na Drugmaker's Biotech Clinoril
Voltaren Mefenamic Acid Tenoxicam
Voren/Voren Forte/Voren SR Escandar Tilcotil
Ibuprofen Fendal Non-Opioid Analgesics
Advil Fenexan Paracetamol
Buroid Gardan Aeknil
Dalnor Gisfen Afebrin
Dolan FP Harpinac Aldep
Laberfen Isagesic Aminofebrin
Midol Istan Baropyrine
Morexen Medianon Biogenerics Paracetamol
Nurofen Syrup Pacimic Biogesic
Painrex Penomor Calpol/Calpol Six Plus
Skelan Forte Pharex Mefenamic Acid Carpacet
Ibuprofen/Aspirin Ponstan Crocin
Anadol Proxyl Delgin
Ibuprofen/Paracetamol Ralgec DLI Paracetamol
Alaxan Revalan Dolexpel
Femol RiteMED Mefenamic Acid Drugmaker's Biotech

63
cancer pain cpm 6TH eDITION

Paracetamol Eperisone Depakene

Europharma Paracetamol Myonal Anxiolytics
Franciphen Orphenadrine Alprazolam
Gendol Susp/Tab Norgesic Xanor
Genpyra Local Anesthetics Bromazepam
Gifaril-P Bupivacaine Lexotan
Lenor Marcaine Clorazepate dipotassium
Medgenol Sensorcaine Spinal Tranxene
Medicol-A Lidocaine Diazepam
Metagesic Abbott 2% Lidocaine Anxionil
Myremol (Premixed) Trazepam
Naprex Dentocaine 2% UL Diazepam
Naprinol Lidocaine HCl 2% Inj-Elin Valium
Neo-Aspilets Xylocaine Flurazepam
Nopain Forte Lidocaine/Prilocaine Dalmane
Norgesic Emla Hydroxyzine
Octagesic/Octagesic Forte Proparacaine Iterax
Opigesic Alcaine Antidepressants
Pacigesic Ropivacaine Citalopram
Pharex Paracetamol Naropin Lupram
Pynal Tetracaine Clomipramine
Rexidol Pontocaine Anafranil
Reximed
Adjuvants Fluoxetine
RiteMED Paracetamol
Anticonvulsants Prozac
Rufenal
Carbamazepine Fluvoxamine
Saridon
Tegretol Faverin
Tempain Syr/Forte Tab/ Forte
Clonazepam Imipramine
Syr/ Drops
Rivotril Tofranil
Temperal
Diazepam Mirtazapine
Tempra/ Tempra Forte
Anxionil Remeron
Tylenol
Trazepam Moclobemide
Paracetamol/Vitamin B-Complex
UL Diazepam Aurorix
Dolo-Neurobion
Valium Paroxetine
Opiates & Antagonists Divalproex sodium Seroxat
Butorphanol Epival Sertraline
Stadol Gabapentin Zoloft
Fentanyl Neurontin Tianeptine
Durogesic Lamotrigine Stablon
Sublimaze Lamictal Trazodone
Morphine sulfate Magnesium sulfate Depresil
Hizon Morphine Sulfate Elin Magnesium Sulfate Trimipramine
Relimal CR Hizon Magnesium Sulfate Surmontil
Tramadol Phenobarbital Venlafaxine
Dolotral Rhea Phenobarbital Efexor XR
Siverol Phenytoin Antiemetics
TDL Dilantin Betahistine
Tradonal Topiramate Merislon
Tramal Topamax Serc
Skeletal Muscle Relaxants Oxcarbazepine Cinnarizine
Baclofen Trileptal Calzirine
Lioresal Valproic acid Drugmaker's Biotech
Cinnarizine
64
CPM 6TH EDITION cancer pain
Sugeron/Stugeron Forte Ascopen Roche Piperazine
Difenidol Buscopan Bisphosphonates
Cephadol Buscopan Plus Alendronate Sodium
Dimenhydrinate Antacids Fosamax
Drugmaker's Biotech Hydrotalcite/Simethicone/Dicy- Disodium Clodronate
Dimenhydrinate cloverine Bonefos
Granisetron Algelan-Plus Risedronate Sodium
Kytril Kremil-S Actonel
Meclizine Aluminum hydroxide/Magnesium Zoledronic Acid
Bonamine carbonate Zometa
Meclozine Almax H2-Receptor Antagonists
Postadoxine Drugmaker's Biotech Aluminum Cimetidine
Metoclopramide Hydroxide/ Magnesium Antag
Cardo Perten Carbonate Biogenerics Cimetidine
Clovomet Aluminum hydroxide/Magnesium Ciclem
Plasil carbonate/ Drugmaker's Biotech Cimeti-
Ondansetron Oxethacaine dine
Zofran Mucaine Duogastril
Promethazine Aluminum hydroxide Europharma Cimetidine
Phenergan Alu-Tab Getidin
Thaprozine Aluminum hydroxide/ Gitadene
Ramosetron Magnesium hydroxide Mestulcer
Nasea Injection Asikit RiteMED Cimetidine
Nasea OD Creamalin Tagamet
Tropisetron Drugmaker's Biotech Aluminum Famotidine
Navoban Hydroxide/ Magnesium H2 Bloc
Prokinetics Hydroxide Pepcidine
Activated dimethicone Gel-Malicid Nizatidine
Disflatyl Laxadan Axid
Domperidone Maalox Ranitidine
Motilium Magalum Drugmaker's Biotech Ranitidine
Metoclopramide Mylanta 2 Incid
Plasil Pepticon Novopharm Ranitidine
Pancreatin/amylase Promulax Pharex Ranitidine
Pankreoflat Aluminum hydroxide/
Ramadine
Promethazine Magnesium hydroxide/
Raxide
Thaprozine Dimethicone
Tagamet
Maalox Plus
Antispasmodics Ulcin
Aluminum hydroxide/
Butropium Zantac/Zantac FR
Magnesium carbonate/
Coliopan Ranitidine/ Bismuth citrate
Magnesium hydroxide/
Dicycloverine Pylorid
Novaluzid
Bentyl Proton pump inhibitors
Calcium carbonate
Cynergic Harveytums Esomeprazole
Dilomin Tums Nexium
DLI Dicycloverine HCl Hydrotalcite/ Simethicone Lansoprazole
Drugmaker's Biotech Mucilan Prevacid
Dicycloverine Hydrochloride UL Antacid Omeprazole
Relestal Simeco Losec
Smodic Magnesium hydroxide OAC HP7*
UL Dicycloverine Philips Milk of Magnesia Pantoprazole
Hyoscine Citric acid/ Piperazine/ Sodium Pantoloc
bicarbonate/ Tartaric acid
65
cancer pain cpm 6TH eDITION

Ulcepraz Medrol
Sodium rabeprazole Solu-Medrol
Pariet Prednisone
Laxatives/Enemas Drazone
Bisacodyl Drugmaker's Biotech Pred-
Dulcolax nisone
Dietary fiber GXI Prednisone
Fibrosine Orasone 5/Orasone 20
DSS/Sorbitol Organon Prednisone
Clyss-Go Pred 5/10/30
Glycerin Roidrenal
Rhea Glycerin Suppository Prednisolone
Ispaghula husk Liquipred
Mucofalk Apple/Orange RiteMED Prednisolone
Granules Triamcinolone
Lactulose Kenacort
Duphalac Kenacort-A Intra-articular/
Duphalac Dry
Lactitol
Importal
Monabasic sodium phosphate/
dibasic sodium phosphate
Fleet Enema
Sodium picosulfate
Laxoberal
Standardized senna concentrate
Senokot
Steroids
Betamethasone
Betnelan
Celestone
Diprospan
Dexamethasone
Decilone
Drenex
Inflam
Oradexon
Oradexon Forte
RiteMED Dexamethasone
Scancortin 4
Scancortin 5
Hydrocortisone
Hydrocort
Hydrotopic Inj
Pharmacort
Phoenix Hydrocortisone So-
dium
Succinate
Solu-Cortef
Methylprednisolone
Depo-Medrol

66