TYPES OF PAIN AND CANCER

PAIN MANAGEMENT

SURG. CDRE TARIQ MAHMOOD

HOD Department of Anesthesiology &
Critical Care
PNS SHIFA HOSPITAL
 OUTLINE
• WHAT IS PAIN ?
• THE PAIN PATHWAY.
• PAIN ASSESMENT.
• PATHOPHYSIOLOGICAL CHANGES ASSOCIATED WITH PAIN.
• CLASSIFICATION. (TYPES OF CANCER PAIN)
• WHY TREAT PAIN ?
• PAIN MANAGEMENT STRATEGIES.
• KEEPING THE BALANCE
 WHAT IS PAIN ?
• Pain is an unpleasant sensory and emotional
experience associated with actual and potential
tissue damage, or described in terms of such
damage.
(American Pain Society[APS],2003; Gordon,2002)

• Implies emotional component. Pain can exist

without tissue damage.

• Emphasizes the highly subjective nature of pain.

 WHAT IS PAIN ?

• “The fifth vital sign” . Identifying pain as the fifth vital sign suggests that
the assessment of pain should be as automatic as taking a patient’s BP and
pulse.
(American Pain Society 2003)

• Pain is the most COMMON reason patient’s seek medical advice.

• Pain is a protective mechanism or a warning to prevent further injury.

PAIN PATHWAY & PHYSIOLOGY
PAIN PATHWAY & PHYSIOLOGY
 PAIN PATHWAY & PHYSIOLOGY
Involves four processes:

- Transduction
- Transmission
- Modulation
- Perception
 Pain Assessment
Why we need to assess pain ?

• To establish degree and nature of pain

• To ensure patient comfort
• To evaluate effectiveness of analgesia
• To help alleviate anxiety
• To decide on type of analgesia
• To aid recovery and prevent complications
 Pain Assessment
When and how to assess pain ?

• Communication with patient is essential

• Usually asked when patient is resting .
• Better indicator is assessment of pain during
coughing , deep breathing or movement .
• Observe for changes in physiological signs
• Consider pain as 5th vital sign
• Use a pain scoring system
• Regular reassessment .
 Pain Assessment
HISTORY : Take a detailed history remember SOCRATES

S SITE
O ONSET
C CHARACTER
R RADIATION
A ASSOCIATED SYMPTOMS
T TIMING
E EXCERBATING / RELIEVING FACTORS
S SEVERITY
 Pain Assessment
PHYSICAL EXAMINATION :

General Physical Exam

• General signs of health or anything that seems unusal

Neurological Exam

• Brain , Spinal Cord and nerve function

• Patients mental status and how well the muscles, senses and reflexes work
 Measurement of Pain

• Verbal Numerical Rating Scale (VNRS)

0 = no pain, 10 = worst pain

• Categorical Rating Scale (CRS)

• Visual Analogue Scale (VAS)

 Measurement of Pain

• Faces Pain Rating Scale

This instrument has six faces depicting expressions that range from
contented to obvious distress

The patient is asked to point to the face that most closely resembles
the intensity of his or her pain.
Measurement of Pain
 Measurement of Pain
What is the pain score for this player?

Pain is whatever the patient thinks it is at the present time.

Pain is always subjective to the patient’s report
 Pain a Hero or a Villain ?
• Positive role of pain

Providing a warning of tissue damage

Inducing immobilization to allow appropriate healing

• Negative effects of pain

Short term negative effects of acute pain i.e. pathophysiological

changes
 Pathophysiological changes associated with Pain
Systemic metabolic response due to the release of neuro-endocrine hormones
& Local cytokines (Interleukin tumor necrosis factor) at the site of injury leads
to
“physiological alterations in all major organ system”
Pathophysiological changes associated with Pain
Inc Heart Rate, Blood Pressure Unstable Angina
Inc Myocardial O2 demand Myocardial Infarction
Hypercoagulation DVT/PE

Dec Lung Volumes Atelactasis

Dec cough Pnemonia
Retension of secretion Hypoxemia

Dec Gastric Emptying Anorexia, Constipation

Bowel Motility Ileus
Pathophysiological changes associated with Pain
Altered release of Hyperglycemia
various Hormones Weight loss/ Muscle wasting
Impaired wound healing
Impaired immune function

Muscle spasm Immobility

Impaired function Weakness, Fatigue

Anxiety Sleep deprivation

Fear Post traumatic Stress disorder
 Pain Classification
A. Nociceptive pain

I. Somatic:

Arising from skin, bones , muscle , joint capsule

well localized, dull or sharp, often worse with movement

II. Visceral:

Arising from visceral organs

poorly localized may be referred pain
 Pain Classification
B. Neuropathic pain

Often described as burning or tingling

Caused by injury to nervous system
I. Central: CNS
II. Peripheral: localized neuropathies
The injury can be Physical i.e tumor putting pressure on spinal cord / nerves
Or Chemical damage to nervous system i.e chemotherapy / radiation

C. Idiopathic pain
 Types of Cancer Pain
Can be Nociceptive or Neuropathic and may arise from

Pain caused by tumor directly (60 – 90 %)

Tumor infilteration of tissues ( bone, visceras )

Tumor resulting in compression of nerves, organ obstruction

Pain caused by diagnostic / therapeutic procedures (5-20%)

Biopsy
Surgery
Chemotherapy /Radiotherapy
 Types of Cancer Pain
Pain caused by malignant disease indirectly (10-20%)

Infection
Inflamation
DVT
Lymphedema

Pain caused by concomitant existence of condition (3-10%)

Diabetic neuropathy, osteoarthritis

 Why treat Pain ?
• Basic human right!
• ↓ pain and suffering
• ↓ complications of unrelieved pain
• ↓ chronic pain development
• ↑ patient satisfaction
• ↑ speed of recovery → ↓ length of stay → ↓cost
• ↑ productivity and quality of life
 Pain Management Strategies
• Non Pharmacological
• Pharmacological
• Adjuncts

Pain treatment continum

Least invasive Most invasive

 Non Pharmacological Options
Management of pain without medications. This method utilizes ways to
alter thoughts and focus concentration to better manage and reduce
pain.

Not a substitute for medication.

Combining nonpharmacologic interventions with medications may be

the most effective way to relieve pain
 Non Pharmacological Options
Methods of non-pharmacological pain management include:

• Biofeedback
• Distraction (focusing the patient’s attention on something other than the pain)
• Relaxation Therapy (patient may close both eyes and breathe slowly and comfortably)
• Cutaneous Stimulation & Massage
• Thermal Therapy (Ice & Heat)
• Hypnosis (Mechanism unclear)
• Music therapy
• Acupuncture
• TENS (Transcutaneous electrical nerve stimulation)
 Non Pharmacological Options

Acupuncture Hypnotherapy
 Non Pharmacological Options

Heat & Cold Therapy TENS Therapy

 Pharmacological Options

• Non Opiods
• Opiods
• Adjuvants
 Non Opiods
e.g Aspirin, Paracetamol, NSAIDs.

Generally the first class of drugs used for treatment of pain. Usually also have
anti-inflammatory properties.

Works primarily at the site of injury, or Peripherally.

Does not produce tolerance or physical dependence.

Have a ceiling effect to analgesia indicating that there is a dose beyond which
there is no improvement in the analgesic effect and there may be an increase
in side effects.
 Non Opiods
NSAIDs mechanism of action
 Non Opiods
Adverse effects of NSAIDs

Gastrointestinal
• Gastric irritation, erosions, peptic ulceration, gastric bleeding/perforation,
esophagitis

Renal
• Na and water retention, chronic renal failure, interstitial nephritis, papillary
necrosis (rare)

Hepatic
• Raised transaminases, hepatic failure (rare)
 Non Opiods
Adverse effects of NSAIDs

CNS
• Head ache, mental confusion. Behavioural disturbances, Seizure
precipitation.

Haematological
• Bleeding, thrombocytopenia, haemolytic anaemia, agranulocytosis

Others
• Asthma exacerbation, nasal polyposis skin rashes, pruritis, angioedema
 Opioids
Opiates, an older term that refers to such drugs derived from opium.

Opioid is a blanket term used for any drug which binds to the opioid receptors.

Opioid receptors found in the central and peripheral nervous system

• Mu (μ1 and μ2 )
• Kappa (k1 & k3)
• Delta (δ)
• Nociceptin/Orphanin (N/OFQ)

Used for moderate to severe pain.

Commonly used opiods : Morphine, Fentanyl, Codeine etc.

 Opioids
Adverse Effects
WARNING !
• Nausea and vomiting
• Constipation When opioids are used for
• Pruritis prolonged periods
• Irritable movement Drug tolerance,
• Psychomimetic effects Chemical dependency,
• Sedation and Addiction may occur.
• Broncho-constriction
• Respiratory Depression
Analgesic ladder for systemic analgesia
Analgesic ladder for systemic analgesia
 Adjuvant Drugs / Techniques
Other Pharmacological Options:

• Ketamine (in subanesthetic dose)

• Antidepressants (neuropathy and other painful

• Anticonvulsants nerve related conditions )

• Local anesthetics

• Corticosteroids (May reduce pain by decreasing inflammation and the resultant

compression of healthy tissues)

• Muscle relaxants

• Benzodiazepines (treatment of anxiety or muscle spasms associated with pain)

 Adjuvant Drugs / Techniques
Epidural Block:

Multipurpose weapon for;

• Epidural Anesthesia.
• Post operative pain relief.
• Treatment of chronic pain.
• Cancer pain, if oral or iv is failed.

Local anesthetics / opiods are injected

In epidural space for
Anesthesia / Analgesia.
 Adjuvant Drugs / Techniques
Epidural Block:

Epidural steroid injection for Radicular pain at Pain Clinic

 Adjuvant Drugs / Techniques
Epidural Block :
 Adjuvant Drugs / Techniques
Peripheral Neural Blockade :

Block at the level of Plexus , Nerves or

Ganglion can be a useful modality for
Achieving surgical anesthesia , post
Operative analgesia, or painful nerve
Conditons. e.g.

Brachial / Lumbar Plexus Block

TAP block
Isolated Sciatic Nerve Block
Femoral Nerve Block for
Post Herpetic neuralgia
done in pain-clinic
 Adjuvant Drugs / Techniques
Radiofrequency Ablation:

Minimally invasive procedure that uses heat to

reduce or stop the transmission of pain.

Radiofrequency waves ablate, or "burn," the

nerve that is causing the pain, eliminating the
transmission of pain signals to the brain.

Treatment option for patients who have

experienced successful pain relief after a
diagnostic nerve/pain receptor block injection.
 Adjuvant Drugs / Techniques
Patient Controlled analgesia :

Method of pain control that gives patients

the power to control their pain.

A computerized pump called the patient-

controlled analgesia pump, containing a
syringe of pain medication (opioid / local
anesthetic) is connected to the patient.

Most commonly used for intravenous opioid

demand dosing although the principle can be
applied to other treatment modalities e.g.
epidural, oral, transcutaneous and intranasal.
 Concepts implementing in ongoing practice

Pre-emptive analgesia: “Wall” in 1980

Analgesic intervention is most effective when made in advance of the pain
stimulus rather than in reaction to it

Multimodal analgesia:
More than one therapy provide superior postoperative analgesia than single
therapy to improve surgical outcome
 What is the “Best Way” to manage Pain?

FIRST , DO NO HARM.
Therefore , the “best way” is a BALANCE.

EFFECTIVE
PATIENT ANALGESIC
SAFETY MODALITIES

“To maximize analgesia while minimizing side-effects “