pain relief for cancer patients

8/12/2019 Pain Relief for Cancer Patients

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Pain Relief for Cancer Patients


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Thirty to 50 percent of patients undergoing activetreatment, and about 70 to 90 percent of those withadvanced solid tumors, experience chronic pain.

Appropriate treatment of pain can result in 90 percent of

cancer patients achieving adequate relief. Barriers to pain control include lack of physician knowledge

of adequate treatment of pain, unrealistic concerns aboutnarcotic addiction, patient underreporting of symptoms,and lack of emphasis on symptom control in comparison

with disease management. Uncontrolled severe pain is an emergency and requires

aggressive treatment.


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WHO has developed a three-step

"ladder" for cancer pain relief If pain occurs, there should be prompt oral administration

of drugs in the following order: nonopioids (aspirin andparacetamol); then, as necessary, mild opioids (codeine);then strong opioids such as morphine, until the patient isfree of pain.

To calm fears and anxiety, additional drugsadjuvants should be used.

To maintain freedom from pain, drugs should be given bythe clock, that is every 3-6 hours, rather than on demand

This three-step approach of administering the right drug inthe right dose at the right time is inexpensive and 80-90%effective. Surgical intervention on appropriate nerves mayprovide further pain relief if drugs are not wholly effective.


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Cancer pain comes in many forms and often isundertreated.

When the pain fails to respond to acetaminophenor nonsteroidal anti-inflammatory drugs, orotherwise becomes intractable, opioids often arerecommended.

Usually, short-acting opioids are used as needed.

When the pain persists throughout the day,short-acting opioids are replaced with longer-acting opioids two or three times daily to provide24-hour relief.


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Treating worsening Pain in Cancer

May be due to

1.Worsening disease

2.Opioid tolerance 3.Adverse effects of opioids (abdominal pain

due to constipation)


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Opioids most commonly used for

cancer pain

Morphine

Diamorphine

Fentanyl Buprenorphine

Oxycodone

Codeine


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COMMON STARTING DOSES

OPIOID-NAIVE PATIENTS * parenteral dosesequianalgesic to morphine sulfate 10mg SQ

codeine 30mg

hydromorphone 2mg levorphanol 2mg

meperidine 50mg

methadone 5mg

morphine 10mg

oxycodone 5mg

EQUIANALGESIC DOSES


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DRUG ROUTES OF

ADMINISTRA

TION

APPROXIMAT

E

EQUIANALGE

SIC

DOSES*

APPROXIMAT

EDURATION

codeine PO,

parenteral

120mg 4-6 hours

hydromorpho

ne

PO,

parenteral PR

2mg 2-5 hours

levorphanol PO,

parenteral

2mg 4-6 hours

meperidine PO,

parenteral

100mg 2-4 hours

methadone PO,

parenteral

10mg 6-12 hours

morphine PO,

parenteral PR

10mg 3-4 hours

oxycodone PO 15mg 4-6 hours

EQUIANALGESIC DOSES


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Morphine

morphine and some other opioids do not have a"ceiling effect".

Morphine can be safely administered in increasingamounts until the pain is relieved without producing an

"overdose", as long as the side-effects are tolerated. There is no standard dose of morphine; the correct

dose is the one that relieves the pain

Different types

1.Immediate releaseliquid or tablet take every 4hours

2.MST - Slow (sustained)releasetablet or capsuletaken every 12 hours


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Diamorphine

Given by injection


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Fentanyl

Skin patch or lozenger


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Buprenorphine

Temgesic or Transtec

Tabletsts to keep under the tongue or patches

Takes 72 hours to achieve blood levels Used for breakthrough pain relief


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Oxycodone

For bone and nerve pain

Esp if morphine has not helped the pain

Immediate release (Oxynorm) Slow release (Oxycontin)


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Tolerance to Opioids

TOLERANCE- This refers to an increased amount of opioidnecessary to produce the same effect previously seen with asmaller amount of opioid. Tolerance develops to several opioid sideeffects - RESPIRATORY DEPRESSION, NAUSEA and VOMITING,SEDATION and CONFUSION. Twycross states that tolerance to theanalgesic effect is not a clinical problem when opioids are used inchronic pain in cancer patients. When patients require more opioid,their disease can frequently be seen to be progressive. Foley notesthat tolerance develops to the ANALGESIC EFFECT and that crosstolerance between opioids is not complete. In either case, sideeffects permitting, opioid doses can be increased when previous

doses are no longer as effective. When switching drugs, thepossibility of incomplete cross tolerance may be considered, and asmaller than equianalgesic dose be started accordingly.


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PHYSICAL DEPENDENCEimplies that awithdrawal syndrome can be seen upon abruptwithdrawal of an opioid or upon administrationof an opioid antagonist. Physical dependence is a

property of the drug, not the patient. It isgenerally not a concern in chronic pain in cancerpatients. Should the need for opioid bedecreased or removed, a withdrawal syndrome

can be avoided by tapering the opioid overseveral days. It has been noted that withdrawalreactions can be prevented if the dose of opioid is25% of the previous day's dose.


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PSYCHOLOGICAL ADDICTION or

PSYCHOLOGICAL DEPENDENCEresults from a

variety of personality, environmental,

psychosocial, etc. factors. It does not result

from simply exposure to the opioid for a

legitimate medical purpose. ADDICTION is

NOT A CONCERN AMONG CANCER PATIENTSWITH CHRONIC PAIN


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Non-opioids drugs

For bone and muscle pain

Aspirin, Ibuprofen, diclofenac, celecoxib


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Other Drugs

Steroids

Bisphosphonates

Anti-depressants Anti-convulsants

Local anaesthetics


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Steroids

Reduce swelling

Prednisolone and dexamethazone used in

cancer


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Bisphosphonates

Controls bone pain so that the amount of pain

killers can be reduced

Slow down or prevent damage cause by

cancer spread to the bones


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Anti-depressants

For nerve pain not responding to other pain

killers

Helps depression associated with chronic pain

Examples are amitriptyline, imipramine,

doxepin and trazodone


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Anti-convulsants

Help burning or tingling pain

Gabapentin (Neurontin), Carbamezapine

(Tegretol), Phenytoin


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Gabapentin

Blocks Sodium channels


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Local Anaesthetics

Nerve Blocks -


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TENS

pain relief for cancer patients

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