Cancer Pain

Cancer Pain Concept

A. HUSNI TANRA

Department of Anesthesiology & ICU and Pain Management

Faculty of MedicineHASANUDDIN UNIVERSITY

MAKASSAR

Palliative CarePalliative CarePalliative Care is comprehensive, interdisciplinary

care for patients whose disease is chronic and progressive, or unresponsive to curative treatment. It includes pain and symptom management as well as psychological, emotional and spiritual care. The goal of palliative care is to achieve the best quality of life for patients and their families, regardless of life expectancy

Center for Health Workforce Studies

School of Public Health, University of AlbanySeptember 2002

CurativeCurative vs. Palliative vs. Palliative Model of CareModel of Care

Disease Progression

DEATH

Curative Palliative

BEREAVEMENT

Disease Progression

DEATH

Curative Palliative

BEREAVEMENT

The Continuum of Palliative CareThe Continuum of Palliative Care

PersonPerson

FamilyFamily

DDIISSEEAASSEE

DDIISSCCOOMMFFOORRTT

DDYYIINNGG

ILLNESS TRAJECTORYILLNESS TRAJECTORY BEREAVEMENTBEREAVEMENTSSYYMMPPTTOOMMSS

DDXX

DDEEAATTHH

Disease Specific RxDisease Specific Rx

Comfort, Supportive RxComfort, Supportive Rx(Palliative Care)(Palliative Care)

Bereavement Bereavement SupportSupport

(Palliative Care)(Palliative Care)

DDIISSTTRREESSSS

DDYYSSFFUUNNCCTTIIOONN

Caregivers and Service providersCaregivers and Service providers

Cancer Pain?

Pain

Unpleasant sensory and emotional experience

-Associated with actual or potential tissue damage

-or described in terms of such damage

International Association for the Study of Pain (1979)

What the textbooks would have you believe

about pain

Noxious (painfull) stimulus to the body

What PAIN is?What PAIN is?

Pain has two dimensions

1. Unpleasant sensory (Physical dimension)

2. Emotional experience (Psychological dimension)

J. Loeser (1980)

Concept of nociception, pain, suffering and pain behavior

PERILAKU NYERI(PAIN BEHAVIOUR)

PENDERITAAN(SUFFERING)

NYERI(PAIN)

BIOPSIKOSOSIAL(BIOPSYCHOSOCIAL)

NOSISEPSI(NOCICEPTION)

PENGERTIAN MODEL NYERI

BYERS AND BONICA, 2001MODIFIKASI PENULIS

•Terapi kognitif•Restorasi fungsional

•Opioid•Tramadol

•Oxcarbazepine•Gabapentin

•Eperisone HCL•Paracetamol

•OAINS

•Antidepresan•Psikotropika•Relaksasi•Spiritual

•Blok Lokal•Diklofenak•Etodolac•Dexketoprofen•Celecoxib

•Modalitas fisik

•steroid

Cancer Pain Conceptby Dr. Cicely Saunders 1967, founder of first Hospice in

London.

‘TOTAL PAIN’ is the sum of 4 components:

1. Physical noxious stimuli

2. Emotional discomfort

3. Interpersonal conflicts

4. Nonacceptance

4 Components of “total pain” by Cicely Saundres using concept Da Vinci’s Vitruvian Man representing person.

Physical PainPhysical Pain

NonacceptanceNonacceptance

InterpersonalInterpersonalConflictsConflicts

EmotionalEmotional discomfortdiscomfort

Aspects of “total pain”.

TOTAL PAIN TOTAL PAIN

Interpersonal Interactions

Individual Fear of isolation from others Fear of loss of career or job status Fear of substance abuse

Interpersonal Interactions Marital discord Estrangement from family Isolation from spouse and children Conflicts with coworkers Mounting financial stress

Inadequate Pain Control Verification patient is receiving

pain medication. Assessment for new physical

cause of pain Altered Metabolic States

Medical conditions such, hypocalcaemia, hypoglycemia, hypoxia, delirium and sepsis

Hormone-Secreting Tumors Pheochromocytoma ACTH-producing tumors Thyroid tumors

Anxiety From Medications Rapid tapering of prednisone. Alcohol withdrawal Akathisia associated with

metoclopramide hydrochloride Preexisting Anxiety

Supportive therapy or medication (or both) helpful

Spirituality Personal values of life, what

death mean for him/her. Fear of dying alaone.

Three-Stage Model A guide to anticipate

difficulties with greater sensitivity:� Initial stage: the patient

faces the threat of death;� Middle stage: a universal

depression that the patient now knows the disease will cause death;

� Third stage: the patient’s acceptance of imminence of own death

Anxiety Nonacceptance

TOTAL

PAIN

ORGANIC PAIN

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 prosedure

Friends do not visit

Delay in diagnosis

Unavailable doctors

Irritability

Therapeutic failure

Fear of hospital or nursing home

Worry about family

Fear of death

Spiritual unrest

Fear of pain

Family finances

Loss of dignity and bodily control

Uncertainty about future

WHO 1986

Pain

Somatic or Visceral

pain

Neuropathic Pain

Psychological

Disturbances

SufferingPsychological State and

Traits

Loss of Work

Physical Disability

FearOf Death

FinancialConcerns

Social/ Familial

Functioning

AMERICAN CANCER SOCIETY 1988

Magnitude of Cancer Pain

WHO 1986

4,5 million people suffering from cancer pain with or without satisfactory treatment every day

More than 9 million cancer deaths will occur in 2015 70 – 80 % of these patients will experience moderate to

severe pain Most of them will die in pain

For many patients pain is the first sign of cancer.

30 – 50 % of all cancer patients will experience moderate to severe pain.

75 – 95 % of patients with advanced stages will experience severe pain.

45 % of cancer patients have inadequate pain control.

25 % Will die in pain. Nature Reviews Cancer March 2002

Pain is extremely a major problem in cancer patients

Pain is the most disruptive on Q of L of cancer patients

Pain is one of the most feared aspect in cancer patients

Unrelieved severe pain may associated with• Disturbed sleep• Reduced appetite• Unrepaired concentration• Irritability and depression, etc.

69 % of severe cancer pain patient to cause consideration of suicide.

(Wisconsin 1985)

Problem of Pain in Cancer Patient

As a doctor, our task is:

*To cure is sometime *To treat is often, but …

*To comfort is always A. Pare (1598)

The “Total” Pain Concept

Spiritual

Emotional

Financial

Physical

•Guilt

•Why me?

•Life closure issues

•From disease•From treatment

•Direct costs

•Indirect costs

•Loss of function

•Coping abilities

PAIN

Types of pain based on neurophysiologic mechanism.

Physical PainPhysical Pain

Neurophysiologic MechanismsNeurophysiologic Mechanisms

Visceral Pain Difficult to localize. Felt as “deep

pressure,” “spasms” associated with nausea, diaphoresis, and emesis.

Somatic Pain Nociceptor stimulation

of skin and deep musculoskeletal tissues.

Well localized as “deep, aching feeling,” tender to palpation.

Neuropathic Pain Damage to the peripheral or the

central nervous tissue. Peripheral nerve described as

“sharp,” “electric,” “burning” pain.

Central pain is “throbbing”; the headache is “dull” and “never relenting”

CAUSE OF CANCER PAIN Can be classified into 3 categories:

1. Pain associated with direct tumor (tumour infiltration, bone metastases)2. Pain associated with cancer therapy (chemotherapy, surgery or radiation)3. Pain unrelated to cancer (RA, OA, headache or herpes zoster)* Due to cancer debility (decubitus)

Types of Cancer Pain

1. Somatic Pain 2. Visceral Pain 3. Neurophatic Pain

Mostly in combine form

Somatic Pain

• Constant pain• May be dull or sharp• Well localized• Often worse with movement

Eg/– Bone & soft tissue– chest wall

Visceral Pain

• Constant or crampy• Poorly localized• Usually with Nausea & Vomit• Often referred

Eg/– CA pancreas– Liver capsule distension– Bowel obstruction

Neuropathic Pain

Damage to the nerve pathways

There can be an abnormal response to a normal stimulus

May be peripheral or central nerve damage

COMPONENT DESCRIPTORS EXAMPLES

Steady, Dysesthetic

• Burning, Freezing

• Constant-aching

• Squeezing, Itching

• Allodynia

• Hyperalgesia

• Diabetic neuropathy

• Post-herpetic neuropathy

Paroxysmal, Neuralgic

• Stabbing

• Lancinating

• Shock-like, electric

• Shooting

• trigeminal neuralgia

• may be a component of any neuropathic pain

FEATURES OF NEUROPATHIC PAIN

Burning, feeling like the feet are on fire

Stabbing, like sharp knives Lancinating, like electric shocks

Freezing, like the feet are on ice, although they feel warm to touch

Modified by Meliala 2006

Breakthrough PainBreakthrough Pain

An intermittent increase in pain that occurs spontaneously and is usually associated with an increase in activity or stress. If

breakthrough pain becomes continuous, it is usually a sign that opioid dose needs to be

increased

Chronic Cancer Pain Chronic Cancer Pain Effectively treating chronic pain poses a great challenge for physicians. This type of pain often

affects a person’s life in many ways. It can change someone’s personality, ability to

function, and quality of life.

According to the American Cancer Society, chronic cancer pain may involve persistent pain

and breakthrough pain. Persistent pain is continuous and may last all day.

Breakthrough PainBreakthrough Pain

BTP is a brief flare-up of severe pain that occurs even while the patient is regularly

taking pain medication. It usually comes on quickly and may last from a few minutes to an hour. Many patients experience a number of episodes of breakthrough pain each day.

Breakthrough PainBreakthrough PainBreakthrough cancer pain can result from the

cancer or cancer treatmen, or it may occur during a certain activity (e.g., walking, dressing, coughing). It also can occur

unexpectedly, without a preceding incident or clear cause. Breakthrough pain usually is

treated with strong, short-acting pain medications that work faster than persistent

pain medications.

Causes of Cancer painDIRECT TUMOR ITSELF

Causes of Cancer pain

Causes of Cancer pain

Cancer painFROM CHEMOTHERAPY

Causes of Cancer painRELATED TO THERAPY

COBALT RADIATION BURN

Cancer painOther Factors

Acute Herpes Zoster

Cancer pain

OTHER FACTORS-Immunocompromised state

Cancer pain

Mucositis

Nociceptor is stimulated by the tumor Peripheral sensitization Enzyme Cox-2

Inflammation. Tumor induced acidosis. ( massive apoptosis) Tumor induced distension of sensory fibers

neurophatic pain Centra sensitization Chronic pain

Cancer cells + macrophage + inflammation cells produce high level of Cox-2 enzyme high level of prostaglandins.

Cancer cells induced acidosis due to that inflammatory cells invade neoplastic tissue release H+ and massive apoptosis also contribute release H+ increase acidosis.

Two ascending pathway are activated. ( STT and PSDCT)

Three Step Ladder WHO, 1986

5 essential concepts By mouth By the clock By the ladder By individual With attention to

detail

By this modality ± 90% of cancer pain can be relieved

Gold Standard of Pain Management

Is constant pain assessment. Pain is whatever the patient says it is.Pain in cancer never purely physical.Nonphysical pain describe as ‘discomfort’Take a careful history of the pain complaintAssess characteristics of each pain; site, type

pattern of referral, aggravating & relieving factors etc.

Assessment of Painusing VAS is !

0 3 421 5 6 7 8 9 10

No distress Unbearable distress

a 10-cm baseline is recommended for VAS

( Visual Analogue and Numeric Scale )

Assessment of Pain Intensity

No Mild Moderate Severe Very Worstpain pain pain pain severe possible

pain pain

Verbal Pain Intensity Scale

No

pain

Visual Analog Scale

Wong-Baker FACES Pain Scale

0 1 2 3 4 5

0–10 Numeric Pain Intensity Scale

No Mild Moderate Worstpain pain pain possible pain

0 1 2 3 4 5 6 7 8 9 10

Worstpossible

pain

29

Types of Cancer Pain 1. Nociceptive Pain

Somatic Pain

Visceral Pain 2. Neurophatic Pain (Mostly in combine form)

3. BreakThrough Pain (BTP)

Somatic Pain

• Constant pain• May be dull or sharp• Well localized• Often worse with movement

Eg/– Bone & soft tissue– chest wall

Visceral Pain

• Constant or crampy• Poorly localized• Usually with Nausea & Vomit• Often referred

Eg/– CA pancreas– Liver capsule distension– Bowel obstruction

Neuropathic Pain

Damage to the nerve pathways

There can be an abnormal response to a normal stimulus

May be peripheral or central nerve damage

COMPONENT DESCRIPTORS EXAMPLES

Steady, Dysesthetic

• Burning, Freezing

• Constant-aching

• Squeezing, Itching

• Allodynia

• Hyperalgesia

• Diabetic neuropathy

• Post-herpetic neuropathy

Paroxysmal, Neuralgic

• Stabbing

• Lancinating

• Shock-like, electric

• Shooting

• trigeminal neuralgia

• may be a component of any neuropathic pain

FEATURES OF NEUROPATHIC PAIN

Burning, feeling like the feet are on fire

Stabbing, like sharp knives Lancinating, like electric shocks

Freezing, like the feet are on ice, although they feel warm to touch

Modified by Meliala 2006

Chronic Cancer Pain Chronic Cancer Pain Effectively treating chronic pain poses a great challenge for physicians. This type of pain often

affects a person’s life in many ways. It can change someone’s personality, ability to

function, and quality of life.

According to the American Cancer Society, chronic cancer pain may involve persistent pain

and breakthrough pain. Persistent pain is continuous and may last all day.

Breakthrough PainBreakthrough Pain

BTP is a brief flare-up of severe pain that occurs even while the patient is regularly

taking pain medication. It usually comes on quickly and may last from a few minutes to an hour. Many patients experience a number of episodes of breakthrough pain each day.

Breakthrough PainBreakthrough PainBreakthrough cancer pain can result from the

cancer or cancer treatmen, or it may occur during a certain activity (e.g., walking, dressing, coughing). It also can occur

unexpectedly, without a preceding incident or clear cause. Breakthrough pain usually is

treated with strong, short-acting pain medications that work faster than persistent

pain medications.

CAUSE OF CANCER PAIN Can be classified into 3 categories:

1. Pain associated with direct tumor (tumour infiltration, bone metastases)2. Pain associated with cancer therapy (chemotherapy, surgery or radiation)3. Pain unrelated to cancer (RA, OA, headache or herpes zoster)* Due to cancer debility (decubitus)

Causes of Cancer painDIRECT TUMOR ITSELF

Causes of Cancer pain

Causes of Cancer pain

Cancer painFROM CHEMOTHERAPY

Causes of Cancer painRELATED TO THERAPY

COBALT RADIATION BURN

Cancer painOther Factors

Acute Herpes Zoster

Cancer pain

OTHER FACTORS-Immunocompromised state

Cancer pain

Mucositis

WHO 3-step Analgesic WHO 3-step Analgesic LadderLadderWHO 3-step Analgesic WHO 3-step Analgesic LadderLadder

1 1 MildMild

22 Moderate Moderate

3 3 SevereSevere

Morphine

Hydromorphone

Methadone

Fentanyl

Oxycodone

± Adjuvants

A/Codeine

A/Hydrocodone

A/Oxycodone

Tramadol

± Adjuvants

ASA

Acetaminophen

NSAIDs

± AdjuvantsAdapted from the EPEC Project

Gold Standard of Pain Management

Is constant pain assessment. Pain is whatever the patient says it is.Pain in cancer never purely physical.Nonphysical pain describe as ‘discomfort’Take a careful history of the pain complaintAssess characteristics of each pain; site, type

pattern of referral, aggravating & relieving factors etc.

The Phenomenon of CANCER PAIN

COMPLEX and COMPLICATED is the cumulative among :• PHYSICAL PAIN

• PSYCHOLOGICAL PAIN• socioeconomic,cultural and

spiritual

TOTAL PAIN

BIOPSYCHOSOCIOCULTUROSPIRITUAL

Paracetamol adjuvants

Weak Opioid for mild to moderate

pain Paracetamol adjuvants

Strong Opioid for severe pain(Morphine)

Celecoxib adjuvants

Increasing painIncreasing pain

WHO three step ladderWHO three step ladder

It’s important to more understanding PAIN, type and characteristic of pain..

Because…

In many parts of Indonesia : Many people may die in pain, but Many more people dying with pain, Even many more people living in pain

This is our task to help them as a Doctor

Take Home Message

San Diego, 2002

Total Pain – Osteopathic Medical Total Pain – Osteopathic Medical Care.Care.

Osteopathic Medical Care is based on osteopathic philosophy; the four components being:

1.The body is a unit.2.The body has self-regulatory

mechanisms.3.Structure and functions are reciprocally

interrelated.4.Rational therapy is based on these

principles.

Structure andStructure andFuntion Funtion ReciprocallyReciprocallyInterrelatedInterrelated

Self-RegulatorySelf-RegulatoryMechanismMechanism

Elisabeth K.Ross (1969) “on death and deying”.

BEHAVIOR CHARES IN CANCER PATIENT

1. DENY

2. ANGER

3. BARGENING

4. DEPRESSION

5. ACCEPTANCE

A Patient’s perspective

“ One of the worst aspect of cancer pain is that it`s a constant reminder of the disease and of death ..

My dreams is for a medication that can relieve my pain while leaving me alert and with no side effects “

Jeanne Stover, 1992

Role of COXIB in cancer painRole of COXIB in cancer painCelecoxib is the rational use for the cancer pain management,

particularly in advance stage, because celecoxib is:

* Strong antiinflammation

* Analgesic * Antipyretic * Carcinoprotective (prevent angiogenesis, tumor

growth and metastasis)

* simple administeration

Non-opioid adjuvants

Weak Opioid for mild to moderate

pain non-opioid adjuvants

Strong Opioid for severe pain

non-opioid adjuvants

Increasing painIncreasing pain

WHO three step ladderWHO three step ladder

84

WHO ANALGESIC LADDER CANCER PAINWHO ANALGESIC LADDER CANCER PAIN

Aspirin&

NSAID+

Adjuvants

Add weak Opioid(if pain

unrelived)+

Adjuvants

Add strong Opioids

+ Adjuvants

PSYCHOLOGICAL & SOCIAL SUPPORT

Nociceptive painNociceptive painA NOCICEPTION has at least 4 components

1. TRANSDUCTION2. CONDUCTION/ TRANSMISSION

3. MODULATION 4. PERCEPTION

SpinothalamicSpinothalamictracttract

PeripheralPeripheralnervenerve

Dorsal HornDorsal Horn

Dorsal root Dorsal root ganglionganglion

PainPain

MedulationMedulation

TransductionTransduction

AscendingAscendinginputinput

DescendingDescendingmodulationmodulation

PeripheralPeripheralnociceptorsnociceptors

TraumaTrauma

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.

PerceptionPerception

transmissiontransmission

ConductionConductionConduction/Conduction/TransmissionTransmission

Modified by AHT

88

Poisons

Mechanical, thermal, chemical, electrical

Tissue damage

Release of mediators

Hydrogen and potassium ions, neurotransmitters, kinins, prostaglandins

Stimulation of nociceptors

Transmission to CNS

via afferent pathways

What is pain?

A NOCICEPTION has at least 4 components

1. TRANSDUCTION2. CONDUCTION/

TRANSMISSION 3. MODULATION

4. PERCEPTION

ACUTE (NOCICEPTIVE) PAIN PATHWAY

Figure 10-13: Referred pain

Allodynia: Nerve Injury Leads to Central Reorganization in the Spinal Dorsal HornAllodynia: Nerve Injury Leads to Central Reorganization in the Spinal Dorsal Horn

Normal terminations of primary afferents in the dorsal hornNormal terminations of primary afferents in the dorsal horn

After Nerve InjuryAfter Nerve Injury

Dorsal Horn

Dorsal rootganglion

Peripheral sensoryNerve fibers

A

A

C

Largefibers

Smallfibers

Two sensory afferent neurons1. Large myelinated A fibers, very fast conduction velocity.

Respond to innocuous stimuli 2. Small myelinated A & C unmyelinated fibers, have slow

conduction velocity. Respond to noxious stimuli

Modified by AHT

Although in normal condition AAlthough in normal condition A fiber does not fiber does not response to noxious stimuli, but it plays a big response to noxious stimuli, but it plays a big role in role in NORMAL SENSATION.NORMAL SENSATION.

The Role of AThe Role of A fiber fiber

Without A fiber fiber, any noxious stimuli will perceive as BURNING PAIN (TN, HZ)

A

A

A

CLateral

Nucleusproprius

Marginal layerSubstantiagelatinosa

Medial

Afferent Synaptic in DHN

Ascending spinomesencephalic and spinothalamic axons

Dorsal Root Ganglion

C Fiber

A delta Fiber

Second Order Sensory Neuron

Lateral horn cell and sympathetic axon

Ventra horn motor neuron

Anterior Lateral Spinal Thalamic Tract

Modified by AHT

Pain

Somatic or Visceral

Pain

Neuropathic Pain

Psychological Pain

SufferingPsychological State and

Traits

Loss of Work

Physical Disability

FearOf Death

FinancialConcerns

Social/ Familial

Functioning

Nature of Cancer Pain

Three Step Ladder WHO, 1986

5 essential concepts By mouth By the clock By the ladder By individual With attention to

detail

By this modality ± 90% of cancer pain can be relieved

Three Step Ladder WHO, 1986

5 essential concepts By mouth By the clock By the ladder By individual With attention to

detail

By this modality ± 90% of cancer pain can be relieved

Step I for MILD PAIN

NSAIDs may delay the need of opioid. About 20% of patients were taking NSAIDs

in the last week of life. Caution is needed when using NSAIDs for

long periods GI bleeding and renal failure are the most

common. It has ceiling effect.

Use paracetamol, aspirin or NSAID

Step Il for MODERATE PAIN Combine Paracetamol, NSAIDs + Codein Formula

Constipation is the most common side effect of codein

Acetominophen 500 mgCodein 10 mgDulcolax ¼ tab

mf pulv dtd XXX6 dd I cap

+ adjuvant06.00 18.0010.00 22.0014.00 02.00 prn

– It is a new multimodal analgesic tablet.– Contains

• 325 mg Acetominophen• 37.5 mg Tramadol

– Doses were selected based on golden ratio synergic effect.

– Decreased side effect, while maintaining efficacy

– Approved in over 25 countries including US, Europe, for moderate to severe pain

TRAMADOL peak = 2-3 hrs T1/2 = 6 hrs

TIME

Dru

g E

ffec

t

APAP peak = 30 min T1/2 = 2 hrs

In combination, T1/2 extends to 7-9 hours

Result of combination:

–Fast onset of action

–Prolonged action

Step lll for SEVERE PAIN

Oral morphine is the mainstay of severe cancer pain.

Strong pain needs strong analgesic. It is a very safe drugs as long as given properly Morphine immediate release is not available MS contin is one of choice

– Sustained release– Long acting

Why Cancer Pain Undertreated

For Step 1 & 2- doses are too low- intervals are too long- not individualized, by titration

For step 3 (strong opioid = morphine)- morphine is underused

STEP 1Nonopioid

STEP 2Weak opioid+ nonopioid

STEP 3Strong opioid+ nonopioid+ adjuvant

Why Morphine is Underused?

Morphin is underused due to:

The Myths and prejudice orInsufficient knowledge

Which is in clinical experience do not show to be true.

MYTHS & PREJUDICE of OPOID

When mention about opioids negative side Our textbooks are filled with a side effects.

– Mostly respiratory depression , addiction,

tolerance , physical dependence,

sedation, nausea/vomiting; etc.

Not the benefit of potential analgesic

In clinical experience those myths & prejudice, do not show to be true.

Myth and Prejudice of Morphine

2. Fear of addiction Addiction is the most feared side effects. When we say morphine addiction is the first

answer, not the analgesic

Large survey, 12.000 patients only 4 patients (0.03%) were considered addict

(Boston Collaborative Drug Surveillance Program) All studies chronic opioid treatment demonstrate

a lack of addiction

No evidence of addiction as long as given properly

Opiophobia

“failure to administer morphin analgesics because of a fear of these drugs to

produce addiction”

ConsequenceDue to those myth and prejudice, most cancer pain patients do not get inappropriate treatment, and failure to get the benefit of opioid.

Tragedy of Needless PainTragedy of Needless Pain

Underused of opioid in Indonesia it might be due that?

PAIN MANAGEMENT IN INDONESIA IS NOT THE PRIORITY.

Where University also should play a big role.

Adjuvant Drugs

Corticosteroids : Dexamethasone, Prednison Anticonvulsant : Carbamazepine, Gabapentin, etc Antidepressant : Amytriptiline, Doxepine Neuroleptics : Methotrimeprazine Antihistamines : Hydroxyzine Local anesthetic/antiarrhytmics : Lidocaine Psycho-stimulans : Dextroamphetamine Laxatives : Bisacodyl, Lactulose, etc Antiemetics : Droperidol, Metoclopropamide, etc

New and Alternative Pain Treatment Options

Tramadol Ultracet Clonidine Calcitonin Accupuncture Magnetic-field therapy Duragesic ( transdermal fentanyl) TENS DepoMorphine etc

Some Invasive Modalities For Cancer Pain Relief

1. Neurolitic Block- Alcohol 100 %

- Phenol glycerin 15 %

2. Epidural / Spinal opioid

3. Celiac Ganglion Block

4. Neural blockade

5. SC Morphine / Pethidine continuous infusion

6. Etc.

ConclusionAbout 90% of cancer pain patients can be

relieved by three step ladder of WHOMorphine such is very safe drug when use

properlyUnderuse morphine due to the myths and

which cannot be verified in clinical practiceMany cancer patients could die free from

pain and with dignity if a few of those myths died

In many parts of Indonesia

*Many people may die due to pain

*Many more people dying with pain

* Even many more people living in pain, particularly cancer patients.

This is our task as a doctor

NATURE OF INDONESIA

MAGNITUDE OF CANCER MAGNITUDE OF CANCER PAINPAIN 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

CANCER PAIN

FACTS ABOUT CANCER PAIN

90% of patients with advanced cancer experience severe pain;

Pain occurs in 30% of all cancer patients, regardless of the stage of the disease.

FACTS ABOUT CANCER PAIN

More than 50% of cancer patients may be undertreated for their pain

Pain usually increases as cancer progresses.

Pain Assessment

Treat patient’s pain and regularly reassess response to therapy.

Discuss care plan with patient and family.

Causes of Cancer Pain

Pain secondary to the tumor itselfPain secondary to cancer therapyOther factors

Nociceptive PainSOMATIC PAIN

Nociceptive PainVISCERAL PAIN

Barriers to Cancer Pain Management

1. Inadequate knowledge of pain management.

2. Low priority given to cancer pain treatment.

3. Restrictive regulations, availability of nonopioid and opioid analgesic.

4. Inadequate reimbursement.

5. Fear of patient’s addiction, tolerance, and side effects of opioids; patient’s reluctance to take pain medication.

Mercadante S. WHO Guidelines – Problem Areas in Cancer Pain Management

+/- adjuvantNon-opioid

Weak opioid

Strong opioid

Pain persist

s or in

creases

By the

Clock

W.H.O. ANALGESIC LADDER

+/- adjuvant

+/- adjuvant

1

2

3

COMBINE DRUGS MAY HAVE 3 EFFECTS

1. Synergetic ............. 2+2>4

2. Additive ................ 2+2=4

3. Subadditive ........... 2+2=3

Statistical Test for a Range of Synergy

ACETAMINOPHEN

TR

AM

AD

OL Line of

Additivity

• Tramodal & Acetaminophen has different action

• Synergistic analghesia

• Reduced adverse effect

• Faster onset longer action

‘‘Isobologram’ for analgesic interaction between acetaminophen and tramadolIsobologram’ for analgesic interaction between acetaminophen and tramadol

Ultracet

Is not an NSAID (not Cox1 or Cox2 inhibitor ) Not associated with

prostaglandin-mediated side effects

Cardiovascular side effects

Not associated with GI bleeding or ulcer formation in clinical trials

No effect on platelet aggregation No risk for NSAID-induced nephrotoxicity

Myth and Prejudice of Morphine

3. Sedation• Drowsiness may occur at the beginning

but this usually disappears after a few days

• Drowsiness due to the fact that the patient has first good sleep.

• No patient would accept pain free with sedation.

WHO ANALGESIC LADDER

Physicaldimention

ORGANIC PAIN• Motivational affective• Cognitive evaluation• The meaning of pain

• unpleasant sensory• emotional experienced

“ an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in term of such damage”

PAIN is defined (by IASP 1979) as :

PAINPsycologicaldimention

Definition of Pain

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage,

or described in terms of such damage”

“Suatu perasaan dan pengalaman emosional yang tidak menyenangkan akibat kerusakan jaringan

yang nyata atau yang berpotensi rusak, atau sesuatu yang tergambarkan seperti itu”

IASP, 1979

Byock’s five key points:

“I forgive you.” “Forgive me.” “Thank you.” “I love you.” “Goodbye.”

Structure andStructure andFuntion Funtion ReciprocallyReciprocallyInterrelatedInterrelated

Self-RegulatorySelf-RegulatoryMechanismMechanism

TYPES OF PAINNEUROPATHICNOCICEPTIVE

Deafferentation Sympathetic Maintained

Peripheral

Somatic• bones, joints• connective tissues• muscles

Visceral• Organs –

heart, liver, pancreas, gut, etc.

J.Loeser (1980)

Concept of nociception, pain, suffering and pain behaviour

Pain behaviour

Suffering

Pain

Nociception

A-Alpha MotorEfferent

SympatheticEfferent

Delta SensoryAfferent

C-Fiber SensoryAfferent

PeripheralNociceptor

Spinal Cord

NSST

PSST

NRMBrainstem

Midbrain

Hypothalamusand Pituitary

Cortex andThalamus

LC

PAG

MTVPL

SSC FLC

AscendingPathaways

DescendingPathaways

SympatheticOutflow

Hypothalamic-Pituitary Outflow

Visceral pain Poorly localized, constant, aching and commonly

referred to cutaneous sites Results from injury to the organs that are

sympathetically innervated Referred pain

Pain and hyperalgesia localized to deep or superficial tissues and often found distant from the source

One proposed mechanism to explain this occurrence is central convergence of afferent impulses

Acute Pain

constant sharp aching well localized

constant dull aching poorly localized usually with nausea and

vomit occasional colicky or cramp often referred to cutaneous sites

Somatic pain Visceral pain

Somatic Pain vs Visceral Pain