Dr U.Kamariah binti U.Ahmad Pain Specialist and Anaesthesiologist Hospital Sultan Ismail, Johor Bahru , Johor. 10th Malaysian Hospice Congress
Oct 24, 2014
Dr U.Kamariah binti U.Ahmad
Pain Specialist and Anaesthesiologist
Hospital Sultan Ismail,
Johor Bahru , Johor.
10th Malaysian Hospice Congress
Introduction
How can we
maximized the
pain management. WHO standard
treatment
Assessment of
patient
Cancer Prevalence in Malaysia Epidemiology of cancer pain Studies on global impact of pain in Ca pt Studies on impact of mood & psychology function
A total of 21,773 cancer
cases were diagnosed
among Malaysians in
Peninsular Malaysia in the
year 2006 and registered
in the National Cancer
Registry. It comprises of
9,974 males and 11,799
females.
Incidence Rate (ASR) for
all cancers in the year
2006 regardless of sex
was 131.3 per 100,000.
the five most common
cancer among
population of Peninsular
Malaysia in 2006 were
breast, colorectal, lung,
cervix and nasopharynx
A total of 18,219 new
cancer cases were
diagnosed in 2007 and
registered at the National
Cancer Registry. It
comprises of 8,123
(44.6%) males and 10,096
(55.4%) females.
The age-standardised
incidence rates (ASR)
were 85.1/100.000 males
and 94.4/100,000
females while the
The five most frequent
cancers among
Malaysian males in 2007
were lung, colorectal,
nasopharynx, prostate
and
lymphoma, while the
five most common
cancers in females were
breast, colorectal,
cervix, ovary and lung
(Table 9,
National Cancer Registry’s Malaysian Cancer Statistics:
Data and Figures, Peninsular Malaysia 2006
Cancer Incidence per 100,000
population by age - Females %
Cancer Incidence per 100,000
population by age - Males %
pain occurs in 30% of all cancer patients, regardless of the stage of the disease.
not all cancer patients feel pain, and pain is rarely a sign of early cancer.
30% - 40% of patients suffers with pain while on active Rx 90% of patients with advanced cancer experience severe pain
Pain usually increases as cancer progresses..
As many as 50% of patients may be under treated for cancer pain
The second most common
cancer pain is caused by
tumors infiltrating the
nerve and hollow viscus.
– Tumors near neural
structures may cause the
most severe pain.
The most common
cancer pain is from
tumors that metastasize
to the bone.
As many as 60-80% of
cancer patients with
bone metastasis
experience pain. The third most common
pain associated with
cancer occurs as a result
of chemotherapy,
radiation, or surgery
WHO standard
treatment
Assessment of
patient
Treatment
Neuroablative techniques
Intraspinal opioids / local anaesthetics
Regional catheters
S/C opioids / adjuvants / ketamine
Oral opioids / adjuvants.
Psychological therapies
Acupuncture; TENS
Simple analgesics; NSAIDs.
Anti-neoplastic drugs; XRT
WHO CANCER PAIN
GUIDELINES.
Three principles of
analgesic use2
By the mouth
By the clock
By the ladder
The three critical components of cancer pain management occur on a cyclical basis:
Cleary JF. Cancer Control 2000;7(2):120-131.
Therapeutic
Opioid Regimen
Integration with
other therapies
Pain
Assessment
History
Examination
Investigation
Look for new
symptoms
Type of pain:
Neuropathic
Nociceptive
Many
cancer
patients
experience
pain from
more than
one source
What cause cancer pain?
Caused by cancer treatment (chemotherapy, radiotherapy @ surgery)
Neuropathic pain:
This pain may occur if treatment damages the nerves.
Burning, sharp, or shooting.
The cancer itself causes burning itself can also cause this kind of pain.
Phantom pain.
may still feel pain or other discomfort coming from a body part that has been removed by surgery.
Important to :
listen and believe the
patient
Take a pain history :
“Tell me about your pain…”
5th Vital Sign: Doctors’ training module: Pain Assessment
P : Place or site of pain “Where does it hurt?”
(a body chart might help describe
their pain)
A : Aggravating factors “What makes the pain worse?”
I : Intensity “How bad is the pain?”
N : Nature and neutralizing
factors “What does it feel like” “What makes the pain
better?”
5th Vital Sign: Doctors’ training module: Pain Assessment
•Xray
•Ultrasound
•Bone scan
•? MRI or CTscan
0-3
4-6
Regular
Higher dose of
weak opioid
Or
IV/SC Morphine
5-10mg 4 hrly
OR
Aqueous
morphine 10-20
mg
± PCM 1gm QID
oral / rectal
± NSAID /
COX2 inhibitor
MILD
MODERATE
SEVERE
Regular
No
medication
or PCM
1gm 6hrly
Regular
Weak Opioid
± PCM 1gm QID
oral
± NSAID /
COX2 inhibitor
PRN
PCM &/or
NSAID /
COX2
inhibitor
7-10
PRN
IV/SC
Morphine
5-10mg
OR
Aqueous
morphine
*Oral or SC
Morphine may
be safely
given at hourly
intervals
PRN
Additional
weak opioid
UNCONTROLLED
To refer to APS for:
PCA or Epidural or
other form of analgesia
Analgesic Ladder for Acute
Pain Management
The Adult Analgesic Ladder for Acute Pain:– pain as 5th vital sign Doctor’s training module KKM guideline :
adopted with modification from West Hertfordshire Hospitals acute pain guideline
Pseudo-resistant • underdosing
• poor absorption
• poor intake
• ignoring psychological
aspects of care
Semi-resistant • Bone metastases
• Neuropathic (Some)
• RICP
• Activity related
Resistant Neuropathic (some)
Muscle spasm
From Melzack and Wall Textbook of Pain 3rd ed 1995
Nociceptive Neuropathic
Superficial
somatic
Deep
somatic
Skeletal
muscle
Visceral
colicky
Visceral
constant • Anti-arrhythmic
• Antiepileptic
• Capsaicin
• Corticosteroid
• Intraspinal
clonidine, opioid
• Nerve block
• Opioid
• Parenteral
ketamine
• TCA
• Heat or cold
• Irrigation
• Local
anaesthetic
• Opioid
• Paracetamol
• Radiotherapy
• Topical
NSAID
• Corticosteroid
• Heat or cold
• Immobilisation
• NSAID
• Opioid
• APAP
• Radiotherapy
• Baclofen
• Clonazepam
• Dantrolene
• Diazepam
• Heat or cold
• Immobilisation
• Massage
• NSAID
• Opioid
• Anti-
spasmodic
• Heat or cold
• Ketorolac
• Nifedipine
• Opioid
• Corticosteroid
• Opioid
• APAP
Adapted from: Mashford ML, et al. Therapeutic Guidelines: Analgesic. 2002.
WHO
recommendation:
Oral route
Types of opioids
Other routes:
patches
Subcutaneous
Intravenous
Intrathecal
Oral Opioids Pharmacology of morphine
slow release and regular
interval How to give:
Dose : calculated
Dosing times: regular
To reduce side
effects / better
compliance:
Slow released opioid
Less sedation
Breakthrough dose:
1/3 – full dose
Slow release drug
Regular interval drug
Patient pre morbid
condition
Dose requirement
Side effects
Availability
Acceptable or
permissible route
Drug interaction
Patients compliance
and acceptability
Sublingual
tablets
Rectal
suppositories
Transdermal
patch
Continuous
subcutaneous
infusion
Subcutaneous
injection
Spinal delivery
Tablet
Liquid
suspensions
Liquid
solutions
Sprinkling on
solid foods
The wide variety of formulation of opioid analgesia increases their clinical utility
Adopted from: Twycross, Wilcock A, symptom management in advance cancer 3rd edition. Abingdon,UK, Redellife Medical Press 2001.
What is the
Maximum dose for
opioids?
No limits
To take as much as
needed till
development od side
effect.
How do you monitor
safety of giving opioid?
Vital sign esp.
respiratory rate, Blood
Pressure. Pulse rate,
Pain score
Conscious level
Comfort score
Definition:
is a physiological
phenomenon where
increasing doses of a
drug are required to
produce the same
pharmacological effect,
or where the same dose
produces less effect.
Patient will escalate
(increased dose
requirement) within
few weeks
But pain relief is still
not satisfactory and not
maintain
Started to developed
side effect
Clinical presentation:
Changing opioid
type:
Opioid rotation
Calculate the
equivalent dose of
the chosen drug
Changing the
mode of giving:
Patch
Subcutaneous
PCA etc
Type of Pain Response to Opioid Drug Treatment
Visceral Totally Responsive Opioid
Soft tissue Partially Responsive Non-opioid/NSAID +
opioid
Bone Partially Responsive NSAID + opioid
Nerve compression Partially Responsive Opioid + corticosteroid,
anticonvulsant
Nerve destruction Partially Responsive
Tricyclic antidepressant,
anticonvulsant, local
anaesthetic
Muscle pain (spasm) Non Responsive Muscle relaxant
Nociceptive Neuropathic
Superficial
somatic
Deep
somatic
Skeletal
muscle
Visceral
colicky
Visceral
constant • Anti-arrhythmic
• Antiepileptic
• Capsaicin
• Corticosteroid
• Intraspinal
clonidine, opioid
• Nerve block
• Opioid
• Parenteral
ketamine
• TCA
• Heat or cold
• Irrigation
• Local
anaesthetic
• Opioid
• Paracetamol
• Radiotherapy
• Topical
NSAID
• Corticosteroid
• Heat or cold
• Immobilisation
• NSAID
• Opioid
• APAP
• Radiotherapy
• Baclofen
• Clonazepam
• Dantrolene
• Diazepam
• Heat or cold
• Immobilisation
• Massage
• NSAID
• Opioid
• Anti-
spasmodic
• Heat or cold
• Ketorolac
• Nifedipine
• Opioid
• Corticosteroid
• Opioid
• APAP
Adapted from: Mashford ML, et al. Therapeutic Guidelines: Analgesic. 2002.
• Antiepileptic:
• Carbamazepine
• Phenytoin
• Gabapentine
• Antidepressent:
• Amitriptyline
• Nortriptyline
• Anti-arrhythmic
• mexilitine
• Capsaicin
Canadian Family Physician June 2010 vol. 56 no. 6
Dr U.Kamariah binti U.Ahmad
Pain Specialist and Anaesthesiologist
Hospital Sultan Ismail,
Johor Bahru , Johor.
10th Malaysian Hospice Congress