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Vuorinen E. Clin J Pain 1993; 9:272-8. Cleeland CS, et al New Engl J Med 1994;330:592-6. Brescia J
¼ ของผปวยพบเมอเรมวนจฉย
2/3 ของผปวยพบระหวางท รบการรกษามะเรง
¾ ของผปวยพบในระยะทโรคลกลาม
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ผรกษาควรจะตองพยายามหาสาเหตของอาการปวดใหได
เสมอ
สบคนเมอมความจ าเปน
อาจตองจดการดแลในรปแบบอนๆ
Effective treatment
Treating "Total Pain"
Proper administration of an opioid,
particularly morphine, has been proven to
provide effective pain management in the
majority of patients with severe pain.
With analgesics according to analgesic ladder
With medications to control special pain problems, as
appropriate. Explain reason for treatment and side
effects; always take into account patient preference
With non-medical treatments
Non-opioid (aspirin or paracetamol
or ibuprofen)
+ Non-opioid (aspirin or paracetamol
or ibuprofen)
Opioid for mild to Moderate pain
(codeine)
+ Non-opioid
Opioid for moderate to severe pain
(oral morphine )
Support and counseling
Psychological, spiritual and emotional support and counseling should accompany pain medications. Pain can be harder to bear when there is guilt, fear of dying, loneliness, anxiety, depression
Answering questions and explaining what is happening is important to relieve fear and anxiety
Deep breathing and relaxation technique unless the patient is psychotic or severely depressed
Distraction, music, imagining and calm scene
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By mouth ( rectal is an alternative –avoid IM)
By clock
Give pain killers at fixed time interval ( by clock or radio or sun)
Start with small dose, then titrate dose against patient’s pain, until the
patient is comfortable
Next dose should happen before effect of previous dose wears off.
For breakthrough pain, give an extra “ rescue” dose same dosing of the
4- hourly dose) in addition to the regular schedule.
Give only one drug from the opioid and non-opioid group at a time:* * exception : if no codeine, aspirin q 4 hours can be combined with Paracetamol q 4 hrs –overlap so one is given every 2 hrs.
แบงเปาหมายออกเปนล าดบขน
STEPWISE GOALS FOR PAIN CONTROL
ไมปวดเลยตอนกลางคน Pain free at night
ไมปวดเลยเวลาพกผอน Pain free at rest
ไมปวดเลยเวลาเคลอนไหว Pain free on movement
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Analgesics Starting dose in adults
Range Side effects / cautions
Non-opioids
Paracetamol 500 mg 2 เมดทก 4-6
ชวโมง (เวนรบประทาน
มอกลางคนหรอใหยาชนด
อนเพอไมใหใชยาเกน 8
เมด.
ในผปวยสงอายหรอไม
แขงแรง อาจใชเพยง 1
เมด หรอเมอใชรวมกบยา
opioids. ถาปวดในระดบ
Mild อาจใหทก 6 ชวโมงก
พอ
อยาใหเกน 8 เมด ตอวน (
อาจท าใหเกด serious
liver toxicity)
Aspirin
(acetylsalicylic
acid)
600 mg ( 2 tabs of
300 mg จ านวน 2 เมด)
ทก 4 ชวโมง
ถามปญหาโรคกระเพาะ.ให
หลกเลยง หยดใชยาถาม
อาการ ปวดทอง อาหารไม
ยอย ถายด า petechiae
หรอเลอดออก อยาใชกบ
เดกอายต ากวา 12 ป.
หลกเลยงถาพบวามปญหา
เลอดออก
Ibuprofen 400 mg ทก 6 ชวโมง สงสดไมเกน 8 เมด/ วน
ST
EP
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Analgesics Starting dose in adults
Range Side effects / cautions
Non-opioids
Paracetamol 500 mg 2 tabs q 4-6
hrs. (skip dose at
night or give another
analgesic to keep total to 8 tabs.
Only 1 tab may be
required in elderly or
very ill or when
combined with
opioids. Mild pain
might be controlled with q 6 hrs. dosing.
Do not exceed eight
500 mg tablets in 24
hrs. ( more can cause serious liver toxicity)
Aspirin
(acetylsalicylic acid)
600 mg ( 2 tabs of 300 mg) q 4 hrs.
Avoid use if gastric
problems. Stop if
epigastric pain,
indigestion, black
stools petechiae or
bleeding. Do not give
to children under 12
years. Avoid if
presence of any bleeding.
Ibuprofen 400 mg q 6 hrs. Max. 8 tabs/ d
ST
EP
1 Analgesics Starting dose in
adults Range Side effects /
cautions
Opioid for mild to moderate pain( give in addtion to aspirin or paracetamol)
Codeine( if not
available,
consider
alternating aspirin and paracetamol)
30 mg q 4 hrs. 30-60 mg q 4-8 hrs.
Maximum daily dose
for pain 180-240 mg
due to constipation – switch to morphine
Give laxative to avoid
constipation unless
diarrhea
Cost
Opioid for moderate to severe pain
Oral morphine 5
mg / 5 ml or 50
mg / 5 ml
Drop into mouth.
Can also be
given rectally ( by syringe)
2.5 – 5 mg q 4 hrs. (
dose can be
increased by 1.5 or
doubled after 24 hrs. if pain persists)
According to need of
patient and breathing.
There is no ceiling dose
Give laxative to avoid
constipation unless
diarrhea
ST
EP
2
ST
EP
3
If patient has a side effect Then manage as follows
• Constipation • increase fluids and bulk
• Give stool softener ( docusate) at time
of prescribing plus stimulant ( senna)
• Prevent by prophylaxis ( unless diarrhea
• Nausea and / or Vomiting Give antiemetic ( metoclopromide,
haloperidol or chlorpromazine). Usually
resolves in several days. May need around the clock dosing
• Respiratory depression ( rare when oral morphine is increased step by step for pain)
If severe, consider withholding next opioid dose then halve dose
• Confusion or drowsiness ( if due to opioids)
• Decreased alertness
•Trouble with decisions
Usually occurs at start of treatment or
dose is increased. Usually resolves within
few days. Can occur at end of life with
renal failure. Halve dose or increase time
between doses. Or provide time with less
analgesia when patient wants to be more fully alert to make decisions
Respond to side effects of morphine or other opioids
If patient has a side effect Then manage as follows
• Twitching ( Myoclonus – if severe or bothers patient during waking hours)
If on high dose, consider reducing dose or
changing opioids ( consult or refer). Re-assess the pain and its treatment.
• Somnolence ( excessively sleepy) Extended sleep can be from exhaustion
due to pain. If persists more than 2 days after stating, reduce the dose by half.
• Itching May occur with normal dose. If present for
more than a few days and hard to tolerance, give chlorpheniramine
• Urinary retention Pass urinary catheter if trained – in and out since it usually does not recur.
Respond to side effects of morphine or other opioids
Special pain problems Medication – adolescent / adult
For burning pain; abnormal sensation pains
; severe, shooting pains with relatively little pain in between ; pins and needles
Low dose amitryptyline ( 25 mg at night or
12.5 mg twice daily ; some start 12.5 mg
daily) wait 2 weeks for response, then
increase gradually to 50 mg at night or 25 mg twice daily.
For muscle spasms in end of life care or paralyzed patient
Diazepam 6 mg orally or rectally 2 -3 times / d
• Herpes zoster ( or the shooting pain
following it)
• Refer patients with ophthalmic zoster
• Low dose amitryptyline
• Early eruption; acyclovir if available;
apply gentian violet if rupture vesicles
• Other locally available remedies
• Late zoster pain; capsicum cream
Give medications to control special pain problems
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Special pain problems Medication – adolescent / adult
Gastrointestinal pain from colic only after
exclusion of intestinal obstruction
( vomiting, no stool and gas passing, visible bowel movements.)
Codeine 30 mg q 4 hrs. or hyoscine (
Buscopan®) 10 mg x3 daily ( can increased up to 40 mgs x3 daily.
Bone pain or renal colic or dysmenorrhea Ibuprofen ( or other NSAIDs)
If pain from
• swelling around tumor
• Severe esophagus ulceration and can not
swallow
• Nerve or spinal cord compression
• Persistent severe headache ( likely from increased ICP
•When giving end of life care and referral
not desired, see instruction for careful steroids use under clinical supervision.