Management Of Pain In Cancer Patient

Management of Pain in Cancer Patient Dr Murali Bhavaraju Lecturer Dept of Radiotherapy & Oncology HUSM

Introduction  Definition

of Pain  Types of Pain  Causes of Pain  Treatment Options  Summary

Definition of Pain Pain is an Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage ( International Association Study )

Pain Perception  Modulated

patient

By:Patient Mood Patient Morale Meaning of pain to the

Approach of Pain Management  Multi

dimensional:Physical Psychological Social Spiritual aspect

Types of Pain Depending on nature of pain  Somatic

Pain  Visceral Pain  Neuropatheic

Somatic Pain  Originate

from Skin/Deep tissue  Character Dull or aching well localized pain  Sites Metastatic Bone Pain Post Surgical Incisional Pain Myofascial/Musculoskeletal Pain

Visceral Pain  Originates

 Causes

Thorax Abdomen Pelvic viscera Infiltration Compression Extension Stretching ( cont….)

( cont…)  Character

of pain Poorly localized Squeezing/ Pressure like Referred pain

Neuropatheic Pain

 Originates

Injury to peripheral nerves or CNS by tumor infiltration or compression

Types of Pain

 Acute

pain  Chronic pain

Acute Pain  Well

defined temporal pattern with subjective & objective signs & symptoms  Hyperactivity of autonomic nervous system  Self limiting  Responds to analgesics Precipitating cause

Chronic Pain  Persistent

pain > 3 months  Lacks objective signs  Leeds to significant changes Personality Life style Functional ability

Management of Pain  Medicines  Radiotherapy  Surgery  Chemotherapy  Anesthetics  Hospice

Goals of Pain Management

 Freedom

from pain during sleep  Freedom from pain during rest  Freedom from pain during movement

Medicines Y Primary

- Analgesics - Opioid Analgesics

Y Secondary

- Steroids - Tricyclic antidepressants - Anxiolytics - Antiemitics

Mode of Administration  Oral  Subcutaneous  Intravenous  Trans

dermal  Per Rectal  Sub Lingual

WHO 3 steps Analgesic ladder Opioid+Adj. Drugs III NSAID+ opioid

NSAID+Adjuvant Drugs I Mild to moderate pain

Severe pain with Fear of step III

II Moderate pain or No relief with step I

Non Opioid Analgesics

 Analgesia  Anti

Inflammatory  Anti Platelets

Commonly used Analgesics

Side Effects  GI

Toxicity

Gastric Erosion Peptic Ulcer Hemorrhage  Respiratory Bronchial Asthma  ENT Tinitus & Deafness  Salt & Water Retention  Potentiation of Hypoglycemic agents  Can cause Renal Toxicity

Week Opioid  As

effective as small doses of Morphine  Easier to obtain & supply  Codeine

Prodrug of morphine 1/10th potent as morphine 10% of population can’t convert to morphine

Tramadol  Alternative

to opioid of step 2 & lower step 3 of WHO scale  Dual mode of action (Analgesic + Pre synaptic reuptake blocker of MAOI)  Best suitable is Oral Route  IV Initial Bolus– CVI

Strong Opioids  Morphine  Phenazocine  Methadone  Oxycodone  Hydromorphine  Fentanyl  Buprinorphine

Morphine  Main

Indication

 Subsidiary  Therapeutic

Pain Dyspnoea Cough Diarrhea

Categories Responsive Semi responsive Resistant

Converting the morphine dose  Oral

morphine to SC ½ the oral dose  Oral morphine to IV give 1/3 oral dose  Oral morphine to SC Diamorphine 1/3 oral dose  Oral Diamorphine to SC Diamorphine ½ the oral dose

Side Effects Morphine  Initial

Vomiting Drowsiness Unsteadiness Confusion  Continuing Constipation  Occasional Dry Mouth Sweating Myoclonus

Stepping Out of Constipation  Exercise,

fluid intake, fiber in the diet  Bulk forming laxatives (Fybogel)  Stool softeners (Coloxyl, Senna)  Osmotic laxatives ( Mg So4)  Stimulants (Senokot, Coloxyl, Senna)  Suppository / Enema  Colonic lavage

Fentanyl Y Strong

opioid Y Trans dermal Patches Y Used Peri operative analgesia Cancer pain management Y Onset of action 3-23 hours Y Elimination from 24 hours Plasma Y Remember to provide Breakthrough Medication

Subcutaneous Administration  Indications

Intractable Vomiting Severe Dysphagia Pt. too weak to swallow drugs Poor GI absorption

 Advantages

Constant Analgesia Reloading after 24 Hrs Comfort & confidence No mobility restriction Better control of nausea & vomiting

 Choice

of Sites Upper chest Upper Arm Abdomen Thigh

Infusion causes painful inflammation  Change

needle site prophylactically  Reducing the irritant drug quantity  Changing to alternative drug  Giving irritant drug IM or PR  Adding hydrocortisone 25-50mgs to syringe  Adding hyaluronidase 1500 units to syringe

Choice of Drugs for SC  Morphine  Diamorphine  Cyclizine  Dexamethasone  Hyoscine  Levomepromazine  Metaclopramide  Midazolam

Adjuvant Drugs 



Bone Pain Biphosphnates

Pamedronate Zylodranate

Calcitonin 32P Strontium Neuropatheic pain Antidepressants Anticonvulsants Steroids Clonidine Benzodizepines Neuroleptics

Drugs used for side effects  Antiemetics

Metaclopramide Ondansetron  Psycho stimulants Caffeine Methyl paiendate Dextroamphitamine  Enhance Analgesia Acetaminophen NSAID Hydroxyzine

Radiotherapy  Palliative

XRT Bone pain Neurological pain SVCO Brain mets

Surgery  Palliative

surgery Tracheostomy Toilet mastectomy Defunctioning Colostomy Pathological # fixation Neurosurgical intervention

Anesthesia

 Intrathecal

Anesthesia  Peripheral nerve block

Hospice  Terminal

care  Symptom management  To give break to the attendants  To interact with patients of same nature

Summary  Multimodality

approach  Opioids are more effective  WHO step ladder to follow for pain control  Systemic/ Targeted treatment also used  Role of religion important if needed