Cancer Pain Management
Pain: Pain is "an unpleasant sensory and emotional experience associated with actual or tissue damage".
Disease related: bone metastasis, abdominal visceral pain, nerve compression and injury Treatment related: chemotherapy (mucositis, peripheral neuropathy), radiotherapy and surgery.
Health care provider related: inadequate knowledge of pain, poor pain assessment, responsibility, fear of patient's addiction.
Patient and family related: fear of addiction, desire of "good" patient
Types of pain
Nociceptive pain: Somatic pain and Visceral pain
Acute and chronic pain
Psychogenic and somatic pain
Referred Vs non referred
Pain resulting from activation of nociceptors or pain fibres in deep and cutaneous tissues
Somatic pain arises from bones, joints, muscle, skin, and connective tissue. Example: metastasis, mucositis and skin lesion.
Visceral pain: Arises from the viscera, such as pancreas, liver, spleen and GI tract.
Pain is poorly localized, intermittent, cramping squeezing, or sharp in quality.
Due to damage to the peripheral, sympathetic of CNS.
It is sharp, burning, tingling, electrical or shooting in quality.
Acute Vs Chronic pain
Acute- duration less than 6 months
Chronic- duration more than 6 months
Psychogenic and somatic pain
Somatogenic pain originating from an actual physical cause. E.g. Trauma pain:
psychogenic pain: for which there is no physical cause.
referred v/s non referred pain
Referred pain:Pain experienced at a point distant to its point of origin.
Non referred pain:Pain at the point of pathology.
Location: single, multiple or referred.
Intensity: By using intensity scales
Quality: Nociceptive, visceral, somatic, neuropathic
Pattern: Persistent, breakthrough pain.
Precipitating factors: Aggravating and relieving factors
Pain history: Includes the word used to describe the pain such as discomfort, hurt, ache etc.
Strategies used to manage the pain etc.
Medication history and meaning of pain.
Pain Assessment Scales:
Visual analogue scales(VAS)
Principles of cancer pain management
Detailed multidimensional assessment of severity of pain is essential f the patient is started on the appropriate level of the ladder for the degree of pain, based upon the results of the assessment
Analgesia is given regularly dependent upon the pharmacokinetics of the chosen drug and its formulation.
Medication for breakthrough pain must be prescribed
Laxatives are required and should be prescribed for the vast majority of patients on opioid analgesics
Adjuvant drugs must be considered and the class of drug chosen according to the type of pain
Paracetamol and/or non-steroidal anti-inflammatory drugs (NSAIDS) should be used at all steps of the ladder unless contraindicated
The oral route of drug delivery is strongly advocated in the chronic pain usually encountered by the person with cancer.
Morphine is the strong opioid of choice.
WHO's cancer pain ladder for adults
WHO has developed a three-step "ladder" for cancer pain relief in adults.
If pain occurs, there should be prompt oral administration of drugs in the following order: no opioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additional drugs – “adjuvants” – should be used.
To maintain freedom from pain, drugs should be given “by the clock”, that is every 3-6 hours, rather than “on demand” This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80-90% effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective. In the case of cancer pain in children, WHO recommends a two-step ladder.
New adaptation of the analgesic ladder: