Cancer Pain Management
Pain: Pain is "an
unpleasant sensory and emotional experience associated with actual or tissue
damage".
Risk
factors
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
Neuropathic pain
Referred Vs non referred
Nociceptive
pain
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.
Neuropathic
pain
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.
Pain
Assessment:
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)
Numeric Scale
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:
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