Pain Relief for Cancer Patients

Thirty to 50 percent of patients undergoing active treatment, and about 70 to 90 percent of those with advanced solid tumors, experience chronic pain. Appropriate treatment of pain can result in 90 percent of cancer patients achieving adequate relief. Barriers to pain control include lack of physician knowledge of adequate treatment of pain, unrealistic concerns about narcotic addiction, patient underreporting of symptoms, and lack of emphasis on symptom control in comparison with disease management. Uncontrolled severe pain is an emergency and requires aggressive treatment.

WHO has developed a three-step "ladder" for cancer pain relief

If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (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.

 Cancer pain comes in many forms and often is undertreated. When the pain fails to respond to acetaminophen or nonsteroidal anti-inflammatory drugs, or otherwise becomes intractable, opioids often are recommended. Usually, short-acting opioids are used as needed. When the pain persists throughout the day, short-acting opioids are replaced with longeracting opioids two or three times daily to provide 24-hour relief.

Treating worsening Pain in Cancer

May be due to 1.Worsening disease 2.Opioid tolerance 3.Adverse effects of opioids (abdominal pain due to constipation)

Opioids most commonly used for cancer pain

Morphine Diamorphine Fentanyl Buprenorphine Oxycodone Codeine

COMMON STARTING DOSES

OPIOID-NAIVE PATIENTS * parenteral doses equianalgesic to morphine sulfate 10mg SQ codeine 30mg hydromorphone 2mg levorphanol 2mg meperidine 50mg methadone 5mg morphine 10mg oxycodone 5mg

EQUIANALGESIC DOSES

DRUG

ROUTES OF ADMINISTRA TION

APPROXIMAT APPROXIMAT E E DURATION EQUIANALGE SIC DOSES* 120mg 4-6 hours 2-5 hours 4-6 hours 2-4 hours 6-12 hours 3-4 hours 4-6 hours

codeine

PO, parenteral

hydromorpho PO, 2mg ne parenteral PR levorphanol meperidine methadone morphine oxycodone PO, parenteral PO, parenteral PO, parenteral 2mg 100mg 10mg

PO, 10mg parenteral PR PO 15mg

Morphine
morphine and some other opioids do not have a "ceiling effect". Morphine can be safely administered in increasing amounts until the pain is relieved without producing an "overdose", as long as the side-effects are tolerated. There is no standard dose of morphine; the correct dose is the one that relieves the pain Different types 1.Immediate release liquid or tablet take every 4 hours 2.MST - Slow (sustained)release tablet or capsule taken every 12 hours

Diamorphine
Given by injection

Fentanyl
Skin patch or lozenger

Buprenorphine
Temgesic or Transtec Tabletsts to keep under the tongue or patches Takes 72 hours to achieve blood levels Used for breakthrough pain relief

Oxycodone
For bone and nerve pain Esp if morphine has not helped the pain Immediate release (Oxynorm) Slow release (Oxycontin)

Codeine
Weak opioid 1st line opioid Combined with paracetamol cocodamol, codydramol

Tolerance to Opioids
TOLERANCE - This refers to an increased amount of opioid necessary to produce the same effect previously seen with a smaller amount of opioid. Tolerance develops to several opioid side effects - RESPIRATORY DEPRESSION, NAUSEA and VOMITING, SEDATION and CONFUSION. Twycross states that tolerance to the analgesic effect is not a clinical problem when opioids are used in chronic pain in cancer patients. When patients require more opioid, their disease can frequently be seen to be progressive. Foley notes that tolerance develops to the ANALGESIC EFFECT and that cross tolerance between opioids is not complete. In either case, side effects permitting, opioid doses can be increased when previous doses are no longer as effective. When switching drugs, the possibility of incomplete cross tolerance may be considered, and a smaller than equianalgesic dose be started accordingly.

 PHYSICAL DEPENDENCE implies that a withdrawal syndrome can be seen upon abrupt withdrawal of an opioid or upon administration of an opioid antagonist. Physical dependence is a property of the drug, not the patient. It is generally not a concern in chronic pain in cancer patients. Should the need for opioid be decreased or removed, a withdrawal syndrome can be avoided by tapering the opioid over several days. It has been noted that withdrawal reactions can be prevented if the dose of opioid is 25% of the previous day's dose.

 PSYCHOLOGICAL ADDICTION or PSYCHOLOGICAL DEPENDENCE results from a variety of personality, environmental, psychosocial, etc. factors. It does not result from simply exposure to the opioid for a legitimate medical purpose. ADDICTION is NOT A CONCERN AMONG CANCER PATIENTS WITH CHRONIC PAIN

Non-opioids drugs
For bone and muscle pain Aspirin, Ibuprofen, diclofenac, celecoxib

Other Drugs
Steroids Bisphosphonates Anti-depressants Anti-convulsants Local anaesthetics

Steroids
Reduce swelling Prednisolone and dexamethazone used in cancer

Bisphosphonates
Controls bone pain so that the amount of pain killers can be reduced Slow down or prevent damage cause by cancer spread to the bones

Anti-depressants
For nerve pain not responding to other pain killers Helps depression associated with chronic pain Examples are amitriptyline, imipramine, doxepin and trazodone

Anti-convulsants
Help burning or tingling pain Gabapentin (Neurontin), Carbamezapine (Tegretol), Phenytoin

Gabapentin
Blocks Sodium channels

Local Anaesthetics
Nerve Blocks -

TENS