10th Malaysian Hospice Congress

Dr U.Kamariah binti U.Ahmad Pain Specialist and Anaesthesiologist Hospital Sultan Ismail, Johor Bahru , Johor.

Introduction How can we maximized the pain management.

WHO standard treatment Assessment of patient

Cancer Prevalence in Malaysia Epidemiology of cancer pain Studies on global impact of pain in Ca pt Studies on impact of mood & psychology function

A total of 21,773 cancer cases were diagnosed among Malaysians in Peninsular Malaysia in the year 2006 and registered in the National Cancer Registry. It comprises of 9,974 males and 11,799 females.

Incidence Rate (ASR) for all cancers in the year 2006 regardless of sex was 131.3 per 100,000. the five most common cancer among population of Peninsular Malaysia in 2006 were breast, colorectal, lung, cervix and nasopharynx

A total of 18,219 new cancer cases were diagnosed in 2007 and registered at the National Cancer Registry. It comprises of 8,123 (44.6%) males and 10,096 (55.4%) females. The age-standardised incidence rates (ASR) were 85.1/100.000 males and 94.4/100,000 females while the

The five most frequent cancers among Malaysian males in 2007 were lung, colorectal, nasopharynx, prostate and lymphoma, while the five most common cancers in females were breast, colorectal, cervix, ovary and lung (Table 9,

National Cancer Registrys Malaysian Cancer Statistics: Data and Figures, Peninsular Malaysia 2006

Cancer Incidence per 100,000 population by age - Males %

Cancer Incidence per 100,000 population by age - Females %

pain occurs in 30% of all cancer patients, regardless of the stage of the disease. not all cancer patients feel pain, and pain is rarely a sign of early cancer. 30% - 40% of patients suffers with pain while on active Rx 90% of patients with advanced cancer experience severe pain Pain usually increases as cancer progresses..

As many as 50% of patients may be under treated for cancer pain

The most common cancer pain is from tumors that metastasize to the bone.

The second most common cancer pain is caused by tumors infiltrating the nerve and hollow viscus.
Tumors near neural structures may cause the most severe pain.

As many as 60-80% of cancer patients with bone metastasis experience pain.

The third most common pain associated with cancer occurs as a result of chemotherapy, radiation, or surgery

WHO standard treatment Assessment of patient Treatment

WHO CANCER PAIN GUIDELINES.

Neuroablative techniques Intraspinal opioids / local anaesthetics Regional catheters S/C opioids / adjuvants / ketamine

Oral opioids / adjuvants.

Psychological therapies Acupuncture; TENS

Simple analgesics; NSAIDs.

Anti-neoplastic drugs; XRT

Three principles of analgesic use2

By the mouth

By the clock

By the ladder

The three critical components of cancer pain management occur on a cyclical basis:

Pain Assessment

Therapeutic Opioid Regimen

Integration with other therapies

Cleary JF. Cancer Control 2000;7(2):120-131.

History Examination Investigation

Look for new symptoms

Type of pain:
Neuropathic Nociceptive

What cause cancer pain?

Caused by cancer treatment (chemotherapy, radiotherapy @ surgery) Neuropathic pain: This pain may occur if treatment damages the nerves. Burning, sharp, or shooting. The cancer itself causes burning itself can also cause this kind of pain.
Phantom

Many cancer patients experience pain from more than one source

pain.

may still feel pain or other discomfort coming from a body part that has been removed by surgery.

Important to :
listen and believe the patient

Take a pain history :

Tell me about your pain

5th Vital Sign: Doctors training module: Pain Assessment

P : Place or site of pain

Where does it hurt? (a body chart might help describe their pain) What makes the pain worse? How bad is the pain?

A : Aggravating factors

I : Intensity

N : Nature and neutralizing factors

What does it feel like What makes the pain better?

5th Vital Sign: Doctors training module: Pain Assessment

Xray
Ultrasound Bone

scan ? MRI or CTscan

Analgesic Ladder for Acute Pain Management

SEVERE 7-10 Regular Higher dose of weak opioid Or IV/SC Morphine 5-10mg 4 hrly OR Aqueous morphine 10-20 mg PCM 1gm QID oral / rectal NSAID / COX2 inhibitor PRN IV/SC Morphine 5-10mg OR Aqueous morphine *Oral or SC Morphine may be safely given at hourly intervals UNCONTROLLED To refer to APS for: PCA or Epidural or other form of analgesia

MODERATE 4-6

MILD 0-3 Regular No medication or PCM 1gm 6hrly PRN PCM &/or NSAID / COX2 inhibitor

Regular Weak Opioid

PCM 1gm QID oral NSAID / COX2 inhibitor

PRN Additional weak opioid

The Adult Analgesic Ladder for Acute Pain: pain as 5th vital sign Doctors training module KKM guideline : adopted with modification from West Hertfordshire Hospitals acute pain guideline

Pseudo-resistant
underdosing poor absorption poor intake ignoring psychological aspects of care

Semi-resistant
Bone metastases Neuropathic (Some) RICP Activity related

Resistant
Neuropathic (some) Muscle spasm

From Melzack and Wall Textbook of Pain 3rd ed 1995

Nociceptive
Superficial somatic
Heat or cold Irrigation Local anaesthetic Opioid Paracetamol Radiotherapy Topical NSAID

Neuropathic
Skeletal muscle
Baclofen Clonazepam Dantrolene Diazepam

Deep somatic
Corticosteroid Heat or cold
Immobilisation

Visceral colicky
Antispasmodic Heat or cold Ketorolac Nifedipine Opioid

Visceral constant
Corticosteroid Opioid APAP

Anti-arrhythmic Antiepileptic Capsaicin Corticosteroid Intraspinal clonidine, opioid Nerve block Opioid Parenteral ketamine TCA

NSAID Opioid APAP Radiotherapy

Heat or cold
Immobilisation

Massage NSAID Opioid

Adapted from: Mashford ML, et al. Therapeutic Guidelines: Analgesic. 2002.

WHO recommendation:
Oral

route Types of opioids Other routes:

patches Subcutaneous Intravenous Intrathecal

Oral Opioids
How

to give: Dose : calculated Dosing times: regular To reduce side effects / better compliance:

Pharmacology of morphine slow release and regular interval

Slow released opioid Less sedation

Breakthrough

dose:

1/3 full dose

Slow release drug Regular interval drug

Patient pre morbid condition Dose requirement Side effects Availability Acceptable or permissible route Drug interaction Patients compliance and acceptability

Tablet

Liquid suspensions Liquid solutions Sprinkling on solid foods

Sublingual tablets Rectal suppositories Transdermal patch

Continuous subcutaneous infusion Subcutaneous injection Spinal delivery

The wide variety of formulation of opioid analgesia increases their clinical utility
Adopted from: Twycross, Wilcock A, symptom management in advance cancer 3rd edition. Abingdon,UK, Redellife Medical Press 2001.

 What

is the Maximum dose for opioids?

No limits To take as much as needed till development od side effect.

How

do you monitor safety of giving opioid?

Vital sign esp. respiratory rate, Blood Pressure. Pulse rate, Pain score Conscious level Comfort score

 Definition:

Clinical presentation:
Patient will escalate (increased dose requirement) within few weeks But pain relief is still not satisfactory and not maintain Started to developed side effect

is a physiological phenomenon where increasing doses of a drug are required to produce the same pharmacological effect, or where the same dose produces less effect.

 Changing

opioid

Changing

type:
Opioid rotation

Calculate the equivalent dose of the chosen drug

the mode of giving: Patch Subcutaneous PCA etc

Type of Pain
Visceral Soft tissue Bone Nerve compression Nerve destruction

Response to Opioid
Totally Responsive Partially Responsive Partially Responsive Partially Responsive Partially Responsive

Drug Treatment
Opioid Non-opioid/NSAID + opioid NSAID + opioid Opioid + corticosteroid, anticonvulsant Tricyclic antidepressant, anticonvulsant, local anaesthetic Muscle relaxant

Muscle pain (spasm)

Non Responsive

Nociceptive
Superficial somatic
Heat or cold Irrigation Local anaesthetic

Neuropathic
Skeletal muscle
Baclofen Clonazepam Dantrolene Diazepam

Deep somatic
Corticosteroid Heat or cold
Immobilisation

Visceral colicky
Antispasmodic Heat or cold Ketorolac

Visceral constant
Corticosteroid Opioid APAP

Anti-arrhythmic Antiepileptic Capsaicin Corticosteroid Intraspinal clonidine, opioid Nerve block Opioid Parenteral ketamine TCA

NSAID

Opioid
Paracetamol Radiotherapy Topical NSAID

Opioid
APAP Radiotherapy

Heat or cold
Immobilisation

Nifedipine
Opioid

Massage NSAID Opioid

Adapted from: Mashford ML, et al. Therapeutic Guidelines: Analgesic. 2002.

Antiepileptic: Carbamazepine Phenytoin Gabapentine

Antidepressent: Amitriptyline Nortriptyline

Anti-arrhythmic mexilitine Capsaicin

Canadian Family Physician June 2010 vol. 56 no. 6

10th Malaysian Hospice Congress

Dr U.Kamariah binti U.Ahmad Pain Specialist and Anaesthesiologist Hospital Sultan Ismail, Johor Bahru , Johor.