CANCER PAIN

A Husni Tanra
Department of Anesthesiology, Intensive Care and Pain Management Faculty of Medicine Hasanuddin University MAKASSAR

A Patients perspective
One of the worst aspect of cancer pain is that it`s a constant reminder of the disease and of death .. My dreams is for a medication that can relieve my pain while leaving me alert and with no side effects
Jeanne Stover, 1992

Definition of Pain (IASP 1979)

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in term of such damage
unpleasant sensory emotional experienced PAIN
has 2 dimensions

Physical dimension

Psycological dimention

Organic Pain

Psychological Pain

Problem of Cancer Pain

Pain is extremely a major problem in cancer patients

Pain is one of the most feared aspect in cancer patients

Unrelieved severe pain may associated with Disturbed sleep Reduced appetite Unrepaired concentration Irritability and depression etc. 69 % of severe cancer pain patient to cause consideration of suicide. (Wisconsin 1985)

Prevalence of Cancer Pain

Bonica 1985 + 50 % of patients of all stage reported pain > 70 % with advanced cancer Faley 1985 15 % of patients with non metastatic cancer had significant pain

60-90 % of patient with advanced cancer reported debilitating pain

25% of all patients with cancer die in pain. WHO 1986 70 % of patient with advanced cancer had pain

3,5 million people suffering from cancer pain with or without satisfacttory treatment every day

The Phenomena of Cancer Pain

COMPLEX and COMPLICATED

is the cumulative among :

ORGANIC PAIN PSYCHOLOGICAL PAIN SUFFERING FROM PAIN

TOTAL PAIN
BIOPSYCHOSOCIOCULTUROSPIRITUAL

WHO 1986
Symptoms of debility
Side-effects of theraphy Non-cancer pathology Cancer

Loss of social position Loss of job prestige and income Loss of role in family Chronic fatigue and insomnia Sense of helpessness Disfigurement

SOMATIC SOURCE (ORGANIC PAIN)

TOTAL PAIN ANXIETY

Bureaucratic bungling Friends who do not visit Delay in diagnosis

DEPRESSION

ANGER

Unavailable doctors
Irritability Therapeutic failure

Fear of hospital or nursing home Worry about family Fear of death Spiritual unrest

Fear of pain Family finances Loss of dignity and bodily control Uncertainty about future

Elisabeth K.Ross (1969) on death and dying. BEHAVIOUR CHANGES IN CANCER PATIENTS
1. DENY

2. ANGER
3. BARGAINING 4. DEPRESSION

5. ACCEPTANCE

Pain In Cancer Patient

Somatic or Visceral Nociception Neuropathic Mechanisms

Psychological Disturbances

Pain

Psychological State and Traits Loss of Work Physical Disability

Suffering

Social/ Familial Functioning

Financial Concerns
Fear Of Death

Mechanism of Cancer Pain

Can be divided into 2 catagories 1. ORGANIC PAIN 2. PSYCHOLOGICAL PAIN ORGANIC PAIN
A. Nociceptive pain 1. Somatic pain (skin, muscle, bone, connective tissue) 2. Visceral pain (thoracic and abdominal viscera) B. Non nociceptive pain 3. Neuropathic pain (deafferentiation pain) damage of peripheral or central n.s.

Nociceptive Pain
Nociceptive pain means, pain with nociception Nociceptive means, activity of afferent neurons induced by a noxious stimulus TRANSDUCTION

TRANSMISSION

MODULATION
PERCEPTION

TRANSDUCTION
Process whereby noxious stimuli are translated into Heat electrical activity at the sensory endings of nerves.
Pressure

Chemical

Transmission

TRANSMISSION
Refers to the propagation
of impulses throughout

the sensory nervous

system.

MODULATION
Process whereby endogenous

Modulation

analgesic systems can modify nociceptive transmission. These endogenous systems (opioid, seretonergic, and noradrenergic) exhibit their inhibitory influence at the dorsal horn.
Plays important role to the

individual perception.

Perception
Final process whereby transduction, transmission, and modulation interact with the uniqueness of the individual to create the final subjective feeling that we call pain.
Pain Perception Brain

Organic pain in cancer patients can be devided into three types:

1. SOMATIC PAIN 2. VISCERAL PAIN 3. NEUROPHATIC PAIN

Characteristic of Somatic Pain

constant aching, gnawing well localized Example : Mechanisms : bone metastasis. tumor of the soft tissue

activation of nociceptors release algesic substances (spesially prostaglandins) Management : Aspirin Acetaminophen NSAID Continous activation of nociceptors may produce sensitization of N.S. (peripherally & centrally)

Characteristic of Visceral Pain

constant deep or dull aching poorly localized usually with nausea and vomit often referred to cuttaneous sites occational colicky or cramp
Mechanisms : Example : Management : activation of nociceptors pancreatic cancer liver/lung metastasis with shoulder pain Opioid (MS confine ) Nerve block (e.g celiac plexus block)

Stimuli Sufficient To Cause Visceral Pain Are:

1. Irritation of mucosal and serosal surfaces 2. Torsion and traction of mesentery

3. Distension or contraction of hollow viscus

4. Impaction of visceral organs

Characteristic of Neuropathic Pain (Deafferentiation Pain)

burning pain paroxysmal shooting or electrical shock-like pain Mechanisms : spontaneus discharges of peripheral or central n.s. loss of central inhibition metastasis brachial or lumbosacral plexopathies post herpetic neuralgia

Example :

Management : antidepressant or anticonvulsant nerve block etc

Classification of Cancer Pain 1. TEMPORAL 2. TOPOGRAPHIC 3. ETIOLOGIC and

4. PATHOPHYSIOLOGIC
1. Pain associated with direct tumor 2. Pain associated with cancer therapy 3. Pain unrelated to cancer

1. Pain associated with direct tumor

Due to invasion of bone
Base of skull Orbital syndrome Parasellar sinus syndrome Sphenoid sinus syndrome Clivus syndrome Jugular foramen syndrome Occipital condyle syndrome Vertebral body Atlantoaxial syndrome C7-T1 syndrome L1 syndrome Sacral syndrome Generalized bone pain Multiple metastase

1. Pain associated with direct tumor

Due to invasion of nerves Peripheral nerve syndrome Paraspinal mass Chest wall mass Retroperitoneal mass Painful polynueropathy Brachial, lumbal, sacral plexopathies Leptomeningeal metastase Epidural spinal cord compression Due to invasion of visceral

Due to invasion of blood vessels

Due to invasion of mucous membranes

2. Pain associated with cancer therapy

Surgery Postthoracotomy syndrome Postmastectomy syndrome Postradical neck dissection syndrome Postamputation syndromes Chemotherapy Painful polyneuropathy Aseptic necrosis of bone Steroid pseudorheumatism Mucositis

Radiation Radiation fibrosis of brachial or lumbosacral plexus Radiation myelophaty Radiation-induced peripheral nerve tumors Mucositis Radiation necrosis of bone

3.Pain indirectly related or unrelated to cancer Myofascial pains Osteoporosis Postherpetic neuralgia Debiliting (decubitus ulcer) Etc

ABCDE Mnemonic for Pain Assessment and Management Ask about pain regularly Believe the patient reports of pain Choose pain control appropriately Deliver in a timely, logical and coordinated

Empower patients and family

Three Step Ladder WHO, 1986

5 essential concepts By mouth By the clock By the ladder For individual With attention to detail

By this modality 90% of cancer pain can be relieved

Pharmacologic Management of Cancer Pain

Individualize cancer pain management to the

patient Use the simplest dosage schedules and the least invasive means An NSAIDs or acetaminophen should be used in the pharmacologic management of mild to modertae peripheral cancer pain, unless there is a contraindication

Step I for MILD PAIN

Use paracetamol, aspirin or NSAID
NSAIDs may delay the need for escalating opioid. About 20% of patients were still taking NSAIDs in the last week of life. NSAIDs have a potential opioid-sparing effect. Caution is needed when using NSAIDs for prolonged periods Risk factors such as aging, renal or GI diseases should be considered. It has ceiling effect.

Step Il for MODERATE PAIN

Combine Paracetamol/Aspirin/ NSAIDs + Codein Formula
Acetaminophen/ Aspirin 500 mg Codein 10 mg Dulcolax tab mf pulv dtd XXX 6 dd I cap + adjuvant 06.00 18.00 10.00 22.00 14.00 02.00 pm

Constipation is the most common side effect of

codein

Step lll for SEVERE PAIN

Oral morphine is the mainstay of severe cancer pain. Strong pain needs strong analgesic. It is a very safe drugs as long as given properly Morphine immediate release is not available in Makassar. MS contin is one of choice
Sustained release Long acting (twice a day) Strong opioid

WHO Analgesic Ladder

STEP 3 Strong opioid + nonopioid + adjuvant

STEP 1 Nonopioid
appropriate

STEP 2 Weak opioid + nonopioid

Consider other treatment modalities when possible and

Radiotherapy, hormonal therapy, palliative chemotherapy, surgery

Consider nonpharmacologic modalities

Physiotherapy, psychotherapy, TENS, Accupucture, etc.

Address all aspects of suffering

Physical, psychosocial, cultural, and/or spiritual

Adjuvant Drugs
Corticosteroids : Dexamethasone, Prednison Anticonvulsant : Carbamazepine, Gabapentin, etc Antidepressant : Amytriptiline, Doxepine Neuroleptics : Methotrimeprazine Antihistamines : Hydroxyzine Local anesthetic/antiarrhytmics : Lidocaine Psycho-stimulans : Dextroamphetamine Laxatives : Bisacodyl, Lactulose, etc Antiemetics : Droperidol, Metoclopropamide, etc

Ours Formula in RSWS

Moderate pain Acetaminophen/ Aspirin mg Codein Dulcolax

Severe pain MST 500 5 - 10 mg 2 dd I tab Celebrex 100200 mg 2 dd I cap

20 mg tab

mf pulv dtd XXX 6 dd I cap + adjuvant

06.00 10.00 14.00 18.00 22.00 02.00 prn

+ adjuvant
06.00 18.00

If we could notable to cure the cancer patients, never deny cancer pain, and let them die free of pain and with IMAN As a doctor, one should keep in mind :

To cure is sometime To treat is often, but To comfort is always

CONCLUSION
1. Pain is a common problem and a major symptom of cancer patients.

2. Pain is one of the most feared aspect and can cause to suicide
3. Cancer pain can be organic or psychological pain

4. Organic pain may be somatic, visceral or neuropathic pain or combined.

5. Total pain is a BIOPSYCHOSOCIOCULTUROSPIRITUAL problem. 6. CANCER PAIN management should be treated integrated and comprehensive by multidisipline doctors.