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Nyeri Kanker

MANAJEMEN NYERI / PPKC

Nyeri Kanker
Nyeri merupakan :
utama pasien-pasien kanker :
selama terapi, dan juga pada
penyakit lanjut & terminal
Simptom untuk melalukan evaluasi terapi
Konsekuensi tersering yang sangat ditakutkan
pasien

Simptom

MANAJEMEN NYERI / PPKC

Bukti tentang nyeri kanker


Nyeri terjadi pada 30% pasien dari berbagai
tingkatan stadium.
stadium.
Nyeri bertambah seiring dengan progres penyakit
90%
90% pasien kanker stadium lanjut mengalami nyeri
hebat
Lebih dari 50% pasien kanker masalah nyeri tidak
tertangani dengan baik
MANAJEMEN NYERI / PPKC

Hambatan Penanganan Nyeri Yang Efektif


Petugas Medis Profesional
Tidak terlatih masalah manajemen nyeri
Ilmu yang kurang up to date
Takut dalam meresepkan obatobat-obat narkotik
Takut akan terjadi adiksi
Takut akan terjadi toleransi analgetik
Takut akan terjadi efek samping
Sifat subjektif nyeri
MANAJEMEN NYERI / PPKC

Gejala kanker stadium lanjut


Bruera.. Why Do We Care? Conference 1992; Memorial SloanBruera
Sloan-Kettering
Asthenia
Anorexia
Pain
Nausea
Constipation
Sedation/Confusion
Dyspnea

% Patients (n=275)
0

10

20

30

40

MANAJEMEN NYERI / PPKC

50

60

70

80

90

Prevalensi Nyeri Kanker


Portenoy.. Cancer 1989;63:2298.
Portenoy
All
All: Advanced
Bone
Pancreas
Stomach
Uterus/Cervix
Lung
Breast
Prostate
Colon
Lymphoma

% Patients

Leukemia
0

10

20

30

MANAJEMEN NYERI / PPKC

40

50

60

70

80

90

Keseluruhan

Mortalitas

Nyeri kanker

203,000-365,400 kasus kanker


baru setiap tahun

Penyebab kematian
terbanyak di dunia

nomor

Nyeri merupakan keluhan utama 89%


pasien-pasien pada unit Paliatif di Dr.
Soetomo Hospital
MANAJEMEN NYERI / PPKC

Nyeri yang tidak tertangani


Penanganan nyeri tidak optimal berhubungan:
Gangguan tidur
Tidak nafsu makan
Konsentrasi menurun
Cemas dan depresi
69% pasien kanker stadium lajut cenderung
melakukan bunuh diri
(Wisconsin 1985)

MANAJEMEN NYERI / PPKC

Definisi Nyeri (IASP 1979):


Pengalaman sensorik dan emosional yang
tidak menyenangkan akibat kerusakan
jaringan yang nyata atau potensial terjadi
atau digambarkan seperti terjadinya
kerusakan
tidak menyenangkan
(sensorik)
emotional expienced
Dimensi
Fisik

Nyeri Organik

Nyeri

Dimensi
Psikologis

Afek Motivasi
Evaluasi Kognitif
MANAJEMEN NYERI / PPKC
The meaning of pain

CANCER PAIN IS TOTAL PAIN


Nyeri kanker sangat COMPLEX and
COMPLICATED dan kumulasi antara :
Nyeri organik
Nyeri psikologis
socioeconomic, cultural and spiritual

TOTAL PAIN
BIOPSYCHOSOCIOCULTUROSPIRITUAL
MANAJEMEN NYERI / PPKC

WHO 1986
Symptoms of debility

Non-cancer pathology

Side-effects of therapy

Cancer

Loss of social position

SOMATIC SOURCE

Loss of job prestige and income


Loss of role in family

Friends who do not visit

TOTAL
DEPRESSION

Chronic fatigue and insomnia


Sense of helplessness

PAIN

ANGER

Delay in diagnosis
Unavailable doctors
Irritability

ANXIETY

Disfigurement

Bureaucratic bungling

Therapeutic failure

Fear of hospital or nursing home

Fear of pain

Worry about family

Family finances

Fear of death

Loss of dignity and bodily control

Spiritual unrest

MANAJEMEN NYERI / PPKC

Uncertainty about future

A cancer is not only a


physical disease, it is a
state of mind.
M. Baden, New York Times, 1979

MANAJEMEN NYERI / PPKC

Nyeri Kanker
Dapat dibagi 2 kategori :
1. Nyeri organik
2. Nyeri psikologis
Nyeri organik
A. Nyeri Nociceptif :
Nyeri somatik
(kulit, otot, jaringan ikat)
Nyeri visceral
(organ dalam torak dan abdomen)
B. Nyeri non nociceptif:
Nyeri neuropatik(nyeri deaferensiasi) /
kerusakan saraf perifer atau saraf pusat
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NYERI NOSISEPTIF
NOSISEPTIF
dapat di bagi :

NYERI SOMATIK
NYERI VISCERAL

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1. NYERI SOMATIK
konstan
tajam, perih
lokasi dapat ditunjuk
Mekanisme:
aktivasi nosiseptor
pelepasan mediator nyeri ( terutama PG)
Contoh:
metastasis tulang
tumor jaringan lunak
Penanganan:
Aspirin
Acetaminophen
NSAID (COX1 or COX2 inhibitor)
MANAJEMEN NYERI / PPKC

Nyeri Nocicepti
Nociceptiff
Nyeri Somatik

MANAJEMEN NYERI / PPKC

2. NYERI VISCERAL
konstan
nyeri dalam atau tumpul
lokasi sulit di tunjuk
diikuti mual dan muntah
kadang nyeri di alihkan ke kulit
kolik & kram
Mekanisme:
Aktivasi nosiseptor
Contoh:
kanker pankreas
metastasis kanker hati/paru ke tulang bahu
Manajemen:
Opioid (MS contin)
Blok saraf (e.g celiac plexus block)
MANAJEMEN NYERI / PPKC

Nyeri Nociceptif
Nyeri Visceral

MANAJEMEN NYERI / PPKC

Penyebab stimulus nyeri visceral :


1.
2.
3.
4.

Iritasi
Iritasi permukaan mukosa dan serosa
organ viscera
Torsi dan tertarikya mesenterium
organ viscera
Distensi atau kontraksi rongga usus
usus..
Tertekannya organ viscera

MANAJEMEN NYERI / PPKC

B. Nyeri non nosiseptif


Nyeri neuropatik (nyeri deaferensiasi)
nyeri luka bakar
nyeri tersetrum & nyeri tertembak
(panas)
Mekanisme:
kerusakan langsung sistem saraf perifer & saraf
sentral
hilangnya hambatan sentral
Contoh:
metastasis brachial or lumbosacral plexopathies
post herpetic neuralgia (PHN)
Penanganan:
obat antidepressant or anticonvulsant
Blok saraf
etc
MANAJEMEN NYERI / PPKC

Nyeri Neuropatik
Neuropatik
Kerusakan jalur saraf
Respon tidak normal pada stimulus
yang normal
Akibat kerusakan saraf perifer & sentral

MANAJEMEN NYERI / PPKC

Allodynia: Nerve Injury Leads to Central


Reorganization in the Spinal Dorsal Horn
Normal terminations of primary afferents in the dorsal horn

After Nerve Injury

MANAJEMEN NYERI / PPKC

Klasifikasi nyeri kanker


TEMPORAL
2. TOPOGRAP
TOPOGRAPII
3. ETIOLOGI
4. PAT
PATOFI
OFISIOLOGI
SIOLOGI
Nyeri yang berhubungan dengan
tumor langsung
Nyeri yang berhubungan dengan
terapi kanker
Nyeri yang tidak berhubungan
dengan kanker
1.

1.

2.

3.

MANAJEMEN NYERI / PPKC

Various Schemes for Classifying Cancer Pain


Etiologic classification:

- Primarily caused by cancer


- Treatment of malignancy
- Debility
- Concurrent pathology

Pathophysiologic classification:

- Nociceptive (somatic, visceral)


- Neuropathic
- Mixed pathophysiology
- Psychogenic

Location of cancer pain syndromes:

- Head and neck pain


- Chest wall syndromes
- Vertebral and radicular pain
- Abdominal or pelvic pain
- Extremity pain (e.g., brachial plexopathy
or bony spread)

Temporal classification:

- Acute
- Breakthrough
- Chronic

Severity-based classification:

- Mild
- Moderate
- Severe
MANAJEMEN NYERI / PPKC

Clinical Characteristics of the Pathophysiologic


Classes of Cancer Pain
Nociceptive Pain

Somatic Pain:

- Character of somatic pain is aching, stabbing,


and throbbing
- Pain is usually well localized

Visceral Pain:

- Character of pain usually gnawing or cramping


when due to obstruction of hollow viscus
- Pain typically described as aching, sharp, throbbing
when due to tumor involvement of organ capsule
- Usually diffuse and difficult to localize
- Visceral pain
may be referred to somatic
MANAJEMEN NYERI / PPKC
structures

Clinical Characteristics of the Pathophysiologic


Classes of Cancer Pain
Neuropathic Pain

Nerve Compression:

- Character of pain often described as burning, pricking, electric-like


- Pain usually located in the area innervated by the compressed
peripheral nerve, plexus or nerve root
- Radiographic imaging may show the malignancy compressing the
neuronal structure

Deafferentation
Nerve Injury:

- Character of pain similar to that of nerve compression may also be


shooting or stabbing in nature
- Dysesthesia or allodynia may be present
- Often associated with loss of afferent sensory function in the
painful region
- Superficial burning pain with allodynia, may also have deep
aching component

Sympathetically
Mediated:

- Associated symptoms include cutaneous vasodilation, increased


skin temperature, abnormal pattern of sweating, trophic changes
and allodynia
- Hallmark is nondermatomal pattern of pain
- Confirmed withMANAJEMEN
diagnostic
block
NYERIsympathetic
/ PPKC

MANAJEMEN NYERI / PPKC

Penyebab nyeri kanker


1. Nyeri yang berhubungan dengan kanker
langsung ::
Invasi ke tulang
Invasi ke saraf
Invasi ke organ visceral
Invasi ke pembuluh darah
Invasi ke membran mukosa

MANAJEMEN NYERI / PPKC

Penyebab nyeri kanker


Tumor itu sendiri

MANAJEMEN NYERI / PPKC

2. Nyeri yang berhubungan dengan


terapi kanker
Sindrom Pasca torakotomi
Sindrom Pasca masektomi
Sindrom Pasca Radical neck disection (RND)
Sindrom Pasca amputasi

Kemoterapi:
Polineuropati
Nekrosis tulang
Pseudorhematoid steroid
Mucositis

Radiasi:
Fibrosis akibat radiasi pleksus brachial dan pleksus
lumbosacral
Mielopati akibat radiasi
Radiasi yang mencetuskan tumor saraf perifer
Mucositis
MANAJEMEN NYERI / PPKC
Nekrosis tulang akibat radiasi

Penyebab Nyeri Kanker


Dari Kemoterapi

MANAJEMEN NYERI / PPKC

Penyebab Nyeri Kanker


Berhubungan dg terapi

COBALT RADIATION BURN


MANAJEMEN NYERI / PPKC

3.Nyeri yang tidak berhubungan


dengan kanker
Nyeri miofasial
Osteoporosis
Postherpetic neuralgia
Debiliting (ulcus decubitus)
Etc

MANAJEMEN NYERI / PPKC

Penyebab nyeri kanker


faktor--faktor lain
faktor

Acute Herpes ZosterMANAJEMEN NYERI / PPKC

Penyebab nyeri kanker


Faktor-faktor lain
FaktorStatus Immunocompromised

MANAJEMEN NYERI / PPKC

MANAJEMEN PASIEN DENGAN


MANAJEMEN
NYERI KANKER
PALLIATIVE CARE
CARE (memperbaiki
kualitas hidup )
Palliative care dalam bentuk :
Pembedahan
Radiasi
Rad
iasi
Kemoterapi
Manajemen Nyeri
MANAJEMEN NYERI / PPKC

PALLIATIVE CARE
World Health Organization Definition:
Palliative care is an approach that improves the
quality of life of patients and their families facing the
problem

associated

with

life-threatening

illness,

through the prevention and relief of suffering by means


of early identification and impeccable assessment and
treatment of pain and other problems, physical,
psychosocial and spiritual.
MANAJEMEN NYERI / PPKC

PRINSIP DASAR
Analgetik
Analge
tik diberikan regularly
Ada akses untuk obat analgetik
Eskalasi potensi analgesic
analgesic sesuai dengan

analgesic ladder
Obat yang sesuai untuk breakthrough pain
Obat untuk mengatasi efek samping
Monitoring pasien secara berkala
MANAJEMEN NYERI / PPKC

Opioids
Infrequent dosing
Toxicity

Effect

Analgesia

Pain

Time
MANAJEMEN NYERI / PPKC

Opioids
Adequate dosing
Toxicity

Analgesia

Pain

Time
MANAJEMEN NYERI / PPKC

Analgesia Monitoring Guidelines


Baseline assessment:
- Obtain RR, HR, BP, O2 saturation, sedation score, and pain score before administering a single or
intermittent dose or initiating continuous infusion.

Intermittent intravenous administration:


- RR, HR, BP, and sedation score every 5 min X 4, then every 30 min X 2, and then as per patients
condition/preexisting orders
- Pain score every 20-30 min
- Continuously monitor O2 saturation only for children whose underlying condition predisposes
them to respiratory depression.

Intravenous additive (to run over 15-20 min):


- RR, HR, BP, and sedation score every 10 min X 2, then every 30 min X 2, and then as per
patients condition
- Pain score at completion of the flush, then every 30 min X 2, and then as per patients
condition/preexisting orders
- Continuously monitor O2 saturation only for children whose underlying condition predisposes
MANAJEMEN NYERI / PPKC
them to respiratory depression.

Analgesia Monitoring Guidelines


Continuous IV infusion/PCA:
- RR, HR, BP, pain score, and sedation score every 1 h X 4, then RR and sedation score every 1 h,
and then HR, BP, and pain score every 4 h
- Continuously monitor O2 saturation and document reading every 1 h

Intermittent epidural administration:


- RR, HR, and BP every 5 min for the first 20 min following a bolus dose,and then RR and sedation
score every 1 h
- HR, BP, pain score, and motor block score every 4 h
- Continuously monitor only for children whose underlying condition predisposes them to
respiratory depression

Continuous epidural infusion:


- RR, HR, BP, sedation score, pain score, and motor block score every 1 h X 4 h, then RR and
sedation score every 1 h, and HR, BP, pain score, and motor block score every 4 h.
- Continuously monitor O2 saturation and document reading every 1 h
MANAJEMEN NYERI / PPKC

CANCER PAIN ASSESMENT


Many ways to asses the level of pain
Most popular is VAS (Visual Analog Scale)
from 0 to 10
0

10

0 = No pain, 10 = Very severe pain


1-3 : Mild Pain
4-6 : Moderate pain
7-10 : Severe pain
MANAJEMEN NYERI / PPKC

Assessment of Pain Intensity


Visual Analog Scale

Verbal Pain Intensity Scale


No
pain

Mild Moderate Severe Very


Worst
pain
pain
pain severe possible
pain
pain

Worst
possible
pain

No
pain

010 Numeric Pain Intensity Scale

0
No
pain

2
Mild
pain

Moderate
pain

Faces Scale

10

Worst
possible pain

MANAJEMEN NYERI / PPKC

WHO Analgesic Ladder

MANAJEMEN NYERI / PPKC

MANAJEMEN NYERI / PPKC

How to apply
THREE STEP LADDER ANALGESIC
As much as possible, depend on patients
condition, drugs should be given by
by::
the patients him/herself
the mouth/oral
the clock (06, 10, 14, 18, 22, 02)
the ladder
Started with step one, two than three
MANAJEMEN NYERI / PPKC

April 19-21, 2008

WHO 33-Step Analgesic Ladder


3.Severe
Morphine*

2.Moderate
Codeine*

1.Mild

Hydrocodone
Oxycodone

ASA*
Acetaminophen*

NSAIDs*
Adjuvants*

Dihydrocodeine
Tramadol*
Adjuvants*
MANAJEMEN NYERI / PPKC

Hydromorphone
Methadone
Levorphanol
Fentanyl*
Oxycodone
Adjuvants*

Level I Analgesics
Paracetamol::
Paracetamol
Simplest and safest analgesic
Mechanism of action not fully elucidated
Central effect
(chemotherapy
(chemotherapy--induced) neuropathy

Non-steroidal antiNonanti-inflammatory
drugs:
Very diverse group
Main mechanism of action:
Reduction PG synthesis
Malignant bone pain
Ceiling analgesic effect
Opioid dosedose-sparing MANAJEMEN
effectNYERI / PPKC
No reduction in side effects

Level II Analgesics
Codeine:
10

Weak analgesic

K i (M )

Combination with paracetamol


0,1

Tramadol:

0,01

Weak opioid activity


Noradrenaline + Serotonin uptake

0,001

ol

ad

in

am
Tr

e
in

Verbale Beoordelingsschaal

Ti
l id

Co
de

Pr
op

ir a

e
in

yfe

Pe

ox

De
xt

ro
p

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th
id

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ne

0,0001

Tilidine::
Tilidine
Weak opioidopioid-like activity

Buprenorphine:

morfine 4,3 g/kg IT

buprenorfine 1,3 g/kg IV

No ceiling effect for analgesia


Ceiling effects for sideside-effects
No restriction for future opioid use
MANAJEMEN
NYERI / PPKC
Additive
effect when cocomorfine 4,3 g/kg IT +
administered
buprenorfine 1,3 g/kg IV

Level III Analgesics


Morphine:
Still standard of care

Hydromorphone:
5x potent as morphine

Fentanyl:

Hydromorphone

Morphine

Oxycodone

Fentanyl

High potency (100x)


High lipid solubility

Oxycodone:
-opioid receptor

Methadon:
Racemic mix
NMDA-antagonist
NMDA-receptor agonist

MANAJEMEN NYERI / PPKC


HalfHalf-life: up to 190 hours

Steady state: 6 - 12 hours of analgesia

Nonopioid Drugs of Cancer Pain Relief


Drug

Dosage

Comments

Acetaminophen

10-15 mg/kg PO, every 4-6 h


Dose limit of 65 mg/kg/day or
4 g/day, whichever is less

Lacks gastrointestinal and hematologic


side effects; lacks anti-inflammatory
effects (may mask infection associated
fever).

Ibuprofen

5-10 mg/kg PO, every 6-8 h


Dose limit of 40 mg/kg/day;
max dose of 2400 mg/day

Anti-inflammatory activity. Use with


caution in patients with hepatic or renal
impairment, compromised cardiac
function or hypertension (may cause fluid
retention, edema), history of GI bleeding
or ulcers, may inhibit platelet
aggregation.

Naproxen

10-20 mg/kg/day PO, divided


every 12 h
Dose limit of 1 g/day

Anti-inflammatory activity. Use with


caution and monitor closely in patients
with impaired renal function. Avoid in
patients with severe renal impairment.

Diclofenac

1 mg/kg PO, every 8-12 h


Dose limit of 50 mg/dose

Anti-inflammatory activity. Similar GI


renal and hepatic precautions as noted
above for ibuprofen and
Naproxen.

MANAJEMEN
NYERI / PPKC
Note: Increasing the dose of nonopioids beyond the
recommended
therapeutic level produces a ceiling effect
(i.e., there is no additional analgesia but there are major increases in toxicity and side effects).

Common Adjuvant Analgesics


Drugs

Symptom control

Tricyclic antidepressants
Antiepileptics
Ketamine

Neuropathic pain

Corticosteroids

Reduce pain associated


with tumour oedema

Benzodiazepines
Baclofen
Buscopan

Muscle spasm

Bisphosphonates

Bone pain

MANAJEMEN NYERI / PPKC

Adjuvant Analgesic Drugs


Drug Category
Antidepressants

Drug, Dosage

Indications

Amitriptyline:
- Initial dose 0.2-0.5 mg/kg PO
- Titrate upward by 0.25 mg/kg
every 2-3 days
- Maintenance: 0.2-3 mg/kg
Alternatives: nortriptyline,
doxepin, or imipramine

Anticonvulsants

Gabapentin:
- Initial dose 5 mg/kg/day PO
- Titrate upward over 3-7 days
- Maintenance: 15-50 mg/kg/day
PO divided TID

Neuropathic pain (i.e.,


vincristine-induced,
radiation plexopathy,
tumor invasion,
CRPS-1), insomnia

Monitor for hematologic,


hepatic, and allergic
reactions. Side effects
include gastrointestinal
upset, ataxia, dizziness,
disorientation, and
somnolence

- Initial dose 10 mg/kg/day PO


divided OD or BID
- Maintenance: up to 20-30 mg/
kg/day PO divided every 8 h.
Increase dose gradually over 24 weeks
Alternatives: clonazepam

Hydroxyzine: 0.5 mg/kg PO


every 6 h

Diphenhydramine: 0.5-1 mg/


kg PO/IV every 6 h

Usually improved sleep and


pain relief within 35 days.
Anticholinergic side effects
are dose-limiting. Use with
caution for children with
increased risk for cardiac
dysfunction.

Neuropathic pain,
especially shooting,
stabbing pain.

Carbamazepine:

Antihistamines

Comments

Opioid-induced
pruritus, anxiety,
nausea

MANAJEMEN NYERI / PPKC

Sedative side effects may be


helpful

Adjuvant Analgesic Drugs


Drug Category

Drug, Dosage

Sedatives,
hypnotics,
anxiolytics

- Diazepam: 0.025-0.2 mg/kg


PO every 6 h
- Lorazepam: 0.05 mg/kg/dose
SL
- Midazolam: 0.5 mg/kg/dose
PO administered 15-30 min
prior to procedure; 0.05 mg/
kg/dose IV for sedation

Acute anxiety, muscle


spasm; premedication
for painful procedures

Sedative effect may limit


opioid use. Other side effects
include depression and
dependence with prolonged
use

Prednisone, prednisolone,
and dexamethasone dosage

Headache from
increased intracranial
pressure, spinal, or
nerve compression;
widespread metastases

Side effects include edema,


dyspeptic symptoms, and
occasional gastrointestinal
bleeding

Opioid-induced
somnolence
Potentiation of opioid
analgesia

Side effects include agitation,


sleep disturbance, and
anorexia.
Administer second dose in
the afternoon to avoid sleep
disturbances

Corticosteroids

Indications

depend son clinical situation.

Dexamethasone:
- Initial dose: 0.2 mg/kg IV.
- Dose limit 10 mg.
- Subsequent dose: 0.3 mg/kg/
day IV divided every 6 h
Psychostimulants

Dextroamphetamine,Methyl
phenidate: 0.1-0.2 mg/kg BID.
Escalate to 0.3-0.5 mg/kg as
needed

MANAJEMEN NYERI / PPKC

Comments

Starting Doses of Opioid Analgesics for Cancer Pain Relief


Drug

Equianalgesic
dosage
(parenteral)

Starting dosage IV

IV:PO
ratio

Starting dosage
PO/Transdermal

Duration of
Action

Morphine

10 mg

- Bolus dose = 0.05-0.1


mg/kg every 2-4 h
- Continuous infusion
= 0.01-0.04 mg/kg/h

1:3

0.15-0.3 mg/kg/dose every


4h

3-4 h

Hydromorphone

1.5 mg

0.015-0.02 mg/kg every


4h

1:5

0.06 mg/kg every 3-4 h

2-4 h

Codeine

120 mg

Not recommended

1 mg/kg every 4 h (dose


limit
1.5 mg/kg/dose)

3-4 h

Oxycodone

5-10 mg

Not recommended

0.1-0.2 mg/kg every 3-4 h

3-4 h

Meperidine

75 mg

0.5-1 mg/kg every 3-4 h

1-2 mg/kg every 3-4 h


(dose
limit 150 mg)

1-3 h

Fentanyl

100 g

1-2 g/kg/h as
continuous infusion

Methadone

10 mg

0.1 mg/kg every 4-8 h

1:4

MANAJEMEN NYERI / PPKC

1:2

25 g patch

0.2 mg/kg every 4-8 h

72 h (patch)

12-50 h

Starting Doses of Opioid Analgesics for Cancer Pain Relief


Drug

Equianalgesic
dosage
(parenteral)

Starting dosage IV

IV:PO
ratio

Controlledrelease
morphine

0.6 mg/kg every 8 h


or 0.9 mg/kg every 12 h

Controlledrelease
hydromorpho
ne

0.18 mg/kg every 12 h

Controlledrelease
codeine

3 mg/kg every 12 h

Controlledrelease
oxycodone

0.30.6 mg/kg every 12 h

MANAJEMEN NYERI / PPKC

Starting dosage
PO/Transdermal

Duration of
Action

STRONG OPIOIDS
Most commonly use:
Morphine*
Hydromorphone
Transdermal fentanyl (Duragesic
(Duragesic)*
)*
Oxycodone
Methadone
DO NOT use Meperidine (Demerol) longlong-term
active metabolite normeperidine seizures
MANAJEMEN NYERI / PPKC

Long Acting Opioids


Drug
Morphine

Brand

Dosing Interval

MS Contin

8-12 hrs

Oramorph-SR

8-12 hrs

Kadian

12-24 hrs

Avinza

24 hrs

Oxycodone

OxyContin

8-12 hrs

Oxymorphone

Opana ER

12 hrs

Fentanyl

Duragesic

48-72 hrs

Methadone

6-12 hrs
MANAJEMEN NYERI / PPKC

Opioid Resistance
limiting side effects
Small group of patients
Pathophysiology of true
resistance ?
Downregulation of number -receptors:
Peripheral nerve damage
Long--term use of opioids
Long

Cholecystokinin (CCK):
Control of opioid sensitivity
Cancer syndromes

DeDe-activation of opioid
opioid--receptors:
GURK--receptor activation
GURK
Inhibition of -receptor
MANAJEMEN NYERI / PPKC

OpioidOpioid-Induced Hyperalgesia (OIH)

Opioid Dose Conversions


Use equianalgesic charts as a guideline,
always titrate to response
Incomplete cross tolerance among
opioids, recommend reducing calculated
equivalent by 3030-50%
Dose reductions not necessary when
switching routes of the same drug
Close observation in the first few days
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Equianalgesic Conversion Chart


Drug

Equianalgesic ORAL

Equianalgesic IV

Codeine

200 mg

130 mg

Hydrocodone

30 mg

---

Morphine

30 mg

10 mg

Hydromorphone

7.5 mg

1.5 mg

Oxycodone

20 mg

---

(patch ~ morphine)

0.1 mg (100 mcg)

Meperidine

300 mg

75 mg

Methadone

10 mg ACUTE

5 mg ACUTE

Fentanyl

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Opioid--Induced Neurotoxicity
Opioid
(OIN)
Neuropsychiatric syndrome
Cognitive dysfunction
Delirium
Hallucinations
Myoclonus/seizures
Hyperalgesia//allodynia
Hyperalgesia
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OIN: Treatment
Opioid rotation
Reduce opioid dose
Hydration
Circadian modulation
Psychostimulants
Other Rx
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Opioid Rotation
Metabolites cause OIN
Change to another opioid analgesic
25 - 50% dose reduction
Morphine/hydromorphone
Morphine/
hydromorphone/oxycodone
/oxycodone
Second line agents:
- fentanyl/
fentanyl/sufentanil
sufentanil
- methadone
MANAJEMEN NYERI / PPKC

Cancer Pain
Breakthrough Pain:
Incidental pain
Severe transitory increase in pain on
baseline of moderate intensity or less
Caused by movement, positioning,
cough, wound dressing, etc
Often associated with bony metastases
Portenoy
R. Sem Onc, 1997;24:S16-7-S16-12
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Components of ModerateModerate-to
to-Severe Chronic Cancer Pain
Around-the-Clock
Medication

Breakthrough
Pain

MANAJEMEN NYERI / PPKC

Breakthrough Pain
Ideal Agent:
Agent:
Potent, pure opioid agonist
Potent,
Rapid onset
Early peak effect
Short duration
Easily administered
Sublingual/Transmucosa
Sublingual/
Transmucosa routes
advantageous
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Breakthrough Pain
Medication type
Fentanyl
Fentanyl
Fentanyl
Fentanyl

Sublingual Dose
12.5 g
25.0 g
50.0 g
100.0 g

Each step repeated 1 - 2 x q 15 min


MANAJEMEN NYERI / PPKC

What anesthesiologist can do


for cancer pain patients:
1. Neurolytic block:
- Alcohol 100%
- Phenol glycerin 15%
- RFG
2. Epidural / Spinal opioid
3. Ganglion block
4. Neural blockade
5. Etc
MANAJEMEN NYERI / PPKC

SUMMARY:
1. Pain is common problem and a major symptom of
cancer patient.
2. Pain is one at most feared aspect and can cause
to suicide.
3. Cancer pain can be organic or psychological pain.
4. Organic pain may be somatic,
neuropathic pain or combined.

visceral

or

5. Total pain is a BIOPSYCHOSOCIOCULTUROSPIRITUAL problem.


6. Basic principle of cancer pain treatment is
following WHO guidelines (three step ladder
analgesic).
7. CANCER PAIN management should be treated
integrated and comprehensive
include spiritual
MANAJEMEN NYERI / PPKC
approach.

NSAID--Opioid Commercial Drug Combinations


NSAID
Combination

Trade Name

Strength mg

Dose by pill

Aspirin +
caffeine +
dihydrocodeine

Synalgos

356.4+30+16

1-2 q4 hr

Moderate to
moderate
severe pain

Good for postoperative


and breakthrough
pain. Also, headaches
and migraine attacks

Aspirin +
carisoprodol +
codeine

Soma
Compound
w/codeine

325+200+16

1-2 TID-QID
(6)

Painful muscle
spasm

Good for postoperative


and breakthrough
pain, especially pain
associated w/spasm

Aspirin +
codeine

Empirin w/
codeine #3
Empirin w/
codeine #4

325+30

1-2 q4 hr

Good for postoperative


and breakthrough pain

325+60

1 q4 hr

Mild to
moderate
pain

LortabASA

500+5

1 q4 hr

Moderate
severe
acute pain

Good for postoperative


and breakthrough pain.
No longer available in the
United States

Aspirin +
hydrocodone

Indication

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Comments

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