Management of Pain in

Cancer Patient

Dr Murali Bhavaraju
Lecturer
Dept of Radiotherapy &
Oncology
HUSM
Introduction
 Definitionof Pain
 Types of Pain
 Causes of Pain
 Treatment Options
 Summary
Definition of Pain
Pain is an Unpleasant sensory and
emotional experience associated with
actual or potential tissue damage or
described in terms of such damage
( International Association Study )
Pain Perception
 Modulated By:-
Patient Mood
Patient Morale
Meaning of pain to the
patient
Approach of Pain
Management
 Multi dimensional:-

Physical
Psychological
Social
Spiritual aspect
Types of Pain
Depending on nature of pain

 Somatic Pain
 Visceral Pain
 Neuropatheic
Somatic Pain
 Originatefrom Skin/Deep tissue
 Character Dull or aching well localized
pain
 Sites Metastatic Bone Pain
Post Surgical Incisional Pain
Myofascial/Musculoskeletal
Pain
Visceral Pain
 Originates Thorax
Abdomen
Pelvic viscera
 Causes Infiltration
Compression
Extension
Stretching
( cont….)
 ( cont…)

 Characterof pain
Poorly localized
Squeezing/ Pressure like
Referred pain
Neuropatheic Pain

 OriginatesInjury to peripheral nerves

or CNS by tumor infiltration or
compression
Types of Pain

 Acute pain
 Chronic pain
Acute Pain

 Well defined temporal pattern with subjective

& objective signs & symptoms
 Hyperactivity of autonomic nervous system
 Self limiting
 Responds to analgesics Precipitating cause
Chronic Pain
 Persistent pain > 3 months
 Lacks objective signs
 Leeds to significant changes
Personality
Life style
Functional ability
 Management of Pain

 Medicines
 Radiotherapy
 Surgery
 Chemotherapy
 Anesthetics
 Hospice
Goals of Pain Management

 Freedom from pain during sleep

 Freedom from pain during rest
 Freedom from pain during movement
 Medicines

Y Primary - Analgesics
- Opioid Analgesics

Y Secondary - Steroids
- Tricyclic antidepressants
- Anxiolytics
- Antiemitics
 Mode of Administration

 Oral
 Subcutaneous
 Intravenous
 Trans dermal
 Per Rectal
 Sub Lingual
WHO 3 steps Analgesic
ladder
Opioid+Adj. Drugs
III

NSAID+ opioid
Severe pain with
Fear of step III
II
NSAID+Adjuvant Moderate pain or
Drugs No relief with step I
I
Mild to moderate
pain
Non Opioid Analgesics

 Analgesia
 Anti Inflammatory
 Anti Platelets
Commonly used Analgesics
Side Effects
 GI Toxicity Gastric Erosion
Peptic Ulcer
Hemorrhage
 Respiratory Bronchial Asthma
 ENT Tinitus & Deafness
 Salt & Water Retention
 Potentiation of Hypoglycemic agents
 Can cause Renal Toxicity
Week Opioid
 Aseffective as small doses of Morphine
 Easier to obtain & supply

 Codeine Prodrug of morphine

1/10th potent as morphine
10% of population can’t
convert to morphine
Tramadol
 Alternative to opioid of step 2 & lower
step 3 of WHO scale
 Dual mode of action (Analgesic + Pre
synaptic reuptake blocker of MAOI)
 Best suitable is Oral Route
 IV Initial Bolus– CVI
Strong Opioids
 Morphine
 Phenazocine
 Methadone
 Oxycodone
 Hydromorphine
 Fentanyl
 Buprinorphine
 Morphine
 Main Indication Pain
Dyspnoea
 Subsidiary Cough
Diarrhea
 Therapeutic Categories
Responsive
Semi responsive
Resistant
Converting the morphine dose
 Oral morphine to SC ½ the oral dose
 Oral morphine to IV give 1/3 oral dose
 Oral morphine to SC Diamorphine 1/3
oral dose
 Oral Diamorphine to SC Diamorphine ½
the oral dose
Side Effects Morphine
 Initial Vomiting
Drowsiness
Unsteadiness
Confusion
 Continuing Constipation
 Occasional Dry Mouth
Sweating
Myoclonus
Stepping Out of Constipation
 Exercise, fluid intake, fiber in the diet
 Bulk forming laxatives (Fybogel)
 Stool softeners (Coloxyl, Senna)
 Osmotic laxatives ( Mg So4)
 Stimulants (Senokot, Coloxyl, Senna)
 Suppository / Enema
 Colonic lavage
Fentanyl
Y Strong opioid
Y Trans dermal Patches
Y Used Peri operative analgesia
Cancer pain management
Y Onset of action 3-23 hours
Y Elimination from 24 hours
Plasma
Y Remember to provide Breakthrough
Medication
Subcutaneous Administration
 Indications
Intractable Vomiting
Severe Dysphagia
Pt. too weak to
swallow drugs
Poor GI absorption
 Advantages
Constant Analgesia
Reloading after 24 Hrs
Comfort & confidence
No mobility restriction
Better control of nausea
& vomiting
 Choice of Sites
Upper chest
Upper Arm
Abdomen
Thigh
Infusion causes painful
inflammation
 Change needle site prophylactically
 Reducing the irritant drug quantity
 Changing to alternative drug
 Giving irritant drug IM or PR
 Adding hydrocortisone 25-50mgs to
syringe
 Adding hyaluronidase 1500 units to
syringe
Choice of Drugs for SC
 Morphine
 Diamorphine
 Cyclizine
 Dexamethasone
 Hyoscine
 Levomepromazine
 Metaclopramide
 Midazolam
Adjuvant Drugs
 Bone Pain
Biphosphnates Pamedronate
Zylodranate
Calcitonin
32P

Strontium
 Neuropatheic pain
Antidepressants Anticonvulsants
Steroids Clonidine
Benzodizepines Neuroleptics
Drugs used for side effects
 Antiemetics Metaclopramide
Ondansetron
 Psycho stimulants Caffeine
Methyl paiendate
Dextroamphitamine
 Enhance Analgesia Acetaminophen
NSAID
Hydroxyzine
Radiotherapy
 Palliative XRT
Bone pain
Neurological pain
SVCO
Brain mets
Surgery
 Palliative surgery
Tracheostomy
Toilet mastectomy
Defunctioning Colostomy
Pathological # fixation
Neurosurgical intervention
Anesthesia

 IntrathecalAnesthesia
 Peripheral nerve block
Hospice
 Terminal care
 Symptom management
 To give break to the attendants
 To interact with patients of same nature
Summary
 Multimodality approach
 Opioids are more effective
 WHO step ladder to follow for pain
control
 Systemic/ Targeted treatment also used
 Role of religion important if needed