PAIN IN CANCER PATIENTS

Dr Munazzah Javed
 Cancer Related Pain - Overview

“Pain is an unpleasant sensory and emotional experience

associated with actual and potential tissue damage”

pain is experienced by 66% of patients suffering from terminal

illness

Tumor Related

CAUSES
Treatment Related
 Tumor Related Causes of Cancer Pain
Causes of Cancer Pain Description
Tumor Growth Pain from tumor pressing on nearby tissues, nerves, or organs

Nerve Compression or
Neuropathic pain due to tumor compressing or invading adjacent nerves
Invasion

Deep, aching pain from cancer spreading to the bones. Worsens with
Bone Metastases
movement or weight-bearing

Visceral Pain Pain originating from internal organs, described as deep, dull, or cramping

Pain due to cancer-induced inflammation, such as abdominal pain in

Inflammatory Processes
pancreatic cancer

Compression of Blood Pain resulting from tumor compressing blood vessels, causing decreased
Vessels blood flow

Chemical Mediators Pain triggered by chemical mediators released by tumors

 Treatment Related Causes of Cancer Pain
Causes of Cancer Pain Description
Pain can result from chemotherapy side effects, such as oral pain (mucositis)
Chemotherapy
or peripheral neuropathy

Pain from radiation therapy side effects, including skin irritation, tissue
Radiation Therapy
inflammation, and localized pain

Surgical Procedures Post-surgical pain following major procedures to remove tumors or organs

Pain resulting from various medical procedures, such as biopsies or central

Procedural Pain
line placements

Chemotherapy-Induced
Pain and neuropathy in the extremities due to specific chemotherapy drugs
Peripheral Neuropathy (CIPN)

Radiation-Induced Oral Oral pain resulting from radiation therapy to the head and neck, causing
Mucositis mucous membrane inflammation

Ischemic Pain from

Pain from thrombosis (blood clots) caused by certain cancer treatments
Thrombosis
 Comprehensive Pain Assessment
• Detailed History

• Intensity

• Location

• Duration

• Alleviating factors

• Meds tried
Comprehensive Pain Assessment

Numeric Rating Scale

The WHO Analgesic Ladder
Comprehensive Pain Assessment
 Opioids - Comparison
Opioid Potency Forms Quantity (mg) Frequency (Time) Side Effects

Oral, Injectable, Extended- Constipation, Sedation,

Morphine Intermediate
Release
15-30 mg Every 4-6 hours
Nausea

Immediate-Release, Extended- Nausea, Constipation,

Oxycodone Intermediate
Release
5-15 mg Every 4-6 hours
Dizziness

Sedation, Respiratory
Fentanyl Highly Potent Transdermal, Lozenges, Injectable Varies based on patch strength Typically every 72 hours (patches)
Depression

Sedation, Constipation,
Hydromorphone Highly Potent Oral, Injectable 2-4 mg Every 4-6 hours
Nausea

Nausea, Constipation,
Hydrocodone Intermediate Combined with other medications 5-10 mg Every 4-6 hours
Dizziness

Nausea, Constipation,
Codeine Low to Moderate Combined with other medications 15-60 mg Every 4-6 hours
Drowsiness

Confusion, Hallucinations,
Meperidine Intermediate Oral, Injectable 50-150 mg Every 3-4 hours Seizures (with prolonged
use)
 NICE Guidelines for Palliative Care of Adults
• Communication

 Concerns of Patients
 Addiction

 Tolerance

 Side Effects

 Provide info about opioids and their Safe Storage

 Offer patients frequent review of pain control

 Starting Strong Opioids - Titrating the Dose

• Start with 20-30 mg/day of sustained release oral morphine for background pain

and 5mg SOS for breakthrough pain

• Dose should be adjusted until a good balance exist between acceptable pain

control and side effects

• Patients should be frequently reviewed particularly in titration phase

 Breakthrough Pain

• Sudden episodic more intense spikes of pain

• Offer 5mg of oral immediate release morphine for the first line rescue

medication of breakthrough pain

• 1/6th of total dose of opioid for breakthrough pain as per SIGN guidelines
 First Line Maintenance Treatment

• Offer oral sustained release morphine as first line maintenance treatment to patients with

advanced & progressive disease who require strong opioid

• Transdermal patch and subcutaneous formulations shouldn’t be used as first line maintenance

treatment to patients in whom oral opioids are suitable

 First Line Treatment - Oral Opioids are not suitable

• Consider initiating transdermal patches with the lowest acquisition cost for patients in whom

oral opioids are not suitable and analgesic requirements are stable

• Consider initiating subcutaneous opioids with the lowest acquisition cost for patients in whom

oral opioids are not suitable and analgesic requirements are unstable
 Management of Opioid’s Side Effects
• Constipation

 Affects nearly all patients receiving strong opioids

 Laxative treatment

• Nausea. Anti-emetic treatment

• Drowsiness. Consider dose reduction in persistent or severe CNS side effects

 Pain Management of Cancer Patient
• Non-Pharmacological Approaches:
 Interventional Procedures. Interventional procedures like nerve blocks,
epidural injections, or neurolytic blocks can provide targeted pain relief
 Physical Therapy. Physical therapy can help patients maintain mobility and
function, reducing pain associated with immobility
 Psychosocial Support. Psychological support, counseling, and relaxation
techniques can help patients cope with pain and improve their overall well-
being-
Thank you