Chronic Pain Management in

Head and Neck Cancers

Dr. G.Durga prasad
Associate professor of Radiation Oncology
and Department of Pain & Palliative care
Govt.Medical college and GGH
Anantapuramu
Andhrapradesh
Chronic Pain Management in

Head and Neck Cancers

Dr.Durgaprasad
 Definition of Pain

An unpleasant sensory and emotional

experience associated with actual or
potential tissue damage or described in
terms of such damage

IASP 1994
Ca tongue
Came with c/o severe pain right half of face
Pain score 10/10
What is the cause of his pain

?
 Mechanism of Acute pain and
Pain pathway

23
Julius D. & Basbaum A.I; Molecular mechanism of nociception; Nature 2001, Sept 13; 413 (6852): 203-10.
Peripheral Sensitisation
Recruitment
 2 nd order Thickest A beta
neurons: Wide
dynamic range
neurons(WDR) A delta & C
I “NS” neurons
II
IVIII
V
VI 2 nd order
neurons:
Nociceptive
specific neurons

Central Sensitisation
 Central Sensitisation
“wind-up”
NMDA

Woolf CJ, Anesth Analg. 1993;77:362-379.

Clinical significance:

Allodynia

Diffuse pain
 Somatic - Neuropathic interphase

Nociceptive Neuropathic
5HT Noradrenaline
 Principles of Management of
Chronic Pain
• By the clock
• By the ladder
 WHO Analgesic ladder
Strong opioids
+Nonopioids
+/- adjuvants
Weak opioids
+Nonopioids
+/- adjuvants
Nonopioids
+/-
adjuvants

Psycho-socio-spiritual
support
 Paracetamol as an analgesic

A Central Prostaglandin Inhibitor

Dose- 500mg- 1gm 4-6hourly

Non Steroidal Anti-inflammatory
Drugs (NSAIDs)

• Non-Selective NSAIDs
• Cox–II Selective NSAIDs
 Coxib Controvery
Merck & Co. Voluntarily withdraws
of Vioxx from the US market

(30 September 2004)

 Arachidonic acid

COX 1 COX2

Prostaglandin Prostaglandin
Kidney, Platelets, GIT Brain, Kidney,Ovary

‘Constitutive’ ‘Inducible’
A long term study of Vioxx
(APPROVe)(patients at risk of
recurrent colon polyp):

Increased risk of cardiovascular

events when taken for more than 18
months (twice the risk as compared to
placebo)
 When using NSAIDS,

• Which patient needs NSAIDs?

• Which drug to choose?
• Is the patient ‘at risk’?
• Is any alternative / protection
feasible?
The American Heart Association
(AHA)
Discourage the use of both
cyclooxygenase 2 (COX-2) inhibitors
and regular (NSAIDs) in patients with
known heart disease or at high risk of
getting heart disease
February
28, 2007
 The AHA Recommendation
for Musculoskeletal Symptoms
• Acetaminophen
• Opioids
• Nonacetylated salicylates
• Non-COX-2 selective NSAIDs
• NSAIDs with some COX-2 activity
• COX-2 selective NSAIDs
 Rheumatology
The initial approach of RA [rheumatoid
arthritis] is institution of therapeutic doses
of anti-inflammatory drugs and disease
modifying therapies.
 Weak Opioids
• Codeine
• Dextropropoxyphene
• Tramadol

• Pentazocin
Strong Opoids

Morphine
Fentanyl
Methadone
Oral Morphine
Poppy flower
• Rajasthan
UP

MP

Poppy cultivation in
India
 The Sad Indian paradox
2 million Indians

like him need

oral morphine

for pain relief.

It reaches less than 1% of the
needy
Oral Morphine is the drug of
choice for severe cancer pain
-WHO
Oral Morphine

How to use
• Start with 5 - 10mg i/r MST
• Always use q4h with double dose at bed
time
• Additional doses can be given p.r.n. for
breakthrough pain
• If pain relief is not satisfactory, increase
by approximately 50% of previous dose
Oral Morphine

How to use
• There is no maximum dose of morphine;
the dose can be increased depending on
the severity of pain

“Pain is the physiological antagonist to the

central side effects of morphine.”
Oral Morphine

How to use
• Always prescribe a laxative (stimulant
+/- softener) prophylactically

“The hand that prescribes the Morphine

should also writes laxatives”

• Prescribe an anti-emetic prophylactically

for the first few days, especially in
patients who are already vomiting
Oral Morphine

Medicine On 10 2 pm 6 pm Bed Extra Reason

Waki am Time dose
-ng
Tab Morphine 1 1 1 1 2 1 Pain
10mg
Tab Bisacodyl 2 Constipation
Tab Metclopromide 1 1 1 Vomiting
10mg
Oral Morphine

Exceptions to ‘every four hours’

• Renal failure
• Very elderly > 70 yrs

Accumulation of M6G leads to enhanced

opioid toxicity.
Oral Morphine

Exceptions to ‘every four hours’

• Occasional attacks of severe pain

• Night pain only

Oral Morphine - Adverse effects

Initial:

Nausea and vomiting

Drowsiness
Unsteadiness
Oral Morphine - Adverse effects (cont.)

Continuing:

Constipation
Nausea and vomiting
Inactivity drowsiness
Dry mouth
Oral Morphine - Adverse effects

Occasional:

Urinary retention
Myoclonus
Itching
Oral Morphine - Adverse effects

Signs of overdose:

Drowsiness
Delirium
Myoclonus
Oral Morphine

Misunderstandings about morphine

‘Morphine is dangerous because it depresses
respiration’
Double dose at bed time does’nt cause RD
Large therapeutic window
Drowsiness and delirium prevents from taking
further dose
Tolerance to respiratory depression develops in
course of time
Oral Morphine

Misunderstandings about morphine (contd)

‘Morphine is addictive’
• Several studies have concluded that risk of addiction is
far less than 1%
• Two studies with more than 500 patients who received
Heroin for pain relief found that no patient could be
documented as having become addicted
– Twycross, 1974; Twycross, Wald, 1976
• Prospective study of 11,882 hospitalised medical
patients only 4 patients could be documented as having
become addicted as a result of receiving opioid
analgesics
– Porter, Jick, 1980
Oral Morphine

Results of 2 year study in India

 Opioid
Opioid dependence
dependence

Physical Psychological
dependence dependence
(withdrawal symptoms) (addiction)
Diarrhoea, palpitation Craving
and sweating unsanctioned dose
loss of other
interests
Oral Morphine

MNJ experience:
Physical dependence:
• Total no. of patient with complete response to
chemo/ radiation:13
• Children:9
• Adults:4
We could weaned them of morphine after chemo
radiation
Oral Morphine

MNJ experience:

Addiction:
• Total no. of patients seen since December
2003- More than 35000 subjects
• One patient had ? Addiction with h/o high
risk behavior
Oral Morphine

Other misunderstandings about Morphine

‘Morphine induces euphoria’

• What happens if a person with no

pain takes oral morphine?

• Pharmaco-kinetics of oral morphine

Oral Morphine

Other Misunderstandings about

Morphine

‘Tolerance to morphine develops

rapidly’

‘If a cancer patient is given

morphine, he is going to die soon’
Oral Morphine

Other Indications

Intractable Cough
Dyspnoea
Intractable diarrhoea
Oral Morphine

• Oral morphine is the drug of choice for

severe cancer pain management
• It is always safe in “safe hands”
• Respiratory depression, addiction and
tolerance are not problems with oral
morphine
 Fentanyl
• Convenient
• 25 times expensive
• Not useful for break through pain
• Latency of action
• Acts up to 24 hrs after removal; of patch
• Titration not possible the if patient becomes
drowsy
• Practically no role as first line
• It works better in cool climate