Optimising Pain Management in Cancer treatment

Esther Cege Munyoro

Gladys Nduku

KNH-Pain and Palliative care unit.

What is Pain?

“An unpleasant sensory or emotional experience associated with actual or potential tissue damage”.

( IASP, 1979)

WELLS, M., DRYDEN, H., GUILD, P., LEVACK, P., FARRER, K. AND MOWAT, P. 2001, The knowledge and attitudes of surgical staff towards the use of opioids in cancer pain management: can the Hospital Palliative Care Team make a difference? European Journal of Cancer Care, 10: 201–211.

• Wells et al 2001 noted the existence of myths and misconceptions about the use of opioids in surgical wards in the United Kingdom. The study found misunderstandings and anxieties about addiction, tolerance and side effects, especially respiratory depression. Even with education that saw improvement in awareness about the properties of opioids, the study found minimal change in attitude and concluded that attitudes may be more difficult to influence than knowledge.

What is pain??• Pain is whatever the person

experiencing says it is

and exists where he

says it does.

( McCaffery & Pasero, 1999)

Defining “Total Pain”

• Dame Cicely Saunders defined the concept of total pain as the suffering that encompasses all of a person's physical, psychological, social, spiritual, and practical struggles.

DEFINING TOTAL PAIN

……………a diagnosis of a life threatening illness

jars open a door of awareness, for most of our

lives we keep this door locked and it comfortably

allows us to keep thoughts about death in the

background.

7Coyle N. The existential slap—a crisis of disclosure. International Journal Palliative Nursing 2004;10: 520. [PubMed]

Why treat pain?

In low-resource countries, pain is the most common indication for visiting a health care practitioner

• Improves compliance to curative treatment

• Extends survival for some patients

• Improves quality of life

• Improves patient – physician relationship

• Reduces unnecessary prolonged admission

• Reduces chances of litigation

IASP: Treatment of pain in low-resource settings (2010) Temel et al- NEJM (2010)

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Total pain

TOTAL PAIN

PHYSICAL

PSYCHOSOCIAL EMOTIONAL

SPIRITUAL

Zaza C, Baine N. Cancer pain and psychosocial factors: a critical review of the literature. J Pain Symptom Manage 2002;24:526–42

OPTIMISING

Make pain visible in our practice

1. Documentation

2. Protocols for pain and other symptoms

3. Education programs for Patients

4. Pain diaries

5. Learn to individualize pain treatment.

6. Multidisciplinary pain management

7. Increased collaboration at End of Life.

DOCUMENTATION

– Assessment charts at clinics must have pain scales for pain scores, body charts.

– Sheets for vital signs must provide a space to pain scores, more importantly healthcare workers must respond appropriately to the reported pain score.

PCAU 13

Body charts

Use the body chart to indicate areas of pain and annotate descriptions such as burning, throbbing, or aching

throbbing

tingling

Clinical Practice Guidelines: Pain Management

• The goals of protocols is to help the primary care provider manage patients with chronic or persistent pain by providing guidance about how to manage pain and guidance about when to refer for specialized pain management services

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WHO STEPWISE THERAPY

Non-Opioid-

Analgesics+/-Adjuvant

Low potent Opioids

+non-opioids+/-

Adjuvants

I

II

III

IV

High potent

Opioids + non opioids+/-

Adjuvants

INVASIVE

THERAPY

STEP 1

Paracetamol

Non steroidal anti-inflammatory

drugs

STEP 2

Codeine

Dihydrocodeine

Tramadol

STEP 3

MorphineMethadone, Oxycodone

Fentanyl

Pethidine

STEP 4

Spinal opiates

Nerve blocks

PATIENT EDUCATION/ Pain Diary

• An accurate record of

your pain

–Pains interference

with activities like

sleep, work or

walking.

–Drugs side effects

–Other treatments herbal etc used

Multidisciplinary Pain teams

• Multidisciplinary pain treatment provides patients with an opportunity to achieve both adequate pain relief and improved physical, behavioral and psychological functioning.

• Physiotherapists, Occupational therapists, Psychologists and Nurses are important team members.

• An important factor in improving psychosocial well-being of patients with chronic pain is to enhance their self-efficacy and perceived ability to control or manage their pain.

It is every health worker’s responsibility

The advent of effective treatment algorithms means that all nurses and physicians can provide effective, high-quality pain treatment

• Pain assessment and treatment in the uncomplicated patient should be integrated into service delivery in all departments

• Specialists in palliative care or anaesthesiologycan be called on for complex cases

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Pain at the End of life

• Pain relief should always be a top priority. If the primary focus is on treating disease, even when the prognosis is poor, get somebody else to provide pain management.

• We are a Death denying society so patients tend to suffer in our hands at the end. Pain medication is reduced as the end gets closer and sometimes stopped so that ? Death does not occur.

• We need to talk about death and reap the benefits.

WHO pain Relief Program

WHO PAIN

RELIEF

PROGRAMME

Multidimensional assessment

Appropriate ladder Level

Oral drugs

Regular medication

Drugs for breakthrough pain

Consider adjuvant drugs

Morphine/ strong opioid of choice

PAIN ASSESSMENT

Description

Location

Duration

Characteristics

Mechanism Cause

Pathological Cancer

nociceptive (tissue) Non- cancer

Neuropathic (nerve) Debility

Functional Treatment

Somatic muscle (e.g. cramp) Concurrent disorder

Visceral Muscle ( e.g. colic)

Non-Physical factors

Psychological

Social

Spiritual

PAIN

History taking

• Is the pain limiting activity?

• What does the patient feel about the pain?

• What are the expectations of treatment?

• What are the patient’s fears?

• What are the patient’s previous experience of pain and illness?

Examination

Investigations:

• What are you trying

to find out?

Pain score-Numeric pain rating scale

• Pain levels 0-10, explained verbally to the patient in which 0 is no pain and 10 is the worst possible pain.

• Patients are asked to rate their pain.

• Record the pain level to make treatment decisions and follow-up.

Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training

Curriculum: Harvard Medical School, Centre for Palliative Care (2007)

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Assessment of pain in cognitively impaired patients

Use the following pointers:

Vocalization e.g. groaning, crying.

Changing body language e.g. fidgeting, guarding of a body part

Physiological changes, e.g.. Increased pulse rate, high temperature and blood pressure.

Behavioural changes e.g. confusion, refusing to eat, anxiety.

Physical changes e.g. skin tears, pressure areas sores andcontractures.

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How to treat pain?

In 1986,WHO developed a 3 step simple algorithm as a guide to treat pain in cancer patients. The WHO Analgesic Ladder

• It incorporates opioids, non- opioids and adjuvant medicines.

• It is extremely effective.

• When the ladder is optimised,85-90% of patients report excellent pain control.

IASP: Treatment of pain in low-resource settings (2010) 30

WHO 3-step Ladder

1 mild

2 moderate

3 severe

Morphine

Methadone

Fentanyl

Oxycodone

± Adjuvants±NSAIDs/

paracetamol

Codeine

Dihydrocodeine

Tramadol

Betapyn

± Adjuvants±NSAIDs/

paracetamol

ASA

Paracetamol /

Acetaminophen

NSAID’s

± Adjuvants

WHO. Geneva, 2008.

The big question is…..

How effective is the ladder even after modification over years???

………First is to question about

your practice!!!

MorphineOral morphine is the gold standard in the treatment

of severe pain in cancer patients (Gordon et al, 1999).

WHO has placed oral morphine on the essential drug list.

Due to its established effectiveness, availability, familiarity to physicians, simplicity of administration and relative cost.

Its short-half-life characteristic generally favour its use because it is easy to titrate.

Morphine

Rectal morphine bio-availability is similar to the oral route.

Reassure the patient about the safety and efficacy.

Constipation occurs at least to 90% of patients and 2/3 develop N/V, Prescribe prophylactic laxatives and antiemetics.

(Europian Journal of pain.vol 11,issue 8, November 2007,p.gs823-830.)

Initiating morphineStarting dose 5-10mg 4hrly.

For opioid naive and elderly patients, or those with renal impairment use smaller doses e.g. 2.5mg 4hrly with close monitoring.

– if pain is not controlled, titrate dose by 25–50% every 24-48 hrs.

Reassess pain daily; this can be done over the phone.

Once pain is controlled, either continue regular immediate relese dose or convert to a 12hrly modified-release preparation.

Rescue dose

All patients on around-the-clock opioid regime should be offered a “rescue dose” (supplemental dose) given on “as-needed basis” to treat pain that breaks through a regular schedule= BTP

Break through pain:

• A transient flare-up of pain of moderate or severe intensity arising on a background of a well controlled pain.

Fentanyl patches:

• A potent opioid analgesic in a topical patch lasting for 72hrs.

Indications of Fentanyl patches

• Second line opioid for moderate to severe responsive pain.

• Pain that is stable.

• Patients unable to tolerate morphine/ diamorphine due to persited side effects.

• Poor compliance but supervised patch application is possible.

http://www.palliativedrugs.com.

Adjuvant analgesics. Opioids are not the only “magic bullets” in pain management.

Adjuvant drugs not primarily designed to control pain but they do control pain.

Have independent analgesic activity for certain pain types like neuropathic pain and pain syndromes e.g. fibromyalgia.

E.g. anticonvulsant, antidepressants, steroids

Beating Pain, 2nd Ed. APCA (2012); Using Opioids to Manage Pain, APCA (2010)

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Golden Rules

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WHO Genf (1986)

by the mouth

by the clock

by the ladder

for the individual

Make it simple !

Invasive analgesic techniques;

• Despite appropriate use of analgesia and non-drug therapies, 8-10% of patients will still have uncontrolled pain or unacceptable side effects or both.

• Such patients should be considered for some invasive analgesic techniques e.g. a simple nerve block or a regional or neuro destructive blocks.

• Hanks GW,Conn F,Chemy N,Hanna M,Kalso E,Mcquary HJ,et al.Morphine and alternative opioid in cancer patients:The EAPC RECOMMENDATIONS.Br J. Cancer 2001:84:587-93

QUESTIONS AND COMMENTS