Malignant pain – management Dr S.Parthasarathy MD., DA., DNB., PhD., FICA.,IDRA., Diploma in Software based statistics

A big salute

What is pain ? Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. In simple terms we can say pain is one which hurts!

Annai adhuragam

So then ! what is cancer pain ? Cancer Pain is a multidimensional pain experience which involves diverse neurophysiological changes and is characterized by significant cognitive, emotional and sociocultural responses-- Simply giving tramadol or morphine or a block may not relieve his/her agony

Why do we need to know ? In India the estimated number of people living with malignancy is around 2.5 million with an every year addition of 7 lakh new cases– Moderate to severe pain experienced by 40% to 50% of cancer patients: Very severe pain experienced by 25% to 30% of cancer patients

Why should cancer patients get pain? Due to cancer Due to treatment Due to incidental other diseases

What are the types of pain ? Nociceptive Somatic visceral Non nociceptive Neuropathic Central psychogenic All types of pain can occur almost !

Assessment Onset , type , Factors increase or decrease Drugs, radiotherapy Breakthrough pains , other disease Psychosocial factors Caregivers Reassess

There can be even films without heroines Type Intensity Etiology Management without assessment and reassessment ? Can we give diclofenac for neuropathic pain ?

Management Brompton cocktail (a mixture of alcohol with cocaine) Made as an elixir 5 ml syrups a lot of variations 1900 s

In 1986 ? What happened ? Sometimes a two step or a four step Its not big science More social !

Possible barriers of pain management? lack of knowledge among health professionals regarding cancer pain assessment and management; fear of the adverse effects of opioids; misconceptions about analgesic use, concerns about pain communication

What are they ? Not the side effects of opioids Respiratory depression Nausea and vomiting Constipation Not the side effects of opioids

Mild pain – VAS around 3 Paracetomol Aspirin or Etoricoxib ? With adjuvants All drugs should be used as round the clock regimen and assessment followed by treatment of breakthrough pain is the cornerstone of management.

Adjuvants Carbamazepine Amitriptyline Lignocaine infusion Melatonin Quetiapine Flupirtine Cannabinoids

Moderate pain (second WHO analgesic step) (VAS 3–6 / 10). acetaminophen, aspirin or NSAID plus a weak immediate release opioid such as codeine, dihydrocodeine, tramadol or propoxyphene Tramadol 1.5mg/kg tds Tapendolol Add adjuvants !

Moderate – severe pain (third WHO analgesic step (VAS > 6/10). Strong opioids: First choice is oral morphine: 30 mg tds can go up to 250 mg/ day with a maimum reported dose of 2000 mg Intravenous is one third the dose usually What is the actual dose? Get the effect or at least significant side effects

Be strong enough to skip steps when needed ? Not necessary to go stepwise a few times Go to step 3 if needed ! Intravenous opioids; buccal, sublingual and intranasal fentanyl drug delivery systems have a shorter onset of analgesia in treating BTP episodes as replacement to oral morphine. BTP = Short duration 30 minutes severe pain ! rapid onset

Not only drugs !! RT, radioisotopes and targeted therapy given in association with analgesics have an important role in the management of bone pain– Cure the disease, Do surgery Sometimes they act as analgesics !!

Many are available in India !

Example If morphine 30 mg 4 hourly is the dose Breakthrough pain – 15 mg given 4 times Then – (30* 6 = 180 )+ (15* 4) = 240 240/ 6 = 40 mg oral 4 hourly Problem comes – go back one step !

Conversion to other opioids Step 1: (calculate the 24 hour fixed dose total) Morphine 30 mg po q 4 hours = 30 x 6 =180 mg Step 2: (apply appropriate ratio) 180 x 1/5 = 36 mg of hydromorphone Step 3: (divide by number of doses per day) 36 / 6 = 6 mg every 4 hours

Fentanyl – cant take drugs orally ! Patch Size: 25, 50, 75 and 100 micrograms Duration of Action: 72 hours Advantages: Easy, convenient use No need to remember to take drugs Disadvantages: Difficult when using high dose of narcotics Thin patients ( usual ca patients) with little subcutaneous tissue

Need to switch opioids Opioid switching is a practice used to improve pain relief and/or drug tolerability. The most frequent switch is from morphine to methadone oral Half life ! Laxatives and antiemetics routine !!

Nerve blocks

Blocks of the ANS ok but somatic blocks ?

Epidural or brachial plexus blocks Infusion of local anesthetic drugs Lumbar plexus infusions Intrathecal opioids Epidural steroids Gasserian blocks

Cancer pain can have other problems Myofascial pain – trigger point injection

Cannot relax Yes even after neurolytic blocks, pain can recur Reassess repeat Increase drugs Time the intervention

Newer non pharmacological methods : SCS, also known as dorsal column stimulation, is a minimally invasive, outpatient technique that involves placement of electrodes in the dorsal epidural space.. Scrambler therapy is placement of multiple cutaneous electrodes in the skin near painful area and their stimulation

Pictures taken from the internet for closed academic work only Transcranial current stimulation Implantable intrathecal pumps

Counsel the patients Counsel the caregivers ! Address the spiritual issues

Summary Seven lakh new cases in India 40 – 50 % suffer moderate pain Assessment Three step ladder – never miss adjuvants Opioids / morphine is the drug – switch opioids Neurolytic blocks – prefer sympathetic Nonpharmacological methods Counsel the patient

Message Thank you all Reduction of barriers – spend time Administer the technique which the patient needs Never administer what we know Thank you all