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

2. A big salute

3. 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!

4. Annai adhuragam

5. 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

6. 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

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

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

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

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

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

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

13. 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

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

15. 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.

16. Adjuvants Carbamazepine Amitriptyline Lignocaine infusion Melatonin
Quetiapine
Flupirtine
Cannabinoids

17. 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 !

18. 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

19. 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

20. 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 !!

21. Many are available in India !

22. 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 !

23. 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

24. 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

25. 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 !!

26. Nerve blocks

27. Blocks of the ANS ok but somatic blocks ?

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

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

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

31. 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

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

33. Counsel the patients
Counsel the caregivers !
Address the spiritual issues

34. 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

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