1. Cancer Pain Management Joanne Chung

2. Outline  Causes for pain  Basic concepts in cancer pain management  Mainstay of treatment – use of drug  Assessment  Principle of non-invasive pain relief methods  Outcome measures  A cancer pain management (& associated symptom) protocol

3. Outline  Causes for pain  Basic concepts in cancer pain management  Mainstay of treatment – use of drug  Assessment  Principle of non-invasive pain relief methods  Outcome measures  A cancer pain management (& associated symptom) protocol

4. Causes of cancer pain  Direct tumour involvement  Changes in body structure  Anti-cancer therapy, including analgesia  Causes unrelated to caner  No immediate cause

5. Barriers  Common misconceptions  Organizational aspects  Work demands in the clinical area  Limitation of prescribing  Interprofessional pain education  Patient barriers

6. Patient barriers  Expected to have pain  No control over pain  Problems with opioid and other analgesics  Wait as long as possible for a pain killer  Culturally/socially unacceptable  Be a good patient...

7. Outline  Causes for pain  Basic concepts in cancer pain management  Mainstay of treatment – use of drug  Assessment  Principle of non-invasive pain relief methods  Outcome measures  A cancer pain management (& associated symptom) protocol

8. Basic Concepts in Pain Management

9. Outline  Causes for pain  Basic concepts in cancer pain management  Mainstay of treatment – use of drug  Assessment  Principle of non-invasive pain relief methods  Outcome measures  A cancer pain management (& associated symptom) protocol

10. Analgesic ladder (WHO, 1998)

11. A basic drug list (WHO, 1994)

13. An illustration: The WHO analgesic ladder for cancer pain management Analgesics Drug of choiceAlternative Step 1painnon-opioid drug  adjuvant aspirin or NSAIDacetaminophen Step 2pain persists or increases weak opioid drug  non-opioid drug  adjuvant codeineoxycodone Step 3pain persists or increases strong opioid drug  non-opioid drug  adjuvant morphinemethadone

14. Approximate equinalgesic doses of opioid analgesics Parenteral Oral morphine10 mg30 mg buprenorphine0.3 mg0.4 mg codeine-240 mg diamorphine (heroin)5-8 mg20 mg ydromorphone1.5 mg7.5 mg (or PR) levorphanol2 mg4 mg methadone10 mg20 mg oxycodone-30 mg (or PR) pentazocine60 mg180 mg pethidine (merepidine)75 mg300 mg tramadol80 mg120 mg (For information)

15. Outline  Causes for pain  Basic concepts in cancer pain management  Mainstay of treatment – use of drug  Assessment  Principle of non-invasive pain relief methods  Outcome measures  A cancer pain management (& associated symptom) protocol

16. Individual Pain phenomena Total pain Intensity The Lens Model Psychosocial Emotional Pharmacological Functional Beliefs and meanings Cultural lens Independent variables Mediating variables Dependent variable

17. A brief description on CCPAT  A summated rating scale  Inclusion of pain intensity dimension  Weights are allocated to each dimension by magnitude scaling  Six dimensions (functional, pharmacological, pain beliefs and meanings, psychosocial, emotional and pain intensity) are measured  The total scores obtained is the Sum (Total Pain Intensity)

18. Outline  Causes for pain  Basic concepts in cancer pain management  Mainstay of treatment – use of drug  Assessment  Principle of non-invasive pain relief methods  Outcome measures  A cancer pain management (& associated symptom) protocol

19. Gate Control Theory (Carr & Mann, 1998) Distraction Humour Imagery Well being Relaxation Warmth Coolness Massage TENS

20. (McGuire, Yarbro & Ferrell, 1995) A multidimensional approach

21. Outline  Causes for pain  Basic concepts in cancer pain management  Mainstay of treatment – use of drug  Assessment  Principle of non-invasive pain relief methods  Outcome measures  A cancer pain management (& associated symptom) protocol

22. Outcome criteria for cancer pain management  General impression of ‘ best – worst ’  Satisfaction with pain relief treatment received  Average pain score over a week  Reduction in analgesic consumption  Reduction in emergency room visit

23.  Effects on activities of daily living  Interference with activity  Overall general health since treatment  Physical findings (e.g. strength of muscles, weight loss)  Laboratory results (e.g. blood sugar, cortisol, cytokines)

24. Outline  Causes for pain  Basic concepts in cancer pain management  Mainstay of treatment – use of drug  Assessment  Principle of non-invasive pain relief methods  Outcome measures  A cancer pain management (& associated symptom) protocol

25. Pain and symptom management algorithm  Assessment Assessment  Evaluation Evaluation