SHORT SUMMARY

1. PAIN MANAGEMENT IN CANCER

2. • Pain is an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage
• Somatopsychic phenomenon modulated by
Patients mood
Patients morale
Meaning of pain for the patient

3. • 75% of advanced cancer patients experience
pain
• One third has single pain
• One third has 2 pain
• One third has 3 or more pain

4. pain
psycholo
gical
Spiritual
Social
Physical

5. PAIN MANAGEMENT
• Evaluation
• Multidimensional process
• Begins with locating the pain
• ‘where exactly is your pain?’
• Duration

6. Characteristics
• Palliative factors
• Provocative factors
• Quality
• Radiation
• Severity
• Temporal factors

7. Causes of pain
• Cancer
• Treatment-mucositis
• Debility-constipation, muscle tension
• Concurrent disorder-spondylosis,
osteoarthritis

8. Mechanism
• Functional
• Somatic muscle tension pains-tension head
ache, cramp
• Visceral-distension, colic

9. • Pathological
• Nocioceptive-tissue distortion or injury
• Neuropathic-compression or injury

10. • Causes
• Cancer-
nerve compression or infiltration
Plexopathy
Spinal cord compression
Thalamic tumor
• Treatment-surgical incision pain
phantom limb pain
peripheral neuropathy
brachial plexopathy

11. • Debility-post herpetic neuralgia
• Concurrent disorder-diabetic neuropathy,
post stroke pain

12. AGGREVATING FACTORS
• Discomfort boredom
• Insomnia mental isolation
• Fatigue social abandonment
• Anxiety
• Fear
• Anger
• Sadness
• depression

13. DECREASED
• Relief of other symptoms
• Sleep
• Understanding
• Companionship
• Creative activity
• Relaxation
• reduction in anxiety
• elevation of mood
• drugs

14. management
Modification of
pathological process
analgesics
Non-drug methods
psychological
Interruption of pain
pathways
Modification of way
of life and
environment

15. • Modification of pathological process-
Radiation therapy
Hormone therapy
Chemotherapy
surgery
Non-drug methods-massage, heat pads
Psychological-relaxation, cognitive behavioral
therapy,

16. • Interruption of pain pathways
local anaesthesia
neurolysis-chemical(alcohol, phenol)
cryotherapy
thermocoagulation
neurosurgery-cervical cordotomy

17. • Modification of way of life and environment
• Avoid precipitating activity
• Immobilisation of painful part-cervical collar,
slings, surgery
• Walking aid

18. ANALGESICS
• Non-opioid
• Opioid
• Adjuvant

19. • Principles governing the analgesic use
• By the mouth
• By the clock-persistent pain needs preventive
therapy
• By the ladder-if after optimising the dose of
drug fails to relieve, move up the ladder
• Individualised treatment-right dose is the one
which relieve the pain
• Use of adjuvant drugs-relieve pain in specific
situation

20. Strong opioid+non-
opioid±adjuvant
Weak opioid+non-
opioid±adjuvant
Non-opioid
±adjuvant

21. Non opioid
Paracetamol,NSAID
Opioids
Codeine(weak)
Morphine(strong)
Adjuvant
Steroids, anti
depressants, anti-
epileptics, anti-
spasmodics, muscle
relaxants

22. NON-OPIOID ANALGESICS
• Paracetamol n NSAIDs
• Paracetamol-anti-pyretic analgesic inhibits
COX in CNS
• Lack anti-inflammatory effect
• Undesirable effect uncommon
• Does not cause gastritis
• Does not affect plasma uric acid
• No effect on platelet function

23. NSAIDs
• Pain associated with inflammation-soft tissue
infiltration, bone metastasis
• Non selective Inhibition of COX
• Its prolog use is limited by its adverse effect

24. • Gastritis
• Antoganise urocosuric drugs
• Salt and water retension
• Renal failure and interstitial nephritis
• Platelet dysfunction
• Aspirin may cause tinnitus and deafness

25. WEAK OPIOIDS
• Codeine, dextroprpoxyphene, dihydrocodeine,
tramadol
• Codeine is 1/10 as potent as morphine
• More constipating than morphine
• Tramadol is 1/10 to 1/5 as potent as morphine
• Dual mechanism of action partly via opioid
receptor partly by inhibiting PRE SYNAPTIC
reuptake of 5-HT and NA

26. • Less constipating
• More effective in neuropathic pain than
morphine
• Lower seizure threshold
• TCA and SSRIs

27. Strong opiods
• Morphine, dimorphine, methadone
• Oral morphine(tablets and aqeous solution)
• Guidelines for starting morphine
• Indicated in patients in patients who does not
respond to optimised combined use of non-
opioid and weak opioid

28. • Start with 10mg q4h or m/r 20-30mg q12h
• Lower dose 5mg q4h in elderly and frail and in
renal failure
• If patients requires two or more p.r.n dose in
24h increase dose by 30-50% every 2-3 days
• Titrate till pain relieves or intolerable effects
limits further escalation

29. • Add drugs which relieves its adverse effects
• Anti emetic haloperidol 1.5mg stat and sos,
metaclopramide
• Prophylactically prescribe laxative to prevent
constipation
• Warn all patients about initial drowsiness
• For outpatients write out drug regimen in
detail time, amount to be taken and arrange
for follow up

30. • Ordinary morphine and modified release
morphine(m/r)
• Once we get the stable q4h ordinary
morphine dose
• Replace it with q12h m/r morphine(3 times
q4h dose)
• Continue to give p.r.n ordinary morphine 1/6
th of total daily m/r dose

31. Adverse effects
• Gastric stasis- epigastric fullness, flatulence,
nausea, anorexia, hiccup-metoclopramide
• Sedation
• Cognitive failure-haloperidol
• Myoclonus and Hyperexcitability -abdominal
muscle cramps, whole body allodynia,
symmetrical jerking of pain

32. • Vestibular stimulation- movement induced
nausea and vomiting
• Pruritus-ondansetron
• Histamine release- broncho constriction

33. • Dimorphine
• More soluble than morphine
• Large amount can be in small volume
• It is used instead of morphine when injections
are necessary
• Twice as potent as morphine in iv

34. Alternative strong opioids
• buprenorphine
• fentanyl
• hydromorphone
• methadone
• Oxycodone
these are used when patients are intolerant
to morphine

35. Indication of methadone-
• Severe intolerable side effects with morphine
at any dose
• Severe pain despite increasingly high doses
• Neuropathic pain not responding to typical
regimen of NSAIDs, morphine, TCA and
valproate
• Renal failure

36. • Stop morphine abruptly
• 1/10 dose of 24h oral morphine up to
maximum 30 mg
• Allow the patient to take the dose in q3h p.r.n
• On day6 amount of methadone taken over
previous 2 days is converted into regular q12h
dose
• If p.r.n dose is still neededincrease the dose of
methadone by 1/3-1/2 every 4-6 days

37. • 2nd scheme
• Stop morphine abruptly
• 5-10mg methadone q4h and q1h p.r.n
• After12-24h if frequent p.r.n dose is needed
• 10-15mg and q1h p.r.n
• After 72 h convert to q8h and q3h p.r.n
• Increase the dose every 4-5 days

38. ADJUVANT ANALGESICS
• They are add on drugs supplementing the
impact of NSAIDs and opioids
• Its main use is in neuropathic pain

39. CLASS INDICATIO
NS
MOA EXAMPLE TYPICAL
REGIMEN
ADVERSE
EFFECTS
STEROIDS Nerve
compressi
on
Reduce
peri
tomor
edema
Prednisolo
ne
dexameth
asone
15-30mg
om
8-16 mg
o.m
Hyperglyc
emia,anxi
ety,steroid
psychosis
ANTIDEPR
ESSANTS
Nerve
injury pain
Potentiati
on of
GABA
inhibition
Amitriptyli
ne
imipramin
e
25-100
o.n
Antimusca
rinis
effects,dr
owsiness,
ANTI
EPILEPTIC
Nerve
injury pain
Potentiati
on of
GABA
inhibition
Valproate
gabapenti
ne
400-
1000mg
o.n
100-
300mg tds
drow
siness
NMDA
RECEPTOR
CHANNEL
BLOCKER
Pain
poorly
respondin
g to
analgesics
Nmda
receptor
block
Methadon
e
ketamine
10-60mg
bd
10-20mg
q6h
Drowsines
s
dysphoria

40. Anti
spasmodics
Bowel colic Relax
smooth
muscles
Hyoscine 60-
160mg/24h
sc
Peripheral
anti
muscarinic
effect
Muscle
relaxants
Muscle
spasm
Relax
somatic
muscle
baclofen 10mg tds
bisphospho
nates
Metastatic
bone pain
Osteoclastic
inhibition
Zolendronic
acid
4mg every
4-8 week
pyrexia

41. • ADJUVANT ANALGESICS FOR NEUROPATHIC
PAIN
• STEP1-Corticosteroids
T
• STEP2-TCA or anti EPILEPTICS
• STEP3-TCA and anti EPILEPTICS
• STEP4-NMDA receptor blocker
• STEP5-Spinal analgesia

42. ALTERNATIVE ROUTES OF ADMINISRATION
• Dispersible tablets
• Liquids or sprinkling
• Sublingual tablets or suppository or
transdermal patch
• Injections

43. Continuous SC infusions
• Battery driven portable syringe drivers
• Useful in patients with severe nausea and
vomiting who cannot swallow drug due to
various reason
• Upper chest, upper arm, abdomen, thighs-
sites for infusion

44. • Advantages
• Better control of nausea and vomiting
• Constant analgesia
• Minimum no of injections
• Does not limit mobility

45. Topical morphine
• 0.1% gel
• Pain associated with Cutaneous ulceration
• Oral mucositis
• Vaginal inflammation associated with fistula
• Rectal ulceration

46. Spinal morphine
• Epidurally or intrathecally
• Much lower dose with greater analgesic effect
• Intractable pain inspite of standard and
adjuvant treatment