Download - Pain Relief for Cancer Patients
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Pain Relief for Cancer Patients
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Thirty to 50 percent of patients undergoing activetreatment, and about 70 to 90 percent of those withadvanced solid tumors, experience chronic pain.
Appropriate treatment of pain can result in 90 percent of
cancer patients achieving adequate relief. Barriers to pain control include lack of physician knowledge
of adequate treatment of pain, unrealistic concerns aboutnarcotic addiction, patient underreporting of symptoms,and lack of emphasis on symptom control in comparison
with disease management. Uncontrolled severe pain is an emergency and requires
aggressive treatment.
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WHO has developed a three-step
"ladder" for cancer pain relief If pain occurs, there should be prompt oral administration
of drugs in the following order: nonopioids (aspirin andparacetamol); then, as necessary, mild opioids (codeine);then strong opioids such as morphine, until the patient isfree of pain.
To calm fears and anxiety, additional drugsadjuvants should be used.
To maintain freedom from pain, drugs should be given bythe clock, that is every 3-6 hours, rather than on demand
This three-step approach of administering the right drug inthe right dose at the right time is inexpensive and 80-90%effective. Surgical intervention on appropriate nerves mayprovide further pain relief if drugs are not wholly effective.
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Cancer pain comes in many forms and often isundertreated.
When the pain fails to respond to acetaminophenor nonsteroidal anti-inflammatory drugs, orotherwise becomes intractable, opioids often arerecommended.
Usually, short-acting opioids are used as needed.
When the pain persists throughout the day,short-acting opioids are replaced with longer-acting opioids two or three times daily to provide24-hour relief.
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Treating worsening Pain in Cancer
May be due to
1.Worsening disease
2.Opioid tolerance 3.Adverse effects of opioids (abdominal pain
due to constipation)
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Opioids most commonly used for
cancer pain
Morphine
Diamorphine
Fentanyl Buprenorphine
Oxycodone
Codeine
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COMMON STARTING DOSES
OPIOID-NAIVE PATIENTS * parenteral dosesequianalgesic to morphine sulfate 10mg SQ
codeine 30mg
hydromorphone 2mg levorphanol 2mg
meperidine 50mg
methadone 5mg
morphine 10mg
oxycodone 5mg
EQUIANALGESIC DOSES
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DRUG ROUTES OF
ADMINISTRA
TION
APPROXIMAT
E
EQUIANALGE
SIC
DOSES*
APPROXIMAT
EDURATION
codeine PO,
parenteral
120mg 4-6 hours
hydromorpho
ne
PO,
parenteral PR
2mg 2-5 hours
levorphanol PO,
parenteral
2mg 4-6 hours
meperidine PO,
parenteral
100mg 2-4 hours
methadone PO,
parenteral
10mg 6-12 hours
morphine PO,
parenteral PR
10mg 3-4 hours
oxycodone PO 15mg 4-6 hours
EQUIANALGESIC DOSES
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Morphine
morphine and some other opioids do not have a"ceiling effect".
Morphine can be safely administered in increasingamounts until the pain is relieved without producing an
"overdose", as long as the side-effects are tolerated. There is no standard dose of morphine; the correct
dose is the one that relieves the pain
Different types
1.Immediate releaseliquid or tablet take every 4hours
2.MST - Slow (sustained)releasetablet or capsuletaken every 12 hours
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Diamorphine
Given by injection
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Fentanyl
Skin patch or lozenger
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Buprenorphine
Temgesic or Transtec
Tabletsts to keep under the tongue or patches
Takes 72 hours to achieve blood levels Used for breakthrough pain relief
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Oxycodone
For bone and nerve pain
Esp if morphine has not helped the pain
Immediate release (Oxynorm) Slow release (Oxycontin)
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Tolerance to Opioids
TOLERANCE- This refers to an increased amount of opioidnecessary to produce the same effect previously seen with asmaller amount of opioid. Tolerance develops to several opioid sideeffects - RESPIRATORY DEPRESSION, NAUSEA and VOMITING,SEDATION and CONFUSION. Twycross states that tolerance to theanalgesic effect is not a clinical problem when opioids are used inchronic pain in cancer patients. When patients require more opioid,their disease can frequently be seen to be progressive. Foley notesthat tolerance develops to the ANALGESIC EFFECT and that crosstolerance between opioids is not complete. In either case, sideeffects permitting, opioid doses can be increased when previous
doses are no longer as effective. When switching drugs, thepossibility of incomplete cross tolerance may be considered, and asmaller than equianalgesic dose be started accordingly.
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PHYSICAL DEPENDENCEimplies that awithdrawal syndrome can be seen upon abruptwithdrawal of an opioid or upon administrationof an opioid antagonist. Physical dependence is a
property of the drug, not the patient. It isgenerally not a concern in chronic pain in cancerpatients. Should the need for opioid bedecreased or removed, a withdrawal syndrome
can be avoided by tapering the opioid overseveral days. It has been noted that withdrawalreactions can be prevented if the dose of opioid is25% of the previous day's dose.
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PSYCHOLOGICAL ADDICTION or
PSYCHOLOGICAL DEPENDENCEresults from a
variety of personality, environmental,
psychosocial, etc. factors. It does not result
from simply exposure to the opioid for a
legitimate medical purpose. ADDICTION is
NOT A CONCERN AMONG CANCER PATIENTSWITH CHRONIC PAIN
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Non-opioids drugs
For bone and muscle pain
Aspirin, Ibuprofen, diclofenac, celecoxib
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Other Drugs
Steroids
Bisphosphonates
Anti-depressants Anti-convulsants
Local anaesthetics
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Steroids
Reduce swelling
Prednisolone and dexamethazone used in
cancer
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Bisphosphonates
Controls bone pain so that the amount of pain
killers can be reduced
Slow down or prevent damage cause by
cancer spread to the bones
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Anti-depressants
For nerve pain not responding to other pain
killers
Helps depression associated with chronic pain
Examples are amitriptyline, imipramine,
doxepin and trazodone
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Anti-convulsants
Help burning or tingling pain
Gabapentin (Neurontin), Carbamezapine
(Tegretol), Phenytoin
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Gabapentin
Blocks Sodium channels
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Local Anaesthetics
Nerve Blocks -
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TENS