Management of Cancer Pain
Guidelines for Healthcare Professionals
Professor Ramani Vijayan, Department of Anaesthesiology, UMMC.
From her notes for participants of Palliative Care Conference,
26 - 27 April 2003 at Monash University Malaysia. (Edited)
Successful pain management in a person suffering from cancer pain depends on a proper assessment and diagnosis of the pain. In other words, the cause of the pain must be identified, together with its intensity and its impact on the quality of life of the terminally ill person.
The possible source of cancer pain can be:
- Pain associate with direct tumour involvement
- Pain associated with treatment
- Pain associated with chronic illness
- Pain unrelated to cancer and its treatment
- Any of the above combination
In 1982, the World Health Organisation (WHO) initiated a programme which aimed to improve the treatment of cancer pain worldwide. These guidelines were published in 1986. The core of these guidelines is a 3-Step analgesic ladder which, depending on individual pain intensity, progresses from:
- NSAIDS (non-steroidal anti-inflammatory drugs)
- Weak opioids
- Strong Opioids
These guidelines stressed that palliative cancer treatment, adjuvant drugs and other symptomatic therapeutic measures may be integrated into every analgesic step.
| Type |
Drugs |
| Non-Opioid |
Paracetamol
NSAIDS |
| Weak Opioid |
Codeine
Dihydro-codeine
Tramadol |
| Strong Opioid |
Morphine
Transdermal Fentanyl
Buprenorphine |
Table 1 Shows a list of drugs available in Malaysia for pain management in cancer.
Adjuvant drugs such as anti-convulsants (clonazepam, carbamazepine) should be commenced without delay if they are indicated. These drugs are especially useful for stabbing neuropathic pain (nerve pain).
Other adjuvant drugs like corticosteroids (dexamethasone, prednisolone) can be used for pain arising from nerve or cord compression, or due to raised intracranial pressure.
Thus, the WHO Analgesic Step Ladder looks like this:
| |
|
Step 3: Strong Opioids
Morphine, Transdermal fentanyl |
| |
Step 2: Weak Opioids
Tramadol, Codeine |
|
| Step 1: NSAIDs |
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Adjuvant drugs may be added at every step, if necessary, to enhance analgesia.
Pethidine is NOT recommended for use in severe pain associated with cancer as the metabolite or breakdown products of pethidine, norpethidine, may acculumate over a period of time and may cause convulsion.
Guidelines for analgesic therapy
- Analgesics form the mainstay of cancer pain control and should, as far as possible, be given orally. Pain can be controlled in 80% of patients with the judicious use of analgesics.
- The choice of analgesics depends on the intensity and type of pain. There are two types of pain:
- The spread of tumour to viscera organs such as the liver, pelvic organs, lungs, bowels, or to deep somatic structures such as the chest wall or bone secondaries produce nociceptive pain.
- The other type of pain resulting from the destruction of nerve from tumour infiltration to the nerves is called neuropathic pain.
- Cancer patients frequently have more than one type of pain. A combination of analgesics is usually necessary to ensure maximum pain relief.
- They should always be given in suitable dose on a time contingent basis and never on a "when necessay" basis.
- There should be rapid progression from Step 1 through to Step 3 of the ladder if pain control is inadequate.
- Early use of adjuvant drugs is recommended.
- If pain relief is inadequate despite strong opioid therapy, re-evaluate the origin of the pain and use other drugs/modalities.
Chronic pain induces physiological, psychological, emotional and psychosocial changes that are largely similar regardless of the aetiology of the pain. However, the impact of cancer pain on the patient and family is much greater than that of non-malignant acute or chronic pain.
In the management of cancer pain, it is important to understand the various factors that alter (diminish or exacerbate) one's perception of pain. Anxiety, depression and anger can heighten or increase the perception of pain.
Besides all the medical modalities that are available, care of these patients should include empathy and kindness.
See Also:
The Use of Morphine in Cancer Pain
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