Cancer Pain David Cameron MB ChB, M Prax Med, M Phil (Palliative Medicine) Assoc Professor of Family Medicine University of Pretoria 20/09/2018

“I’m not afraid to die…… Woody Allen I just don’t want to be there when it happens.” 20/09/2018

Introduction to Pain Management What is Pain? An unpleasant feeling An unpleasant thought An unpleasant emotion Just imagine…… 20/09/2018

You are relaxing in the garden Thought Feeling Emotion!!! 20/09/2018

What do we know about Cancer Pain? Common & Under-treated Persistent and Progressive Feeling, Thought, Emotion “Total Pain” Concept 20/09/2018

WHO Analgesic Ladder Add extra “helpers” Morphine Strong Opioid Codeine Tramadol + Weak Opioid 3. Severe Pain NSAIDs Amitrityline Cortisone 2. Moderate Pain Paracetamol 1.Mild Pain Adjuvants Add extra “helpers” 20/09/2018

Why is morphine the ideal drug for treating pain in advanced cancer? 1. Effective 2. Flexible 3. Available 4. Economical 5. Safe 20/09/2018

1. Effective: Different kinds of pain Pain of varying severity Rapid onset Sustained action No maximum dose! 20/09/2018

2. Flexible: Variety of forms: liquid, tablet, injection, suppository Variety of routes: PO, PR, SC, IM, IV, IT, Nasal Combines well with many drugs 20/09/2018

3. Available: Private & Public Sector Urban & Rural Primary, Secondary & Tertiary Levels 20/09/2018

Drug Dosage Cost/day 4. Economical Oral Morphine 100 mg/ day Oral Morphine Solution 16 mg 4 hrly R4.50 Sustained release morphine tablets 50 mg 12 hrly R30.30 Fentanyl Transdermal Patch 25 micro gms/ 72 hrs R45.00 20/09/2018

5. Safe Most side effects are temporary Many side effects can be overcome Not dangerous in most patients 20/09/2018

How to give morphine: 1. By mouth 2. By the clock: 6am, 10am, 2pm, 6pm, 10pm, 2am 3. By the ladder: Step up when needed 4. How much? As much as needed! 5. How should I increase the dose? Add 50% and “round up” 6. Breakthrough or Incident Pain Same as 4hrly dose (NB: Extra) 20/09/2018

Side effects of Morphine Sedation Confusion Dizziness Sweating Dry mouth Constipation Urticaria Nausea and vomiting Neurotoxity 20/09/2018

What are the reasons for withholding Morphine? 1. Respiratory Depression 2. Addiction 3. Tolerance 4. Side effects 5. Too much bother?? 20/09/2018

What else can we do? 1. Non-Steroidal Anti-Inflammatory Drugs 2. Steroids 3. Palliative Radiotherapy 4. Palliative Chemotherapy 5. Anti-convulsants 6. Anti-depressants 7. Ketamine 8. Nerve Blocks 20/09/2018

What is Palliative Care? I’m not a failure if my patient dies I won’t abandon you What is Palliative Care? Accepts: Death is a natural part of life Alleviates: When we cannot cure Aim: Best possible quality of life & preparation for death 20/09/2018

You should never have to say... “I can do nothing more for you.” “I’m sure there is something we can do.” 20/09/2018

You have learnt to manage cancer pain in 3 easy steps You can choose what type of doctor you will be 20/09/2018