Cancer Pain management Hesam modin hariri,MD Palliative & supportive care center

به نام خداوند جان و خرد

Definition of pain  “Pain is an unpleasant sensory and emotional experience associated with actual and potential tissue damage or described in terms of such damage”

Physical Psychological Social Spiritual TOTAL PAIN

Prevalence  64% in patients with metastatic or advanced stage disease  59% in patients on anticancer treatment  33% in patients after curative treatment

The experience of pain can  Induce depression  Exacerbate anxiety  Interfere with social performance and impair the quality of relationships.  Negatively impact on physical capability.  Prevent work & reduce income.  Challenge existential beliefs.  Constantly impact on the patient’s experience of pain.

Causes  Cancer itself (this is by far the most common): Extension into soft tissues Visceral involvement Bone involvement Nerve compression Nerve injury Raising intracranial pressure

Causes  Related to the cancer e.g. muscle spasm, lymphoedema, constipation, bedsores  Related to anticancer treatment e.g. chronic postsurgical scar pain, chemotherapy-induced mucositis  Concurrent disorder e.g. spondylosis, osteoarthritis

Evaluation 1. Believe the patient’s report of pain 2. Initiate discussions about pain 3. Evaluate the severity of the pain 4. Take a detailed history of the pain 5. Evaluate the psychological state of the patient 6. Perform a careful physical examination 7. Order & personally review any necessary investigations 8. Consider alternative methods of pain control 9. Monitor the results of treatment

Approaches to pain management in cancer patients  Psychological approaches:  Understanding  Companionship  Cognitive behavioural therapies  Modification of pathological process:  Radiotherapy  Hormone therapy  Chemotherapy  Surgery  Drugs:  Analgesics  Antidepressants  Anticonvulsants  Anxiolytics  Neuroleptics Interruption of pain pathways: Local anaesthetics Neurolytic agents Neurosurgery Immobilization: Modification of daily activities Rest Cervical collar or corset Plastic splints or slings Orthopedic surgery

“Drug treatment is the mainstay of cancer pain management”

WHO guidelines for analgesics use to control cancer pain ̶ By mouth ̶ By the clock ̶ By the ladder ̶ For the individual ̶ Attention to detail World Health Organization. Cancer pain relief.

Analgesic given on PRN basis PRN Analgesic

Analgesic given by the clock By the clock analgesic Breakthrough pain Baseline pain

Analgesic given by the clock By the clock analgesic Breakthrough pain PRN analgesic Baseline pain

1 Non-opioid ± Adjuvant 2 Weak opioid ± Non-opioid ± Adjuvant 3 Strong opioid ± Non-opioid ± Adjuvant Pain Pain persisting or increasing Pain persisting or increasing

WHO. Cancer Pain Relief

The risk of respiratory depression from opioid analgesic is more myth than fact”

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