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

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

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

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

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

6. 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

7. 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

8. 1. Effective: Different kinds of pain Pain of varying severity
Rapid onset
Sustained action
No maximum dose!
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9. 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

10. 3. Available: Private & Public Sector Urban & Rural
Primary, Secondary & Tertiary Levels
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11. 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
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12. 5. Safe Most side effects are temporary
Many side effects can be overcome
Not dangerous in most patients
20/09/2018

13. 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)
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14. Side effects of Morphine
Sedation
Confusion
Dizziness
Sweating
Dry mouth
Constipation
Urticaria
Nausea and vomiting
Neurotoxity
20/09/2018

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

16. 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

17. 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

18. 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

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