1. Slavica Lahajnar Institute of Oncology Ljubljana Choice of Analgesic Appropriate to Pain Intensity PMI in Patients at the Institute of Oncology

2. Chronic Pain in Cancer Around 60-80 % of patients with advanced cancer suffer pain. Up to 40 % suffer from uncontrolled pain (VAS≥4). Inappropriate use of opioids may often be the cause of uncontrolled pain. Evendingen MH, Rijke JM, Kessels AG et all. Ann Oncol 2007; 18: 1437-49 Cohen MZ, Easley MK, Ellis C et all. J Pain Symptom Manage 2003; 25: 519-527 Maltoni M. Ann Oncol 2008; 19: 5-7

3. Negative PMI: considering pain intensity, the prescribed analgesic is not strong enough. Metaanalysis of 26 trials (Ann. Oncol. 2008): 43% (8-82%) has negative PMI. Estimate of the pain management interventions on the basis of good clinical practice (using WHO three-grade pain scale). Rough estimate of the pain management in general population. Pain Management Index (PMI) Cleeland CS, Gonin R, Hatfield AK et all. N Engl J Med 1994; 330: 592-6 Wit R, Dam F, Loonstra S et all. Pain 2001; 91: 339-349 Deandrea S, Montanari M, Moja L. Ann Oncol 2008; 19: 1985-91

4. 248 patients’ charts Negative PMI in patients with uncontrolled pain. Comparison with a similar study performed in 2005. Other causes of uncontrolled pain. Raziskava na Onkološkem inštitutu - prescribed analgesic - patient’s estimate of pain intensity (the 5 th vital sign) A Study Carried Out at the Institute of Oncology

5. 18% 45% 18%

6. A Study Carried Out at the Institute of Oncology 74 % 22 %

7. A Study Carried Out at the Institute of Oncology 11% 56% 13 - 2 prescribed analgesic – pain intensity = PMI -=

8. A Study Carried Out at the Institute of Oncology Conclusions (1): In 2009 (in comparison to 2005): -Less patients with VAS ≥ 4 (none with VAS ≥ 7). -The patients with VAS ≥4 are receiving analgesics (the majority are treated with a strong opioid, noone with nonopioid alone). -Less patients are treated with analgesics that are not strong enough considering the pain intensity (neg. PMI). ○ Instructions provided to therapists, nurses and patients

9. PMI Positive Patients with Uncontrolled Pain 3 prescribed analgesic – pain intensity = PMI 3 -= 0 immediate-release opioid for break-through pain adjuvant agents to relieve side effects of opioids adjuvant agents and interventions to relieve neuropathic pain cancer treatment (bone metastases)

10. A Study Carried Out at the Institute of Oncology Patients under Opioid Treatment pain intensity pain management VAS ≥ 4 N=46 VAS ≤ 3 N=91 strong opioid74%34% immediate-release opiod85 %78 % laxative59 %27.5 % antiemetic9 %13 % agents and interventions to relieve neuropathic pain 19.5 %12 % agents and interventions to releive pain caused by bone metastases 13 %15 % corticosteroid6.5 %9 % locally advanced disease and bone metastases 65 %52 %

11. A Study Carried out at the Institute of Oncology Conclusions (2): Patients with z VAS ≥ 4 are treated with inadequate dose of controlled-release opioid. They do not take “rescue” dose of immediate-release opioid as prescribed Patients with advanced cancer (bone metastases) often suffer uncontrolled pain. titration of opioid rotation of strong opioid treatment efficiency follow-up individulized pain management

12. Thank you for your attention!