Oncological Pain Management

Evidence Based Practice

WORK PREPARED: LAURYNA SIDLAUSKAITE, TADAS JACKUS

OF KLAIPEDA STATE COLLEGE, LITHUANIA 2013.

THE AIM OF WORK: to discuss about the

oncological pain management

Work tasks:
1. Review primary causes of cancer-related
pain.
2. Recognize effects of pain on cancer
patients.
3. View pain conception.

Pain is whatever the experiencing person

says it is, and exists whenever he/she
says it does.

An unpleasant sensory and emotional

experience in associational with actual or
potential tissue damage, or described in
terms of such damage.

Cancer statistics
One in eight deaths worldwide is due to
cancer worldwide. Cancer causes more
deaths than AIDS, tuberculosis, and
malaria combined. There were more than
12 million new cancer cases in 2007
worldwide By 2050, the global burden is
expected to grow to 27 million new cancer
cases and 17.5 million cancer deaths due
to cancer .

Types of pain:
Neuropathic pain
Nociceptive pain
Cancer pain

Neuropathic pain
Compressing or infiltrating nerves/nerve
roots/blood supply to nerve
Nerve damage from treatments
Shooting, sharp, burning, pins & needles
Cranial neuropathies
Post-herpetic neuropathies
Brachial plexus neuropathies
Post-radiationpain
Neuropathic pain can be a sharp, intense,
shocking, or shooting pain.

Nociceptive pain
Nociceptive pain is the type of pain you feel
when you burn yourself, twist your ankle, or stub
your toe. It is a dull or sharp aching pain, and it
can be mild to severe. This type of pain can
usually be controlled. Nociceptive pain can be a
temporary condition, such as when you have a
sprained ankle, but it can also be a chronic
condition. Cancer pain and arthritis pain are
common types of chronic nociceptive pain.

Cancer pain
Pain in cancer may arise from tumor
compression or infiltration of tissue; from
treatments and diagnostic procedures; or from
skin, nerve and other changes caused by the
body's immune response or hormones released
by the tumor. Most acute (short-term) pain is
caused by treatment or diagnostic procedures,
though radiotherapy and chemotherapy may
produce painful conditions that persist long after
treatment has ended.

Physiological effects of Pain

Increased catabolic demands: poor wound
healing, weakness, muscle breakdown
Decreased limb movement: increased risk of
DVT/PE
Respiratory effects: shallow breathing,
tachypnea, cough suppression increasing risk of
pneumonia and atelectasis
Increased sodium and water retention (renal)
Decreased gastrointestinal mobility
Tachycardia and elevated blood pressure

What can we
do ?

To Give Better Quality Of Life

Patients should have the opportunity to

express their emotions, thoughts, fears
and expectations regarding their pain.

SPECIAL GROUPS

( Sau pasirasyti: Certain groups of individuals may be at a higher risk of

under treatment for cancer pain. )

These groups include:

older people.
the cognitively impaired.
people whose first language is not English.
known or suspected substance abusers.
patients at the end of their lives..

Sau pasirasyti: People who are being treated for cancer may also be at
risk of developing pain syndromes as a direct result of cancer treatment
strategies. Pain assessment tools to assess cancer pain in special groups
should be made available.

Psychosocial factors
Negative emotions: anxiety, depression
Sleep deprivation
Existential suffering

An assessment of the psychosocial factors

influencing the experience of pain will
include:
the patients understanding of their condition.
what the pain means to the individual and their
family.
how the pain may impact upon relationships
within the patients family.
whether the pain influences the patients mood.
changes in mood.
coping strategies adopted by the patient.
the patients sleep pattern.
any economic impact.

What Pain Rating

Scales Do We
Know??

Descriptive pain rating scales

Numeric pain rating scale

Verbal Pain Scale

Wong-Baker faces pain rating scale

Visual Analog Scale

Sympathy is not enough

WHO ladder system

Non opioid adjuvants
Weak opioids
Strong opioids

WHO ladder system

The WHO ladder states that non-opioids
(Paracetamol & NSAIDs) should be
administered first,
followed by weak opioids (Codeine) and
then, if required, strong opioids
(Morphine).
It also recommends the use of adjuvant
drugs to calm fears and anxieties.

Medicines used to relieve pain

The type of medicine and the way the medicine
is given depend on the type and cause of pain.
For example, chronic pain is best relieved by
methods that deliver a steady dose of pain
medicine over a long period of time, such as a
patch that releases medicine through the skin or
slow-release pills. On the other hand,
breakthrough pain is best treated with medicines
that work fast (quick release), but stay in the
system only for a short time. Below is an
overview of the types of medicines used to
relieve pain.

For mild to moderate pain

Non-opioid analgesics are pain medications for mild to
moderate pain. Non-opioid analgesics include NSAIDs,
such as ibuprofen, as well as other analgesics such as
acetaminophen and aspirin. These medications also
include adjuvant analgesics, which are those that relieve
pain even though pain relief is not their primary purpose.
Examples include antidepressants and anticonvulsants,
both regularly used to treat certain types of chronic pain.
Non-opioid analgesics may be short-acting or long-acting
pain medications. They may be taken alone for pain
management, though they may also be taken in
combination with opioids to relieve moderate to severe
pain.

For moderate to severe pain

Opioids have long been used to treat severe pain,
though their use in the management of chronic pain
remains somewhat controversial. Some people are able
to tolerate opioids for years without any adverse effects,
while others may become physically dependent or even
develop a tolerance with regular use. Like most
medications, opioids work differently for everyone.
Opioids are a type of analgesic, or medication used to
control pain sensations. Because they are classified as
narcotics, they are available by prescription only. Opioids
work by attaching to certain receptors in the nervous
system and changing the way the brain perceives and
interprets pain.

For breakthrough pain

Rapid-onset opioids: Fast-acting oral
morphine; fentanyl in a lozenge or
"sucker" form (These forms of fentanyl are
absorbed from your mouth as you suck on
them -- they are not swallowed.)
A short-acting opioid, which relieves
breakthrough pain quickly, is often used
with a long-acting opioid for chronic pain.

For tingling and burning pain

Antidepressants: Amitriptyline, nortriptyline,
and desipramine
Antidepressants are prescribed to relieve certain
types of pain. Taking an antidepressant does not
mean that you are depressed or have a mental
illness.
Anti-convulsants (anti-seizure medicines):
Carbamazepine, gabapentin, and phenytoin
Despite the name, anti-convulsants are not only
used for convulsions (seizures), but also to
control burning and tingling (nerve) pain.

Complementary and
alternative medicine
There is a weak evidence base for the
effectiveness of complementary therapies in
terms of pain control, but they
may improve well-being. Safety issues are
also a consideration.

Introduction
Complementary and alternative medicine (CAM) refers
to a diverse array of treatment modalities and diagnostic
techniques. It has been defined as, diagnosis, treatment
and/or prevention which complements mainstream
medicine by contributing to a common whole.
A large proportion of cancer pain patients use CAM. The
reasons for this include dissatisfaction with conventional
medicine, desperation, compatibility between the
philosophy of CAM and the patients own beliefs and the
wish for more control over ones own health.
CAM therapies have the potential to increase wellbeing
and thus influence pain. They are often employed in
addition to conventional treatments in palliative and
supportive cancer care.

Acupuncture
This is the insertion of needles into the skin and
underlying tissues for therapeutic or preventive purposes
at specific sites, known as acupuncture points.
A systematic review identified two randomized clinical
trials (RCTs) and found no compelling evidence that
acupuncture controls cancer pain, which was confirmed
by other reviewers. Subsequent RCTs did not produce
convincing evidence of effectiveness. However, it is
effective in alleviating chemotherapy-related nausea and
vomiting and may hence contribute to pain control.

Aromatherapy
This is the controlled use of plant essences,
applied either to the skin through massage,
added to baths or inhaledwith steaming water.
A Cochrane systematic review concluded that
aromatherapy and/or massage have beneficial
short-term effects on well-being in cancer
patients. However, it has not been convincingly
demonstrated whether it is associated with
clinically relevant analgesic effects.

Herbal medicine
The medical use of preparations, which
contain exclusively plant material.
There is no convincing evidence for any
herbal medicine to suggest effectiveness
for treating cancer pain (Ernst, 2007).

Homeopathy
This is where the diluted preparations of
substances are taken whose effects when
administered to healthy subjects
correspond to the symptoms and clinical
signs of the disorder in patients.
A systematic review of 6 RCTs found no
convincing evidence that homeopathic
remedies have analgesic effects in cancer
patients.

Hypnotherapy
This is the induction of a trance-like state to facilitate
relaxation and enhance suggestibility for treating
conditions and introduce behavioural changes.
Studies have suggested the usefulness of hypnotherapy
in palliative cancer care. A systematic review found
encouraging evidence that hypnotherapy can alleviate
cancer pain. Due to the often poor methodology of the
primary data, this evidence was deemed inconclusive.
Similar conclusions were reached in two systematic
reviews for procedural pain in paediatric cancer patients.

Massage
This is the manipulation of the bodies soft tissue
using various manual techniques and the
application of pressure and traction.
Massage seems to increase well-being through
the reduction of stress and anxiety levels, and
thus may contribute to pain control. The
evidence for analgesic effects in cancer patients
is encouraging but not convincing.

Music therapy
The use of receptive (passive) and/or
active music therapy, most commonly
based on psychoanalytical, humanistic,
cognitive behavioural or developmental
theory.
There is no convincing evidence from RCT
data to suggest effectiveness for pain
control in cancer patients (Ernst, 2007).

Reflexology
The use of manual pressure applied to
specific areas, or zones, of the feet (and
sometimes the hands or ears) that are
believed to correspond to other body
areas or organs.
A few small RCTs generated no
convincing evidence that reflexology
improves quality of life or pain of cancer
patients (Stephenson, 2000).

Relaxation
This involves techniques for eliciting a relaxation
response of the autonomic nervous system, resulting in
the
normalizing of blood supply to the muscles and a
decrease in oxygen consumption, heart rate, respiration
and
skeletal muscle activity. Most commonly, progressive
muscle relaxation is used.
Relaxation techniques have the potential to increase
well-being and thus may contribute to
controlling pain. Whether these techniques have direct
analgesic effects remains, however,
unknown.

Supplements
Oral medical use of preparations of herbal
or non-herbal origin.
A systematic review of nine RCTs that
tested cannabinoids concluded that they
are not superior to codeine in controlling
cancer pain. As cannabinoids cause
central nervous depression, their
introduction into routine care was deemed
undesirable (Campbell, 2001).

Conclusion
Cancer pain can be from the cancer itself,
or from cancer-related treatments
Can be nociceptive, visceral, or
neuropathic
Choose non-opioid / adjuvants carefully
paying close attention to side effect profile

Conclusion
Use WHO ladder guidelines when titrating
pain medications.
Use long-acting opioids for chronic cancer
pain.
Ask the patient about pain and
REASSESS!

Can we offer this ?

Thank you for

attention!

References

European Pain in Cancer (EPIC) survey (2007). Cited in

www.EPICsurvey.com.
Cancer Pain Management (2013).The British Pain Society's.
Ahmedzai SH, Walsh TD. Palliative medicine and modern cancer
care. (2001). Seminars Oncology