The Role of Opioid in

Cancer Pain
Management

OPIUM
Among the
remedies which it
has pleased
almighty God to
give man to relieve
his sufferings, none
is so universal and
so efficacious as
opium
Sir Thomas
Sydenham
1680
Opioid
is selectiively
eliminate
suffering from pain. Dont damage
organ.

Concept of Cancer Pain

1.
2.
3.
4.

TOTAL PAIN is the sum of 4

components:
Physical noxious stimuli
Emotional discomfort
Interpersonal conflicts
Nonacceptance

(Dr. Cicely Saunders 1967, founder of first Hospice in

WHO 1986
Symptoms of debility

Non-cancer pathology

Side-effects of theraphy

Cancer

ORGANIC PAIN
Loss of social position

Bureaucratic procedure

Loss of job prestige and

income

Friends do not visit

Loss of role in family

DEPRESSION

ANGER

Delay in diagnosis
Unavailable doctors

Chronic fatigue and insomnia

Irritability

ANXIETY

Sense of helplessness

Therapeutic failure

Disfigurement

Fear of hospital or nursing home

Fear of pain

Worry about family

Family finances

Fear of death

Loss of dignity and bodily

control

Spiritual unrest

Uncertainty about future

(Biopsychosociospiritul disesase)

Anger
Neuropatic &
Nopciceptic pain

Anxiety

Fear

Depression
PSYCHOLOGICAL

A
cancer pain

PAIN

Noxious Stimuli

Cancer Pain Prevalence

For many patients pain is the first sign of
cancer.

30 50 % of all cancer patients will

experience moderate to
severe pain.
75 95 % of patients with
advanced stages
will experience
severe pain.
45 %
of cancer patients have
inadequate pain control.
25 %
Will die in pain.

Aetilogy of Cancer
Pain
Cancer-related: 60 - 90%
Cancer-associated:
10
- 25%
Treatment-related:
520%
Non-cancer -related : 3 -

There are many ways to deal

with cancer pain.
- Three Step Ladder of WHO

5 essential
concepts
By mouth
By the clock
By the ladder
By individual
With attention
to detail

By this method about 90% of cancer pain can

be relieved

WHO guidelines for the

treatment of cancer pain
90% of cancer pain syndromes can be
well controlled by using guidelines
established by the WHO.
Only
About 10% of patients are still suffering
pain.
So, only 10% of patients need special
skill or techniques pain treatment

Rule 1 in Cancer Pain

treatment
1.Pain assessment
Pain assessment is very
important and should be
assessed constantly.
Never treat the pain before
assessing the intensity of pain.
Because you would have
never known how good or how
bad you are in treating the

Pain Assesment
Is pain present?
Where is the pain?
What are descriptions of the pain?
(Quality)
What is pain intensity rating (0-10)?
(Quantity)
What make your pain worst or
better?
What is the current pain regimen?

Pain Assessment
Two things must be determined before
treating
cancer pain.
1. Type of pain ( quality of pain)
Somatic pain
Visceral pain
Neurophatic pain
In most cancers pain, mostly combined form

2.

Intensity of pain (quantity of pain)

Mild pain
13
Moderate pain 4 7
Severe pain
8 10

After pain assesment

Application of
Three Step Ladder
of WHO

Three-Step ladder of
WHO
Step III

pain,
Seveare pain Severe
Strong Opioid analgesics

Pain level

Step II Moderate Pain

For mild to moderate pain,
Mild Opioid analgesics

Non-opioid analgesics
adjuvant analgesics

Non-opioid analgesics
adjuvant analgesics

Step I Mild Pain

Non-opioid analgesics
adjuvant analgesics

Pain

Strong opioids
Morphine (MST Continus)

Pain

Mild Opioid
Codeine or Tramadol

Paracetamol+Codeine
paracetamol+Tramadol
APAP /NSAIDs adjuvants
Successive change

APAP/NSAIDs adjuvants

Step I (VAS 1-3)Mild

Pain
Analgesic Non-opioid

NSAIDs
Paracetamol
adjuvants
Steroid (dexamethasone)

Anti depressant (tricyclic)

Gabapentinoid (pregabalin)
Dextrometorphan/ Ketamin

Step II (VAS 4-7)

Moderate
Pain
Weak opioids 1. Codeine
2. Tramadol

Paracetamol
NSAIDs / Coxib (Celecoxib)
Adjuvants

Combine (Codeine +Paracetamol)

(Codeine + NSAID)
(Codeine + Celecoxib)
Codeine is very constipating, less nausea &
vomiting
When use codeine, must be added anti constipation
Combine (Tramadol+Paracetamol)
(Tramadol is high
nausea/vomiting; but
h
less constipating)
Adjuvants

Rule 2 seveare or strong pain

If VAS >7 seveare or strong
pain
2. Strong pain needs strong
analgesic

Strong analgesic is opioid

(Morphine)

Remember!!!

* All non opioid has ceiling effect and should be given with
Never administered by drips.
* Only opioid can be administered by drips.

Step III (VAS 7-10)

Strong-Opioid

Never apply monomodal , always multimodal analgesia, get op

What is MST?
MST is Morphine Sulfat Tablet
Continues release
Onset 3 hours an duration 12
hours.
Tablet 10 mg, 15,30mg
Establish total dose of morphine
needed in 24 hour , than divide into 2
for every 12 hours.

Breakthrough Pain
BTP is a brief severe pain that
occurs even while the patient is
regularly taking pain medication. It
usually comes on quickly and may
last from a few minutes to an hour.
Breakthrough pain might be a sign
of tolerance to opioid, means a sign
that opioid dose needs to be
increased.

Time Pattern of Cancer

Pain
Over Medication

Around-the-Clock
Medication

Breakthrough
pain

n
d pai
n
u
o
r
g
Back
Time

Treatment of
Breakthrough Pain
Breakthrough pain usually is treated
with strong, rapid onset and shortacting pain medications.
Thee drugs have shown to be more
effective than oral morphine in the
treatment of breakthrough pain.

common side effects of

Opioid:
Constipation
Sedation
Nausea and vomiting
tolerance
Delirium
Myoclonus
Pruritus
Respiratory depression
Addiction?
McNicol E, Management of Opioid Side Effects in Cancer-Related and
Chronic Noncancer Pain: A Systematic Review. The Journal of Pain, Vol 4, No 5 ,
2003: pp 231-256.

Rule 3 of pain
treatment

3. Dosage should be titrated and

escalation.

Because patients dont want

to be analgesia with
sedation
but,Patient wants to be
analgesia with full alert.

INTEGRATION OF OTHER
INTERVENTIONS TO THE WHO
LADDER
Anaesthetic
interventions

Cancer
therapies

surgery

Fr
e
ca ed
nc om
er fr
pa om
in

Pa
in
in per
cr si
ea st
si ing
ng o
r

Pa
in
in per
cr si
ea st
si ing
ng o
r
Pa
in
in per
cr si
e a st
si ing
ng o
r

physiotherapy
Occupational
therapy

psychology

Spiritual care

90% of Cancer Pain can be managed by

using WHO Step Ladder.
WHO Step Ladder

Severe Pain
Moderate Pain
Mild Pain
Nonopioid
adjuvant
Acetaminophen
Ibuprofen
Celecoxibe

Mild Opioid
nonopioid
adjuvant

Codein or Tramadol
Paracetamol
or
NSAID or Coxib

Strong Opioid
nonopioid
adjuvant

Morphine

- Rapid relies; tab

or liquid
- Slow relies MST

Fentanyl Patch
Modify AHT

WHO three step ladder

Paracetamol
adjuvants
Increasing pain

Weak Opioid for

mild to moderate
pain
Paracetamol
adjuvants

Strong Opioid for

severe pain
(Morphine)
adjuvants

Take Home Message

Opioid therapy is the mainstay
treatment in cancer pain with 90%
effectiveness
Opioid is not a life threatening drug if
you use it properly.
Be confident of using opioid when its
necessary.
Do palliative care concept with good
palliation of symptom.
1.

2.

VielhaberA, Portenoy RK. Advances in cancer pain

management
Hematology/oncology Clinics of North America Vol 16, No 3,
2002
Fallon M. Palliation of breathlessness. Clinical Medicine Vol 6

Rule 3 of pain
treatment

3. Dosage should be titrated and

escalation.

Because patients dont want

to be analgesia with
sedation
but,
Patient wants to be
analgesia
with full alert.

INTEGRATION OF OTHER
INTERVENTIONS TO THE WHO
LADDER
Anaesthetic
interventions

Cancer
therapies

surgery

Fr
e
ca ed
nc om
er fr
pa om
in

Pa
in
in per
cr si
ea st
si ing
ng o
r

Pa
in
in per
cr si
ea st
si ing
ng o
r
Pa
in
in per
cr si
e a st
si ing
ng o
r

physiotherapy
Occupational
therapy

psychology

Spiritual care

90% of Cancer Pain can be managed by

using WHO Step Ladder.
WHO Step Ladder

Severe Pain
Moderate Pain
Mild Pain
Nonopioid
adjuvant
Acetaminophen
Ibuprofen
Celecoxibe

Mild Opioid
nonopioid
adjuvant

Codein or Tramadol
Paracetamol
or
NSAID or Coxib

Strong Opioid
nonopioid
adjuvant

Morphine

- Rapid relies; tab

or liquid
- Slow relies MST

Fentanyl Patch
Modify AHT

WHO three step ladder

Paracetamol
adjuvants
Increasing pain

Weak Opioid for

mild to moderate
pain
Paracetamol
adjuvants

Strong Opioid for

severe pain
(Morphine)
Celecoxib
adjuvants

Take Home Message

Opioid therapy is the mainstay
treatment in cancer pain with 90%
effectiveness
Opioid is not a life threatening drug if
you use it properly.
Be confident of using opioid when its
necessary.
Do palliative care concept with good
palliation of symptom.
1.

2.

VielhaberA, Portenoy RK. Advances in cancer pain

management
Hematology/oncology Clinics of North America Vol 16, No 3,
2002
Fallon M. Palliation of breathlessness. Clinical Medicine Vol 6