Pain Management

Tan Lip Sheng

Introduction
• Pain is a common and feared symptom of cancer

• Many patients with non-malignant, life-threatening disease also suffer

pain

• WHO/ International Association for the Study of Pain: Pain Relief is a

Basic Human Right

• Since 2008, Ministry of Health Malaysia implemented PAIN as 5th vital sign
“I think the simplest and probably the best definition of pain is what
the patient says hurts. I think that they may be expressing a very multi-
faceted thing. They may have physical, psychological, family, social and
spiritual things all wound up in this one whole experience. But I think
we should believe people and once you believe somebody you can
begin to under- stand, and perhaps tease out the various elements that
are making up the pain.”

Dame Cicely Saunders (1918–2005), founder of the modern hospice.

Concept of “total pain”
Origins of pain may be:
• Physical
• Social
• Psychological
• Spiritual

Effective management of cancer pain requires a multidisciplinary approach

that addresses the patient’s concerns and fears, as well as treating the
physical aspects of pain. As a result, the provision of analgesics should be
combined with the provision of emotional, social and spiritual supports
Physical cancer pain
• Acute or Chronic
• Chronic
• Background pain – persistent baseline pain
• Breakthrough pain – pain “breaks through” a regular pain-medicine schedule
Causes of Cancer Pain
The cancer itself Bony/visceral/soft tissue involvement,
nerve compression or infiltration, muscle
spasm, ulceration, raised intracranial
pressure, etc.
Complications of the cancer Pressure sores, constipation, post-
herpetic neuralgia, candidiasis,
lymphoedema, etc.
Treatment of the cancer Neuropathy caused by chemotherapy,
mucositis caused by radiotherapy, post-
operative pain, etc.
Co-morbidities Angina, diabetic neuropathy, arthritis,
etc.
Classification of cancer pain
• Nociceptive pain
• Neuropathic pain

Why ?
- Different types of pain respond to different types of analgesia
- To determine what type of pain in order to prescribe the right
analgesia
- Many may have mixed pain syndrome
Nociceptive pain
• Somatic pain
• Results from stimulation of skin, muscle, bone receptors
• Character is stabbing, throbbing, aching or pressure and usually are well-localized
• Eg bone cancer/metastasis, malignant skin ulcer

• Visceral pain
• results from infiltration, compression or the distension of thoracic or abdominal
viscera
• often poorly localized and may be described as gnawing, cramping, aching or sharp
• Referred pain
Neuropathic pain
• caused by injury to the peripheral and/or CNS
• pain occurs because the injured nerves either react abnormally to stimuli
or discharge spontaneously.
• character: burning, tingling, shooting or electric shock-like sensations.
• It may be associated with hyperalgesia, allodynia, or dysesthesia
• Eg
• Brachial plexopathy from pancoast tumour (pain radiating down upper limb)
• Lumbosacral plexopathy from large pelvic mass (pain radiating down lower limbs)
• Radicular pain from spinal metastasis (pain radiating around trunk like a belt/band)
• Facial pain/headache/trigeminal neuralgia (head and neck cancer)
Assessment
• P – Place / Site of pain (“Where is the pain?”)
• A - Aggravating factors (“What makes it worse?”)
• I – intensity (“How bad is the pain?” – use pain scale)
• N – Nature & Neutralizing factors (“What does it feel like?” & “What
makes it better?”)
Recommended Pain Scales

1. Adult patients – numerical analogue scale/visual analogue scale

(NRS/VAS)
2. Pediatric patients
• 1 month to 3 years old - FLACC scale
• >3 – 7 years old – Wong-Baker Faces scale
• > 7 years old – NRS/VAS
• All scales score from 0 to 10
• always use the same scale for the same patient
Wong-Baker Faces Scale
NRS/VAS
FLACC scale
Measuring intensity
Pain scores Pain intensity

1-4 Mild pain

5-6 Moderate pain

7-10 Severe pain

Classification of analgesics…
1. Non – opioid
• aspirin, paracetamol, NSAIDs

2. Opioids –
• drugs that are agonists at opioid receptor sites
• three types of opioid receptor (mu, kappa and delta)
• found in several areas of the brain and throughout the spinal cord
• Stimulation of opioid receptors results in a variety of responses, including analgesia,
respiratory depression, myosis, reduced gastrointestinal motility and euphoria
• receptor affinity – differences between opioids
• ‘weak’ opioids – dihydrocodeine, tramadol
• ‘strong’ opioids – morphine, fentanyl, oxycodone
…Classification of analgesics
3. Adjuvant analgesics
• do not function primarily as analgesics
• used in combination with opioids
• act to relieve pain in specific circumstances
• choice of adjuvant drug is generally guided by the nature of the underlying
pain
• Eg,
• Antidepressant/anticonvulsant – neuropathic pain
Principle of pain management
• WHO ANALGESIC LADDER according to pain intensity
• Step 1 (mild pain) – use non-opioid analgesics (Paracetamol, NSAIDs, COX-2
inhibitors)
• Step 2 (moderate pain) – use weak opioid analgesics +/- combination of step
1 drugs (tramadol, dihydrocodeine, codeine)
• Step 3 (severe pain) – use strong opioid analgesics (morphine, oxycodone,
fentanyl) +/- combination with step 1 drugs
Principle of pain management
The WHO method can be summarized in five phrases:

1. By the mouth – oral is route of choice

2. By the clock – regular interval for persistent pain, not PRN
3. By the ladder – WHO analgesics ladder
4. For the individual
5. Attention to detail
Principle of pain management
• The right dose of an analgesic is the dose that relieves pain without causing unmanageable
side-effects

• Mild to moderate somatic pain may respond well to NSAIDs and COX-2 inhibitors where there
is strong inflammatory process

• Visceral pain responds well to opioid analgesics

• Neuropathic pain may respond to opioid analgesics but often only partially and will require
addition of adjuvant analgesics

• Morphine is the drug of first choice for treatment of severe cancer pain
STEP 1
• Paracetamol
• NSAIDS
• risk/benefit
Paracetamol/acetaminophen
• analgesic and antipyretic
• lacks an anti-inflammatory effect
• mechanism of action remains unclear
• minimal toxicity at recommended doses
• Hepatotoxic if >4g / 24hrs
• increased risk if underlying liver disease
NSAIDS
• cyclo-oxygenase inhibitor : COX-1 or COX-2; inhibit production of
prostaglandins
• Aspirin not used - difficult to tolerate at analgesic doses due to its
side-effects
• high incidence of adverse events – GI and renal toxicity, CV events
• non-selective NSAIDs - GI effects common
• selective COX-2 inhibitors – less GI effects
Step 2 -‘weak’ opioid

• Codeine
• Codeine is a much weaker agonist at mu receptors than morphine
• Tramadol
• mixed mechanism - weaker agonist at mu receptors /noradrenaline and
selective serotonin-reuptake inhibitor (SSRI)
• A/E – nausea, vomiting, drowsiness, dizziness; tramadol may reduce
seizure threshold
STEP 3
• Morphine is the drug of first choice for treatment of severe cancer
pain
• no “ceiling effect”
• liver is the principal site of morphine metabolism
• products of morphine metabolism are eliminated by the kidney
• oral, rectal, SC, IV. Oral is the preferred route; next best s/c
• Immediate release(peak 1hr, effect 4hrs) vs modified-release/slow
release (peak 2-6hrs, effect 12 or 24hrs)
Principles of opioid prescription
Opioids are safe, effective and appropriate drugs for the management
of cancer pain, provided that:
• Appropriate starting doses and titration are observed
• The properties and relative potencies of different opioids are
understood
• Opioid-related adverse effects are monitored and managed
• Prescribers are aware that some types of pain are poorly responsive
to opioids and require other types of analgesics (adjuvant analgesics)
Starting morphine
• starting dose 5-10mg (usually 5mg) every 4 hours
• elderly/frail 2.5-5mg 4-6hrly
• In renal or liver impairment, lower dose (2.5-5mg) with longer internal
6-8hrly (Fentanyl is the safer opioid to use in renal impairment)
• ALSO prescribe PRN dose for breakthrough pain (same dose as regular
dose)
• After 24hrs, calculate total morphine dose (regular plus PRN)
• once pain is controlled , total morphine dose is divided by 2 and
prescribe nearest slow- release morphine dose 12hrly + prn doses
Opioid Side-effects
• Constipation – always prescribe prophylactic laxatives when using
regular opioid analgesia (lactulose, bisacodyl, senna)
• Nausea / Vomiting – occurs in first 1 week after starting. Treat with
metoclopramide 10mg TDS/QID
• Sedation – occurs during initial dose and normally subsides after a
few days.
Opioid toxicity
• rare
• precipitated by
• excessive increase in opioid dose
• dehydration or renal impairment/change in disease status – hepatic failure
• infection
• drug interaction
• signs and symptoms –
• Drowsiness
• Hallucinations (most commonly visual) • Confusion
• Vomiting
• Myoclonus
• Pinpoint pupils
• Respiratory depression (if severe)
• Naloxone (reversal agent) rarely used unless significant respiratory depression RR < 12
Opioid switching
• changing from morphine to another opioid or changing route of administration
• may be considered if :
• Pain is not well controlled despite optimal titration
• Intolerable side effects occur with morphine
• Renal impairment develops
• cannot swallow medication
• patient’s choice
• unwilling to take oral morphine regularly eg transdermal opioid – fentanyl
• Example
• oxycodone, diamorphine
• Fentanyl
• Buprenorphine
Common conversion factors for opioid
switching

• 1mg IV/SC morphine = 2.5mg oral morphine

• 1mg oral oxycodone = 1.5mg oral morphine
• 25mcg/h fentanyl patch = 75mg oral morphine/day
• 200mg tramadol/day = 30-40mg oral morphine/day

* Transdermal fentanyl(patch) should be used only in patients with

stable pain. It should not be used for titration in patients with
uncontrolled pain.
Neuropathic pain
• Use adjuvant analgesics in combination with opioids:
• Example
• Painful polyneuropathy – TCA, gabapentin, pregabalin, opioids and tramadol
• Postherpetic neuralgia - TCAs, gabapentin, pregabalin, opioids and tramadol
• Trigeminal neuralgia – carbamazepine
• spinal cord - gabapentin, pregabalin and opioids
• post stroke – amitriptyline
• the end