목차
[Cancer Pain]
PAIN CONTROL IN ADVANCED CANCER NCCN Guideline 2009
PAIN
“an unpleasant sensory and emotional experience associated with actual or potential tissue damage”
- Always subjective
- What the patient says it is
PHYSICAL PAIN
* SOMATIC – Well localised, sharp, throbbing, and pressure-like pain (eg. bone metastases) * VISCERAL – Often poorly localised, deep, aching, or colicky pain (eg. liver capsule pain) * NEUROPATHIC- Burning, electrical, or shooting. Caused by nerve damage / destruction
CANCER PAIN PREVALENCE
64% of cancer patients suffer from pain, with 75% of those sufferers categorizing their pain as moderate to very severe1) Moderate to severe pain in 50% of cancer patient 2) More than 70% of patients with advanced cancer3)
MANAGEMENT OF CANCER PAIN
* Primary therapy – Surgery, radiation, chemotherapy * Pharmacotherapy * Indirect delivery system: systemic analgesia * Direct delivery system: neuraxial drug delivery & neuroablation * Other modalities – Physiatric, psychological, neurostimulatory interventions
THREE-STEP ANALGESIC LADDER, WHO 1986
STEP ONE
non-opioid +/- adjuvants
STEP TWO
weak opioid +/- non-opioid +/- adjuvants
STEP THREE
strong opioid + non-opioid +/- adjuvants
MANAGEMENT
PAIN ASSESSMENT
* Quantify pain intensity * Ask patients to describe * Comprehensive pain assessment– Quality, history, intensity, location, referral pattern, radiation, associated factors, current plan, response, prior therapies, pychosocial factors, patient’s goal and expectation
PAIN ASSESSMENT
* Medical emergency * Oncologic emergency
- Bone fracture
- brain metastasis
- infection
- Obstructed or perforated viscus
- Etc
PRINCIPLES
* Opioid begin bowel regimen * Recognize and treat analgesic side effects * Consider adding co-analgesics * Provide psychosocial support * Provide patient and family education * Optimize non-pharmacologic interventions * Prefer oral route
LEVELS OF PAIN INTENSITY
What number describes your worst pain in the past 24 hours?
PAIN IN PATIENTS NOT TAKING OPIOIDS
Severe | Score 7-10 | Rapid titration of short-acting opioid | Reevaluate within 24 hours |
Moderate | Score 4-6 | Titration of short-acting opioid | Reevaluate within 24-48 hours |
Mild | Score 1-3 | NSAID or acetaminophen, or Titration of short-acting opioid | Reevaluate at each contact |
NSAIDS & ACETAMINOPHEN (1)
Use any well-worked NSAIDs in the past or – Ibuprofen, 400mg x q6hr (max. 3200mg/d) – Ketorolac 15-30mg IV q6hr for max. 5days, if needed – Acetaminophen, 650mg q4hr or 1g q6h (max. 4g/d)
CAUTION: – Renal, GI, cardiac toxicities, thrombocytopenia, bleeding disorder
Monitoring – BP, BUN, Cr, CBC, fecal occult blood – Repeat every 3 month
Further decisions – Two NSAIDs w/o efficacy use opioid – Effective but toxicity another NSAID – Consider tropical NSAIDs if not feasible
OPIOID FOR ACUTE PAIN- Oral route
Initial oral dose – 5-15mg of morphine sulfate or equivalent – 10-20% of previous 24-hour dose Reassessment of efficacy & side-effects every 60 min. – Increased or unchanged: increase 50-100% – Score 4-6: same dose reassess after 60 min – Score 0-3: as per need, reassess after 2-3 hours *Failure after 2-3 cycles: IV or reassessment
OPIOID FOR ACUTE PAIN- IV route
Initial IV loading dose
- 2-5mg of IV morphine sulfate or equivalent
- 10-20% of previous 24-hour dose
Reassessment of efficacy & side-effects every 15 min.
- Increased or unchanged: increase 50-100%
- Score 4-6: same dose reassess after 15 min
- Score 0-3: as per need, reassess after 2-3 hours
- Failure after 2-3 cycles: alternate strategies or reassessment
SUBSEQUANT TREATMENT FOR PAIN
Severe to moderate pain (score 4+) – Reevaluate all – Consider opioid rotation – Consider specific pain syndrome – Consider pain specialty consultation – Consider interventional strategies
Mild pain (score 1-3) or goal – Reevaluate pain at each contact – Routine follow-up