추적: • cancer_pain

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[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 opioidReevaluate 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

  1. 2-5mg of IV morphine sulfate or equivalent
  2. 10-20% of previous 24-hour dose

Reassessment of efficacy & side-effects every 15 min.

  1. Increased or unchanged: increase 50-100%
  2. Score 4-6: same dose reassess after 15 min
  3. 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

1)
Meier DE. J Pain Symptom manage 2002
2)
Vainio A, J Pain Symptom manage 1996
3)
Ventafridda V, Pain Rev 1996