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med:cancer_pain [2013/12/23 15:51] – [PAIN IN PATIENTS NOT TAKING OPIOIDS] anonmed:cancer_pain [2015/06/07 13:37] (현재) – 바깥 편집 127.0.0.1
줄 1: 줄 1:
 +====== [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 severe((Meier DE. J Pain Symptom manage 2002))
 +Moderate to severe pain in 50% of cancer patient ((Vainio A, J Pain Symptom manage 1996))
 +More than 70% of patients with advanced cancer((Ventafridda V, Pain Rev 1996))
 +
 +
 +
 +
 +=====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
 +