Management of Cancer Pain
Jiři Šedo
Ondřej Sláma
Masaryk Memorial Cancer Institute, Brno
Prevalence of pain
• 30% diagnosis
• 50% during active tumor oriented therapy
• 70-90% advanced and terminal stages
Many patients suffer from unrelieved pain!!!!!
• Focusing on the cause, pain itself is
overlooked….
• Poor assessment
• Lack of knowledge
• Fear of
– addiction
– tolerance
– adverse effects
Reality
L.B.
• 58 y man
• Dg.: NSCLC (lung cancer), bone metastases,
• 3 series of standard chemotherapy were given
• Coming to our office with pain 6/10 in his back,
with episodes of 9/10 irradiating to left leg on some
movement
• Medication: He is taking Ibuprofen 400mg
4-5 tbl daily without any effect
Let’s treat our first patient…
• History
• Presenting complaint - describing pain:
– Intensity
– Type
– Irradiation
– Breakthrough pain:
provoking moments, duration, relief
• Physical examination
• Imaging…
Assessment:
• X-ray image
• CT
• MRI
• Nuclear medicine:
– Bone scan with 99mTc
– SPECT/CT
– PET, PET/CT – not for bone metastases
Imaging
X-ray
X-ray
CT
MRI
bone scan (scintigraphy)
Nociceptive pain:
◦ Irritation of nociceptors caused by local tissue damage
(inflamation, ischemia, infiltration by tumor)
Neuropathic pain:
◦ Central Nervous System:
 Spinal cord or root compression (pathological fracture of the
vertebrae)
◦ Peripheral Nervous System:
 Plexus infiltration
 Herpes Zoster
 Chemotherapy itself (paclitaxel)
Combination (mixed)
Types of pain
L.B.
• How would you characterize the pain
• How would you manage the pain?
L.B.
WHO ladder
III. Severe pain
I. Mild pain
II. Moderate pain Strong opioids
- morphine
- hydromorphone
- oxycodone
- fentanyl
- buprenorphine
Mild opioids
- dihydrocodein(DHC)
- tramadol(Tramal)
Non-opioid analgesics
- paracetamol/acetaminophen
- NSAIDs(diclofenac, metamizol,
ibuprofen)
- COX2 pref. (nimesulid)
+/- non-opioids +/- non-opioids
+/- co-analgesics
 Paracetamol/acetaminophen
 NSAIDs
◦ diclofenac(Veral)
◦ metamizol(Novalgin)
◦ Ibuprofen(Motrin)
 COX2 pref.
◦ nimesulid(Aulin, Coxtral)
 Adverse effects:
◦ GI toxicity
◦ Nefrotoxicity
◦ Thrombocytes aggregation - bleeding
◦ Hepatotoxicity (nimesulid, acetaminophen)
◦ Agranulocytosis
Non-opiods
Tramadol (Tramal, Tralgit)
+ immediate/sustained release tablets available
- nausea, vomiting, weakness, sedation
- Ceiling dose at 400mg daily
Dihydrocodein (DHC continus)
- Ceiling dose at 240mg
Opioids for moderate pain
• Tramadol SR 100mg 1-0-1
• Eventually Metamizol 500mg every 8hours or
Nimesulide 100 mg 1-0-1 (or paracetamol 1000mg TID)
• Tramadol IR 50mg as a rescue every 6hours
What are you going to do next?
• He underwent irradiation 5 x 4Gy to the vertebrae
Th 11 – L3
• After that just residual pain
• He was taking Tramadol SR 0-0-1 for 3 months
L.B. medication
…L.B.
• 4 months later – progression of lung cancer in
bone, liver
• …strong low back pain and right epigastrium
pain despite tramadol 400 mg/D + metamizol
3000 mg/d
• What would you do?
Strong opioids
• Opioid receptor agonists (CNS, PNS, lung,
lymphocytes..)
• Effect/ advers effects are dose dependent
• Individual dose „titration“
• Drug of choice for severe cancer pain
(prognosis is not relevant)
Postoperative, ICU setting (parenteral)
• sufentanyl
• piritramide (Dipidolor)
• pethidine (Dolsin)
Chronic pain (oral, transdermal)
• morphine
• hydromorphone
• oxycodone
• fentanyl
• buprenorphine
• tapentadol
Strong opioids
• Long-acting
• Tablets (morphine, oxycodone, hydromorphone)
• Transdermal patches (fentanyl, buprenorphine)
• Short-acting
• Morphine s.c., i.v.
• Tablets po
• Buccal tablets – fentanyl (Effentora)
• Nasal spray - fentanyl (Instanyl)
• Sublingual tablets (Lunaldin)
Forms of Opioids
• Cancer progressed in spine, pelvis and lymph
nodes
What opiates did we choose ?
– Fentanyl patches 25ug/h → 75ug/h every 72hours
– Morpine p.o. 20mg tablets 2-3x daily
What side effects could we expect?
• V.B. presented with:
– Fatique, sleepiness, weakness, worse concentration
– Obstipation, nausea, loss of appetite
V.B.
Balance
Pain relief Adverse effects
Nausea and Vomitting
 Transitory, usualy disappears after 5-10 days
 Stimulation of CTZ
◦ anti-D2:
haloperidol 0.5mg-2mg q6-12h
triethylperazin (Torecan): 6,5mg q8h
metoclopramide(Degan): 10 mg q6h
EPS (especially combination with AD)
◦ 5-HT3:
ondasetron (Zofran): 8 mg, $, antipsychotic effect?
olanzapine (Zyprexa)
 Gastric stasis (vomiting)
◦ metoclopramide (Degan)
Sedation
• Common at start, tolerance develops
• D/C of contributing medications: antihistamines,
antidepressants, anxiolytics,
• Dose reduction, invasive methods of opioids application
• Opioids rotation
• Common, tolerance doesn´t develop
• Laxatives
– Osmotic: Lactulose
– Stimulatns: picosulphate(Gutalax)
– …..
• Oxycodon/Naloxon (TARGIN)
• Methylnaltrexon(Relistor)
– S.c. injection q48h
– Antagonist of the opioid receptors in the gut, but
no effect on central opioid receptors
Constipation
Respiratory depression
• Rare in chronical pain management
• Tolerance usually develop
• D/C benzodiazepines
• Naloxone
• – if less than 8breaths / minute
• - systemic withdrawal syndrome
General recommendations in
management of the side-effects:
(1) Balance the doses of systemic opioids (use rescue
medication)
(2) Manage actively the adverse effects of opioids
(3) Opioid rotation
Equianalgesic dose minus 20-30% (lower tolerance to the new
opioid)
(4) Change the route of administration
• Opioids are safe and effective
• Side effects are manageable
– Central Nervous System:
– Spinal cord or root compression (pathological fracture of the
vertebrae)
– Peripheral Nervous System:
– Plexus infiltration
– Herpes Zoster
– Chemotherapy itself (paclitaxel)
Neuropathic pain
• Antidepressants
– TCA (Amitryptilin, Nortryptilin, Dosulepin)
• Anticonvulsants (Gabapentin, Pregabalin,
Carbamazepine)
• Corticosteroids (Dexamethasone)
– Especially in case of root/spine cord compression
Co-analgesics for neuropathic pain
Subarachnoidal delivery
- Use mixture od opioid + anaesthetics (bupivacaine,
mesocaine)
• Continual infusion to the epidural catether
• Morphine 5ml(20→50mg) + Bupivacaine 1%
5ml + saline solution 10ml v=2-3ml/h
• Effect:
– no pain
– some level of sedation
V.B.
• In August symptoms of chronic sepsis
• Worsening of pain
• CT: huge abscess invading gluteal muscles,
both lesser and greater pelvis on the right
V.B.
 Analgetic radiotherapy
◦ Skeletal and subcutaneous metastases
 Neurolysis of ggl. coeliacum
◦ Pain originates at the innervated area
◦ Usually pancreas/gastric cancer
◦ Alcohol application under CT-guidance
 Medical cannabis
 Neurostimulation: TENS
 Psychological approaches
◦ Cognitively-behavioural therapies, relaxation….
Other methods
Summary
• Cancer pain is manageable
• Need of comprehensive assessment
• Comprehensive intervention
• Opioids are safe and effective drugs for the
management of severe cancer pain
• Side effects are manageable