Cancer pain management

2. Cancer Pain Management &
Morphine

3. 3
What is Pain?
 Robert Twycross defines
- “Pain is what the patient says hurt”.
 In 1979, IASP defines pain as
‘an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage’.

4.  Among Cancer patients
Most prevalent symptom is Fatigue 100
%
And then Pain 65 to 70%
All of them were under treatment

5. In advanced cancer
 3 / 4 th of patients experience pain
 1 /4 th of patients do not experience
pain
 1 /3 have a single pain
 1 /3 have two pain
 1 /3 have three or more pain

6. Cancer pain and palliative care
Death
(2009)
Proportion
with
moderate/s
evere pain
Number of
deaths with
moderate/
severe pain
Cancer 91,494 80% 73,196
Ref: Global access to pain relief initiative, PPSG

8. total pain
Physical
Other symptoms, Insomnia
Adverse effects of treatment, chronic fatigue
Psychological Social
Anger delay in diagnosis Worry about family
Anger treatment failure
Fear about death/pain
Feeling of isolation/
Disfigurement abandonment
Feeling of helplessness
Spiritual
Why has this happened to me ?
Why does God allow me to suffer like this ?
What is the point in all this ?
Is there meaning in life ?
Total Pain

10. Causes of Pain
Pain in cancer can be groped into four
causal categories –
 cancer itself –
e.g. –Soft tissue, visceral, bone or
neuropathic.
 Treatment related:-
Chemo-Therapy –Mucositis.
Radiotherapy induced fibrosis
 Debility e.g. constipation, muscle tension,
spasm.

11. 11
Patho-physiology of cancer pain:
Complex & occur different ways
 Tumor secretes mediators – facilitate pain
 Tumor contain immune system:
 Release
 Endothelin
 PG
 TNF 
 Proteolytic enzyme
 Direct invasion to viscera - visceral pain
Sensitize peripheral nociceptic afferent
damage sensory &
sympathetic nerve fibers
Neuropathic
Pain

12. Types of pain
Nociceptive Neuropathic

13. 13
Allodynia
 Pain caused by a stimulus that
normally
does not provoke pain

14. 14
Breakthrough pain
 Transitory flare of pain that occur on a
back ground of relatively well
controlled baseline pain e.g. common
cause - bony metastasis.

15. 15
Breakthrough pain

16. 16
Numerical Rating Scale
0 1 2 3 4 5 6 7 8 9 10
No
Pain
Worst
imaginable
pain

17. 17
Non-verbal Scale
Wong-Baker Faces
0
No Hurt
1
Hurts
Little Bit
2
Hurts
Little
More
3
Hurts
Even
More
4
Hurts
Whole
More
5
Hurts
Worst

19. Management of Pain:
1.
Modification of the pathological
process
 Surgery
 Chemotherapy
 Radiation therapy
 Hormone therapy

20. 20
+/
+/-
- adjuvant
adjuvant
Non
Non-
-opioid
opioid
Weak opioid
Weak opioid
Strong opioid
Strong opioid
Pain persists or increases
Pain persists or increases
By the
Clock
W.H.O. ANALGESIC LADDER
W.H.O. ANALGESIC LADDER
+/
+/-
- Step 1
Step 1
+/
+/-
-Step 1
Step 1
1
2
3

21. 2. Analgesics:
Non-opioid (Paracetamol, Ibuprofen,
Ketorolac etc)
Opioid
 Weak Opioid eg. Tramadol
 Strong Opioid eg Morphine, Fentanyl
Adjuvants
 Corticosteroids, Antidepressants etc.

22. 3. Non drug methods
 Physical
Massage
Heat pad
TENS
 Psychological
 Social
 Spiritual

24. 4. Interruption to pain
pathways
 Local Anaesthesia
e.g. Lignocaine, Bupivacaine
 Neurolysis
e.g. Chemical-alcohol, phenol
 Cryotherapy
 Block

25. 5. Modification of way of life
& environment
 Immobilization
 Cervical collar
 Walking aid
 Wheel chair

27. Morphine: God’s own
medicine
 Morpheus: God of dream
 Golden drug for cancer pain

29. Global Consumption of Morphine, 2010
**Austria’s consumption includes use of morphine for substitution therapy
Sources: International Narcotics Control Board; World Health Organization population data
By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2012
mg/capita
152 countries
Global Mean
5.9912

30. Morphine: Pharmacology
 Metabolized in liver
 Excreted in Urine
 Palsma half life: 2-2.5 hrs
 Duration of action: 4 hours
 Well absorbed from all sites of
administration
 Acts on opioid receptor in CNS and
also peripheri

31. Indications (In Palliative Care)
Main
 Morphine Sensitive moderate to
severe Pains
 Dyspnoea
Subsidiary
 Cough
 Diarrhoea

32. Cancer Pain
 Morphine responsive
 Morphine semi-responsive
(needs an adjuvant) e.g. Bone
metastasis > NSAID, RT, Nerve
Compression > Steroid
 Morphine resistant. Headache, Muscle
spasm, Nerve destruction,
malabsorption in GIT

33. Dose: No standard or specific
dose
 Range of 5 mg---1200mg every 4
hourly has been used. (15 mg – 3600
mg 12 hourly)
 Median maximum dose 15---20 mg 4
hrly (60 mg 12 hrly)

34. Adverse Effects

35. Adverse effects
• Nausea, vomiting, drowsiness
• Constipation Continuing
• Hypotension
• Bronchospasm
• Respiratory depression!
• Addiction!
• Physical dependence
• Tolerance

36. Bangladesh Med. Research
Council 2014 : 40
Khan F, Ahmad N, Iqbal M &
Kamal AM
n = 1000 physicians ( 58’3%
response rate)
• 85% = Pethidine preference
• 53% = ignorant of narcotic
law
• 89% = would restrict opioid
dose for fear of addiction
or tolerance
“Physicians
knowledge &
attitude of
opioid
availability
accessibility and
use in pain
management in
Bangladesh”

37. Relative Contraindication
 Renal failure
 Hypersensitivity to Morphine

38. Available trade forms in
Bangladesh
 Injection 15mg in 1ml amp
and Sustained release (15 mg tablets)
manufactured by Gono shaystho
Phamaceuticals.
 Immediate Release tablet (MSL-10)
10 mg
Sustained release tab MSL SR 15mg
and Syrup MSL 1mg in 1ml
by UniMed & UniHealth

39. 39
Ongoing assessment of
patients with pain
 Increase analgesics until pain
relieved or adverse effects
unacceptable
 Be prepared for sudden changes in pain
 Driving is safe if
◦ pain controlled, opioid dose stable, no
adverse effects