Cancer Pain

Cancer Pain Concept
A. HUSNI TANRA
Department of Anesthesiology & ICU and Pain
Management
Faculty of Medicine
HASANUDDIN UNIVERSITY
MAKASSAR

Palliative CarePalliative Care
Palliative Care is comprehensive, interdisciplinary
care for patients whose disease is chronic and
progressive, or unresponsive to curative treatment.
It includes pain and symptom management as well
as psychological, emotional and spiritual care. The
goal of palliative care is to achieve the best quality
of life for patients and their families, regardless of
life expectancy
Center for Health Workforce Studies
School of Public Health, University of Albany
September 2002

CurativeCurative vs. Palliativevs. Palliative
Model of CareModel of Care
Disease Progression
D
E
A
T
H
Curative Palliative
B
E
R
E
A
V
E
M
E
N
T

The Continuum of Palliative CareThe Continuum of Palliative Care
PersonPerson
FamilyFamily
DD
II
SS
EE
AA
SS
EE
DD
II
SS
CC
OO
MM
FF
OO
RR
TT
DD
YY
II
NN
GG
ILLNESS TRAJECTORYILLNESS TRAJECTORY BEREAVEMENTBEREAVEMENT
SS
YY
MM
PP
TT
OO
MM
SS
DD
XX
DD
EE
AA
TT
HH
Disease Specific RxDisease Specific Rx
Comfort, Supportive RxComfort, Supportive Rx
(Palliative Care)(Palliative Care)
BereavementBereavement
SupportSupport
(Palliative Care)(Palliative Care)
DD
II
SS
TT
RR
EE
SS
SS
DD
YY
SS
FF
UU
NN
CC
TT
II
OO
NN
Caregivers and Service providersCaregivers and Service providers

Pain
 Unpleasant sensory and
emotional experience
-Associated with actual or
potential tissue damage
-or described in terms of
such damage
International Association for the Study of Pain
(1979)

What the textbooks
would have you believe
about pain
Noxious (painfull)
stimulus to the body
What PAIN is?What PAIN is?

Pain has two dimensions
1. Unpleasant sensory
(Physical dimension)
2. Emotional experience
(Psychological dimension)

J. Loeser
(1980)
Concept of nociception, pain, suffering and pain behavior

PERILAKU NYERI
(PAIN BEHAVIOUR)
PENDERITAAN
(SUFFERING)
NYERI
(PAIN)
BIOPSIKOSOSIAL
(BIOPSYCHOSOCIAL)
NOSISEPSI
(NOCICEPTION)
PENGERTIAN MODEL NYERI
BYERS AND BONICA, 2001
MODIFIKASI PENULIS
•Terapi kognitif
•Restorasi fungsional
•Opioid
•Tramadol
•Oxcarbazepine
•Gabapentin
•Eperisone HCL
•Paracetamol
•OAINS
•Antidepresan
•Psikotropika
•Relaksasi
•Spiritual
•Blok Lokal
•Diklofenak
•Etodolac
•Dexketoprofen
•Celecoxib
•Modalitas fisik
•steroid

Cancer Pain Concept
by Dr. Cicely Saunders 1967, founder of first Hospice in
London.
‘TOTAL PAIN’ is the sum of 4 components:
1. Physical noxious stimuli
2. Emotional discomfort
3. Interpersonal conflicts
4. Nonacceptance

4 Components of “total pain” by Cicely Saundres using concept Da Vinci’s
Vitruvian Man representing person.
Physical PainPhysical Pain
NonacceptanceNonacceptance
InterpersonalInterpersonal
ConflictsConflicts
EmotionalEmotional
discomfortdiscomfort

Aspects of “total pain”.
TOTAL PAINTOTAL PAIN
Interpersonal Interactions
 Individual
 Fear of isolation from others
 Fear of loss of career or job status
 Fear of substance abuse
 Interpersonal Interactions
 Marital discord
 Estrangement from family
 Isolation from spouse and children
 Conflicts with coworkers
 Mounting financial stress
 Inadequate Pain Control
 Verification patient is receiving
pain medication.
 Assessment for new physical
cause of pain
 Altered Metabolic States
 Medical conditions such,
hypocalcaemia, hypoglycemia,
hypoxia, delirium and sepsis
 Hormone-Secreting
Tumors
 Pheochromocytoma
 ACTH-producing tumors
 Thyroid tumors
 Anxiety From Medications
 Rapid tapering of prednisone.
 Alcohol withdrawal
 Akathisia associated with
metoclopramide hydrochloride
 Preexisting Anxiety
 Supportive therapy or medication
(or both) helpful
 Spirituality
 Personal values of life, what
death mean for him/her.
 Fear of dying alaone.
 Three-Stage Model
 A guide to anticipate
difficulties with greater
sensitivity:
̶ Initial stage: the patient
faces the threat of death;
̶ Middle stage: a universal
depression that the patient
now knows the disease
will cause death;
̶ Third stage: the patient’s
acceptance of imminence
of own death
Anxiety Nonacceptance

TOTAL
PAIN
ORGANIC PAIN
ANXIETY
ANGERDEPRESSION
Non-cancer pathology
Cancer
Symptoms of debility
Side-effects of theraphy
Loss of social position
Loss of job prestige and
income
Loss of role in family
Chronic fatigue and
insomnia
Sense of helpessness
Disfigurement
Bureaucratic prosedure
Friends do not visit
Delay in diagnosis
Unavailable doctors
Irritability
Therapeutic failure
Fear of hospital or nursing
home
Worry about family
Fear of death
Spiritual unrest
Fear of pain
Family finances
Loss of dignity and bodily
control
Uncertainty about future
WHO 1986

Pain
Somatic or
Visceral
pain
Neuropathic
Pain
Psychologica
l
Disturbances
SufferingPsychologica
l State and
Traits
Loss of
Work
Physical
Disability
Fear
Of Death
Financial
Concerns
Social/
Familial
Functioning
AMERICAN CANCER SOCIETY 1988

Magnitude of Cancer Pain
 WHO 1986
4,5 million people suffering from cancer pain with or
without satisfactory treatment every day
 More than 9 million cancer deaths will occur in 2015
 70 – 80 % of these patients will experience moderate to
severe pain
 Most of them will die in pain

For many patients pain is the first sign of cancer.
30 – 50 % of all cancer patients will
experience moderate to severe
pain.
75 – 95 % of patients with advanced stages
will experience severe pain.
45 % of cancer patients have
inadequate pain control.
25 % Will die in pain.
Nature Reviews Cancer March 2002

Pain is extremely a major problem in cancer patients
Pain is the most disruptive on Q of L of cancer patients
Pain is one of the most feared aspect in cancer patients
Unrelieved severe pain may associated with
• Disturbed sleep
• Reduced appetite
• Unrepaired concentration
• Irritability and depression, etc.
 69 % of severe cancer pain patient to cause consideration of
suicide.
(Wisconsin 1985)
Problem of Pain in Cancer Patient

As a doctor, our task is:
*To cure is sometime
*To treat is often, but …
*To comfort is always
A. Pare (1598)

The “Total” Pain Concept
Spiritua
l
Emotional
Financial
Physical
•Guilt
•Why me?
•Life closure
issues
•From disease
•From treatment
•Direct costs
•Indirect costs
•Loss of function
•Coping abilities
PAIN

Types of pain based on
neurophysiologic mechanism.
Physical PainPhysical Pain
Neurophysiologic MechanismsNeurophysiologic Mechanisms
Visceral Pain
 Difficult to localize.
 Felt as “deep
pressure,” “spasms”
associated with
nausea, diaphoresis,
and emesis.
Somatic Pain
 Nociceptor stimulation
of skin and deep
musculoskeletal
tissues.
 Well localized as
“deep, aching feeling,”
tender to palpation.
Neuropathic Pain
 Damage to the peripheral or the
central nervous tissue.
 Peripheral nerve described as
“sharp,” “electric,” “burning”
pain.
 Central pain is “throbbing”; the
headache is “dull” and “never
relenting”

CAUSE OF CANCER PAIN
Can be classified into 3 categories:
1. Pain associated with direct tumor
(tumour infiltration, bone metastases)
2. Pain associated with cancer therapy
(chemotherapy, surgery or radiation)
3. Pain unrelated to cancer
(RA, OA, headache or herpes zoster)
* Due to cancer debility
(decubitus)

Types of Cancer Pain
 1. Somatic Pain
 2. Visceral Pain
 3. Neurophatic Pain
Mostly in combine form

Somatic Pain
• Constant pain
• May be dull or sharp
• Well localized
• Often worse with movement
Eg/
– Bone & soft tissue
– chest wall

Visceral Pain
• Constant or crampy
• Poorly localized
• Usually with Nausea & Vomit
• Often referred
Eg/
– CA pancreas
– Liver capsule distension
– Bowel obstruction

Neuropathic Pain
Damage to the nerve pathways
There can be an abnormal response to a
normal stimulus
May be peripheral or central nerve damage

COMPONENT DESCRIPTORS EXAMPLES
Steady,
Dysesthetic
• Burning, Freezing
• Constant-aching
• Squeezing, Itching
• Allodynia
• Hyperalgesia
• Diabetic neuropathy
• Post-herpetic
neuropathy
Paroxysmal,
Neuralgic
• Stabbing
• Lancinating
• Shock-like, electric
• Shooting
• trigeminal neuralgia
• may be a component
of any neuropathic
pain
FEATURES OF NEUROPATHIC PAIN

Burning, feeling like the feet are on fire
Stabbing, like sharp knives Lancinating, like electric shocks
Freezing, like the feet are on ice,
although they feel warm to touch
Modified by Meliala 2006

Breakthrough PainBreakthrough Pain
An intermittent increase in pain that occurs
spontaneously and is usually associated
with an increase in activity or stress. If
breakthrough pain becomes continuous, it is
usually a sign that opioid dose needs to be
increased

Chronic Cancer PainChronic Cancer Pain
Effectively treating chronic pain poses a great
challenge for physicians. This type of pain
often affects a person’s life in many ways. It
can change someone’s personality, ability to
function, and quality of life.
According to the American Cancer Society,
chronic cancer pain may involve persistent
pain and breakthrough pain. Persistent pain
is continuous and may last all day.

BTP is a brief flare-up of severe pain that
occurs even while the patient is regularly
taking pain medication. It usually comes on
quickly and may last from a few minutes to
an hour. Many patients experience a number
of episodes of breakthrough pain each day.

Breakthrough cancer pain can result from the
cancer or cancer treatmen, or it may occur
during a certain activity (e.g., walking,
dressing, coughing). It also can occur
unexpectedly, without a preceding incident
or clear cause. Breakthrough pain usually is
treated with strong, short-acting pain
medications that work faster than persistent
pain medications.

Causes of Cancer pain
DIRECT TUMOR ITSELF

Cancer pain
FROM CHEMOTHERAPY

Causes of Cancer pain
RELATED TO THERAPY
COBALT RADIATION BURN

Cancer pain
Other Factors
Acute Herpes Zoster

Cancer pain
 OTHER FACTORS-
Immunocompromised state

 Nociceptor is stimulated by the tumor
 Peripheral sensitization  Enzyme Cox-2
Inflammation.
 Tumor induced acidosis. ( massive apoptosis)
 Tumor induced distension of sensory fibers
 neurophatic pain
 Centra sensitization  Chronic pain

Cancer cells + macrophage + inflammation
cells produce high level of Cox-2 enzyme
 high level of prostaglandins.
 Cancer cells induced acidosis due to that
inflammatory cells invade neoplastic tissue
 release H+ and massive apoptosis also
contribute release H+  increase acidosis.
 Two ascending pathway are activated.
( STT and PSDCT)

Three Step Ladder WHO, 1986
5 essential concepts
 By mouth
 By the clock
 By the ladder
 By individual
 With attention to
detail
By this modality ± 90% of cancer pain can be relieved

Gold Standard of
Pain Management
Is constant pain assessment.
Pain is whatever the patient says it is.
Pain in cancer never purely physical.
Nonphysical pain describe as ‘discomfort’
Take a careful history of the pain complaint
Assess characteristics of each pain; site, type
pattern of referral, aggravating & relieving
factors etc.

Assessment of Pain
using VAS is !
0 3 421 5 6 7 8 9 10
No distress Unbearable
distress
a 10-cm baseline is recommended for VAS
( Visual Analogue and Numeric Scale )

Assessment of Pain Intensity
No Mild Moderate Severe Very Worst
pain pain pain pain severe possible
pain pain
Verbal Pain Intensity Scale
No
pai
n
Visual Analog Scale
Wong-Baker FACES Pain Scale
0 1 2 3 4 5
0–10 Numeric Pain Intensity Scale
No Mild Moderate Worst
pain pain pain possible pain
0 1 2 3 4 5 6 7 8 9 10
Worst
possible
pain
29

Types of Cancer Pain
 1. Nociceptive Pain
Somatic Pain
Visceral Pain
 2. Neurophatic Pain
(Mostly in combine form)
 3. BreakThrough Pain (BTP)

WHO 3-step AnalgesicWHO 3-step Analgesic
LadderLadder
11 MildMild
22 ModerateModerate
33 SevereSevere
Morphine
Hydromorphone
Methadone
Fentanyl
Oxycodone
± Adjuvants
A/Codeine
A/Hydrocodone
A/Oxycodone
Tramadol
± Adjuvants
ASA
Acetaminophen
NSAIDs
± Adjuvants
Adapted from the EPEC Project

The Phenomenon of CANCER PAIN
COMPLEXand COMPLICATED
is the cumulative among :
• PHYSICAL PAIN
• PSYCHOLOGICAL PAIN
• socioeconomic,cultural and spiritual
TOTAL PAIN
BIOPSYCHOSOCIOCULTUROSPIRITUAL

Paracetamol
± adjuvants
Weak Opioid for
mild to moderate
pain
± Paracetamol
± adjuvants
Strong Opioid for
severe pain
(Morphine)
± Celecoxib
± adjuvants
Increasing painIncreasing pain
WHO three step ladderWHO three step ladder

It’s important to more understanding PAIN,
type and characteristic of pain..
Because…
In many parts of Indonesia :
Many people may die in pain, but
Many more people dying with pain,
Even many more people living in pain
This is our task to help them as a Doctor
Take Home Message

Total Pain – Osteopathic MedicalTotal Pain – Osteopathic Medical
Care.Care.
Osteopathic Medical Care is based on
osteopathic philosophy; the four
components being:
1.The body is a unit.
2.The body has self-regulatory
mechanisms.
3.Structure and functions are reciprocally
interrelated.
4.Rational therapy is based on these
principles.

Structure andStructure and
FuntionFuntion
ReciprocallyReciprocally
InterrelatedInterrelated
Self-RegulatorySelf-Regulatory
MechanismMechanism

Elisabeth K.Ross (1969)  “on death
and deying”.
BEHAVIOR CHARES IN CANCER PATIENT
1. DENY
2. ANGER
3. BARGENING
4. DEPRESSION
5. ACCEPTANCE

A Patient’s perspective
“ One of the worst aspect of cancer pain is that
it`s a constant reminder of the disease and of
death ..
My dreams is for a medication that can relieve
my pain while leaving me alert and with no side
effects “
Jeanne Stover, 1992

Role of COXIB in cancer painRole of COXIB in cancer pain
Celecoxib is the rational use for the cancer
pain management, particularly in advance
stage, because celecoxib is:
* Strong antiinflammation
* Analgesic
* Antipyretic
* Carcinoprotective (prevent angiogenesis,
tumor growth and metastasis)
* simple administeration

Non-opioid
± adjuvants
Weak Opioid for
mild to moderate
pain
± non-opioid
± adjuvants
Strong Opioid for
severe pain
± non-opioid
± adjuvants
Increasing painIncreasing pain
WHO three step ladderWHO three step ladder

WHO ANALGESIC LADDER CANCER PAINWHO ANALGESIC LADDER CANCER PAIN
Aspirin
&
NSAID
+
Adjuvants
Add weak
Opioid
(if pain
unrelived)
+
Adjuvants
Add strong
Opioids
+
Adjuvants
PSYCHOLOGICAL &
SOCIAL SUPPORT

Nociceptive painNociceptive pain
A NOCICEPTION has at least 4
components
1. TRANSDUCTION
2. CONDUCTION/
TRANSMISSION
3. MODULATION
4. PERCEPTION
SpinothalamicSpinothalamic
tracttract
PeripheralPeripheral
nervenerve
Dorsal HornDorsal Horn
Dorsal rootDorsal root
ganglionganglion
PainPain
MedulationMedulation
TransductionTransduction
AscendingAscending
inputinput
DescendingDescending
modulationmodulation
PeripheralPeripheral
nociceptorsnociceptors
TraumaTrauma
Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
PerceptionPerception
transmissiontransmission
ConductionConductionConduction/Conduction/
TransmissionTransmission
Modified by AHT

88
Poisons
Mechanical, thermal, chemical, electrical
Tissue damage
Release of mediators
Hydrogen and potassium ions,
neurotransmitters, kinins, prostaglandins
Stimulation of nociceptors
Transmission to CNS
via afferent pathways
What is pain?

A NOCICEPTION has at least 4 components
1. TRANSDUCTION
2. CONDUCTION/
TRANSMISSION
3. MODULATION
4. PERCEPTION
ACUTE (NOCICEPTIVE)
PAIN PATHWAY

Allodynia: Nerve Injury Leads to Central
Reorganization in the Spinal Dorsal Horn
Normal terminations of primary
afferents in the dorsal horn
After Nerve Injury

Dorsal Horn
Dorsal root
ganglion
Peripheral sensory
Nerve fibers
Aβ
Aδ
C
Large
fibers
Small
fibers
Two sensory afferent neurons
1. Large myelinated Aβ fibers, very fast conduction velocity.
Respond to innocuous stimuli
2. Small myelinated Aδ & C unmyelinated fibers, have slow
conduction velocity. Respond to noxious stimuli
Modified by AHT

Although in normal condition AAlthough in normal condition Aββ fiber does notfiber does not
response to noxious stimuli, but it plays a bigresponse to noxious stimuli, but it plays a big
role inrole in NORMAL SENSATION.NORMAL SENSATION.
The Role of AThe Role of Aββ fiberfiber
Without Aββ fiberfiber, any noxious stimuli will perceive
as BURNING PAIN (TN, HZ)
A ββ

Aβ
Aδ
CLateral
Nucleus
proprius
Marginal layer
Substantia
gelatinosa
Medial
Afferent Synaptic in DHN

Ascending spinomesencephalic
and spinothalamic axons
Dorsal
Root
Ganglion
C
Fiber
A delta Fiber
Second Order
Sensory Neuron
Lateral horn cell
and sympathetic axon
Ventra horn
motor neuron
Anterior Lateral
Spinal Thalamic
Tract
Modified by AHT

Pain
Somatic or
Visceral
Pain
Neuropathic
Pain
Psychologica
l Pain
SufferingPsychologica
l State and
Traits
Loss of
Work
Physical
Disability
Fear
Of Death
Financial
Concerns
Social/
Familial
Functioning
Nature of Cancer Pain

Step I for MILD PAIN
 NSAIDs may delay the need of opioid.
 About 20% of patients were taking NSAIDs
in the last week of life.
 Caution is needed when using NSAIDs for
long periods
 GI bleeding and renal failure are the most
common.
 It has ceiling effect.
Use paracetamol, aspirin or NSAID

Step Il for MODERATE PAIN
 Combine Paracetamol, NSAIDs + Codein
 Formula
 Constipation is the most common side effect of
codein
Acetominophen 500 mg
Codein 10 mg
Dulcolax ¼ tab
mf pulv dtd XXX
6 dd I cap
+ adjuvant
06.00 18.00
10.00 22.00
14.00 02.00 prn

– It is a new multimodal analgesic tablet.
– Contains
• 325 mg Acetominophen
• 37.5 mg Tramadol
– Doses were selected based on golden ratio 
synergic effect.
– Decreased side effect, while maintaining
efficacy
– Approved in over 25 countries including US,
Europe, for moderate to severe pain

TRAMADOL
peak = 2-3 hrs
T1/2 = 6 hrs
TIME
DrugEffect
APAP
peak = 30 min
T1/2 = 2 hrs
In combination, T1/2 extends to 7-9 hours
Result of combination:
–Fast onset of action
–Prolonged action

Step lll for SEVERE PAIN
 Oral morphine is the mainstay of severe cancer
pain.
 Strong pain needs strong analgesic.
 It is a very safe drugs as long as given properly
 Morphine immediate release is not available
 MS contin is one of choice
– Sustained release
– Long acting

Why Cancer Pain Undertreated
 For Step 1 & 2
- doses are too low
- intervals are too long
- not individualized, by titration
 For step 3 (strong opioid = morphine)
- morphine is underused
STEP 1
Nonopioid
STEP 2
Weak opioid
+ nonopioid
STEP 3
Strong opioid
+ nonopioid
+ adjuvant

Why Morphine is Underused?
Morphin is underused due to:
The Myths and prejudice or
Insufficient knowledge
Which is in clinical experience do not
show to be true.

MYTHS & PREJUDICE of OPOID
When mention about opioids  negative side
Our textbooks are filled with a side effects.
– Mostly respiratory depression , addiction,
tolerance , physical dependence,
sedation, nausea/vomiting; etc.
 Not the benefit of potential analgesic
In clinical experience those myths & prejudice,
do not show to be true.

Myth and Prejudice of Morphine
2. Fear of addiction
 Addiction is the most feared side effects.
 When we say morphine addiction is the first
answer, not the analgesic
 Large survey, 12.000 patients only 4 patients
(0.03%) were considered addict
(Boston Collaborative Drug Surveillance Program)
 All studies chronic opioid treatment demonstrate
a lack of addiction
 No evidence of addiction as long as given properly

Opiophobia
“failure to administer
morphin analgesics because
of a fear of these drugs to
produce addiction”

Consequence
Due to those myth and prejudice,
most cancer pain patients do not
get inappropriate treatment, and
failure to get the benefit of opioid.
Tragedy of Needless PainTragedy of Needless Pain

Underused of opioid in
Indonesia it might be due that?
 PAIN MANAGEMENT IN
INDONESIA IS NOT THE
PRIORITY.
 Where University also
should play a big role.

Adjuvant Drugs
 Corticosteroids : Dexamethasone, Prednison
 Anticonvulsant : Carbamazepine, Gabapentin, etc
 Antidepressant : Amytriptiline, Doxepine
 Neuroleptics : Methotrimeprazine
 Antihistamines : Hydroxyzine
 Local anesthetic/antiarrhytmics : Lidocaine
 Psycho-stimulans : Dextroamphetamine
 Laxatives : Bisacodyl, Lactulose, etc
 Antiemetics : Droperidol, Metoclopropamide, etc

New and Alternative Pain
Treatment Options
 Tramadol
 Ultracet
 Clonidine
 Calcitonin
 Accupuncture
 Magnetic-field therapy
 Duragesic ( transdermal fentanyl)
 TENS
 DepoMorphine
 etc

Some Invasive Modalities For
Cancer Pain Relief
1. Neurolitic Block
- Alcohol 100 %
- Phenol glycerin 15 %
1. Epidural / Spinal opioid
2. Celiac Ganglion Block
3. Neural blockade
4. SC Morphine / Pethidine continuous infusion
5. Etc.

Conclusion
About 90% of cancer pain patients can be
relieved by three step ladder of WHO
Morphine such is very safe drug when use
properly
Underuse morphine due to the myths and
which cannot be verified in clinical practice
Many cancer patients could die free from
pain and with dignity if a few of those
myths died

In many parts of Indonesia
*Many people may die due to pain
*Many more people dying with pain
* Even many more people living in pain,
particularly cancer patients.
This is our task as a doctor
NATURE OF INDONESIA

MAGNITUDE OF CANCERMAGNITUDE OF CANCER
PAINPAIN Bonica 1985
– 50 % of patient of all stage reported pain
– > 70 % with advanced cancer
 Faley 1985
– 50 % of patient with non metastatic cancer had significant pain
– 60-90 % of patient with advanced cancer reported debilitating
pain
 WHO 1986
– 70 % of patient with advanced cancer has pain
– 3,5 million people suffering from cancer pain with or without
satisfactory treatment every day
 Paice, 2006
– 20-75% have pain at first diagnosis
– 23- 100% report pain in advance stage

FACTS ABOUT CANCER
PAIN
90% of patients with advanced cancer
experience severe pain;
Pain occurs in 30% of all cancer patients,
regardless of the stage of the disease.

FACTS ABOUT CANCER
PAIN
More than 50% of cancer patients may be
undertreated for their pain
Pain usually increases as cancer progresses.

Pain Assessment
Treat patient’s pain and regularly reassess
response to therapy.
Discuss care plan with patient and family.

Causes of Cancer Pain
Pain secondary to the tumor itself
Pain secondary to cancer therapy
Other factors

Nociceptive Pain
VISCERAL PAIN

Barriers to Cancer Pain Management
1. Inadequate knowledge of pain management.
2. Low priority given to cancer pain treatment.
3. Restrictive regulations, availability of nonopioid
and opioid analgesic.
4. Inadequate reimbursement.
5. Fear of patient’s addiction, tolerance, and side
effects of opioids; patient’s reluctance to take
pain medication.
Mercadante S. WHO Guidelines –
Problem Areas in Cancer Pain Management

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

COMBINE DRUGS MAY HAVE
3 EFFECTS
1. Synergetic ............. 2+2>4
2. Additive ................ 2+2=4
3. Subadditive ........... 2+2=3

Statistical Test for a Range of Synergy
ACETAMINOPHEN
TRAMADOL
Line of
Additivity
• Tramodal &
Acetaminophen
has different
action
• Synergistic
analghesia
• Reduced
adverse effect
• Faster onset
longer action
‘‘Isobologram’ for analgesic interaction between acetaminophen and tramadolIsobologram’ for analgesic interaction between acetaminophen and tramadol

Ultracet
 Is not an NSAID (not Cox1 or Cox2 inhibitor )
 Not associated with
 prostaglandin-mediated side effects
 Cardiovascular side effects
 Not associated with GI bleeding
or ulcer formation in clinical trials
 No effect on platelet aggregation
 No risk for NSAID-induced nephrotoxicity

Myth and Prejudice of Morphine
3. Sedation
• Drowsiness may occur at the beginning
but this usually disappears after a few days
• Drowsiness due to the fact that the patient
has first good sleep.
• No patient would accept pain free with
sedation.

Physical
dimention
ORGANIC PAIN
• Motivational affective
• Cognitive evaluation
• The meaning of pain
• unpleasant sensory
• emotional experienced
“ an unpleasant sensory and emotional
experience associated with actual or
potential tissue damage or described in
term of such damage”
PAIN is defined (by IASP1979) as :
PAIN
Psycological
dimention

Definition of Pain
“An unpleasant sensory and emotional experience
associated with actual or potential tissue damage,
or described in terms of such damage”
“Suatu perasaan dan pengalaman emosional yang
tidak menyenangkan akibat kerusakan jaringan
yang nyata atau yang berpotensi rusak, atau
sesuatu yang tergambarkan seperti itu”
IASP, 1979

Byock’s five key points:
 “I forgive you.”
 “Forgive me.”
 “Thank you.”
 “I love you.”
 “Goodbye.”

TYPES OF PAIN
NEUROPATHICNOCICEPTIVE
Deafferentation Sympathetic
Maintained
Peripheral
Somatic
• bones, joints
• connective tissues
• muscles
Visceral
• Organs –
heart, liver,
pancreas, gut,
etc.

J.Loeser (1980)
Concept of nociception, pain, suffering and pain behaviour
Pain behaviour
Suffering
Pain
Nociception

A-Alpha Motor
Efferent
Sympathetic
Efferent
Delta Sensory
Afferent
C-Fiber Sensory
Afferent
Peripheral
Nociceptor
Spinal Cord
NSST
PSST
NRMBrainstem
Midbrain
Hypothalamus
and Pituitary
Cortex and
Thalamus
LC
PAG
MTVPL
SSC FLC
Ascending
Pathaways
Descending
Pathaways
Sympathetic
Outflow
Hypothalamic-
Pituitary Outflow

 Visceral pain
 Poorly localized, constant, aching and commonly
referred to cutaneous sites
 Results from injury to the organs that are
sympathetically innervated
 Referred pain
 Pain and hyperalgesia localized to deep or superficial tissues
and often found distant from the source
 One proposed mechanism to explain this occurrence is central
convergence of afferent impulses
Acute Pain

 constant
 sharp aching
 well localized
 constant
 dull aching
 poorly localized
 usually with nausea and
vomit
 occasional colicky or cramp
 often referred to
cutaneous sites
Somatic pain Visceral pain
Somatic Pain vs Visceral Pain

Cancer Pain

More Related Content

What's hot

Similar to Cancer Pain

More from Hasanuddin University

Recently uploaded

Cancer Pain

Editor's Notes