This document discusses optimizing pain management in cancer treatment. It provides an overview of concepts like total pain, the WHO analgesic ladder for treating pain with opioids, and the importance of proper pain assessment and documentation. The key points are: 1) Total pain includes physical, psychosocial, emotional, and spiritual suffering experienced by cancer patients. 2) The WHO analgesic ladder recommends treating mild pain with non-opioids like paracetamol, moderate pain with weak opioids like codeine, and severe pain with strong opioids like morphine. 3) Proper pain assessment involves documenting pain scores, characteristics, causes, and impact on function to effectively guide pain treatment decisions.

1. Optimising Pain Management in
Cancer treatment
Esther Cege Munyoro
Gladys Nduku
KNH-Pain and Palliative care unit.

3. What is Pain?
“An unpleasant sensory or
emotional experience associated
with actual or potential tissue
damage”.
( IASP, 1979)

4. • Wells et al 2001 noted the existence of myths
and misconceptions about the use of opioids
in surgical wards in the United Kingdom. The
study found misunderstandings and anxieties
about addiction, tolerance and side effects,
especially respiratory depression. Even with
education that saw improvement in
awareness about the properties of opioids,
the study found minimal change in attitude
and concluded that attitudes may be more
difficult to influence than knowledge.
WELLS, M., DRYDEN, H., GUILD, P., LEVACK, P., FARRER, K. AND MOWAT, P. 2001, The
knowledge and attitudes of surgical staff towards the use of opioids in cancer pain
management: can the Hospital Palliative Care Team make a difference? European
Journal of Cancer Care, 10: 201–211.

5. What is pain??
• Pain is whatever the person
experiencing says it is
and exists where he
says it does.
( McCaffery & Pasero, 1999)

6. Defining “Total Pain”
• Dame Cicely Saunders
defined the concept of
total pain as the suffering
that encompasses all of a
person's physical,
psychological, social,
spiritual, and practical
struggles.

7. DEFINING TOTAL PAIN
……………a diagnosis of a life threatening illness
jars open a door of awareness, for most of our
lives we keep this door locked and it comfortably
allows us to keep thoughts about death in the
background.
7
Coyle N. The existential slap—a crisis of disclosure. International Journal Palliative Nursing 2004;10: 520. [PubMed]

8. Why treat pain?
In low-resource countries, pain is the most
common indication for visiting a health care
practitioner
• Improves compliance to curative treatment
• Extends survival for some patients
• Improves quality of life
• Improves patient – physician relationship
• Reduces unnecessary prolonged admission
• Reduces chances of litigation
IASP: Treatment of pain in low-resource settings (2010)
Temel et al- NEJM (2010)
8

9. Total pain
PHYSICAL
PSYCHOSOCIAL EMOTIONAL
TOTAL PAIN
SPIRITUAL

10. Zaza C, Baine N. Cancer pain and psychosocial factors: a critical review of the literature. J Pain Symptom Manage 2002;24:526–42

11. OPTIMISING
Make pain visible in our practice
1. Documentation
2. Protocols for pain and other symptoms
3. Education programs for Patients
4. Pain diaries
5. Learn to individualize pain treatment.
6. Multidisciplinary pain management
7. Increased collaboration at End of Life.

12. DOCUMENTATION
– Assessment charts at
clinics must have pain
scales for pain scores,
body charts.
– Sheets for vital signs
must provide a space to
pain scores, more
importantly healthcare
workers must respond
appropriately to the
reported pain score.

13. Body charts
Use the body chart to
indicate areas of pain and
annotate descriptions such
as burning, throbbing, or
aching
PCAU 13
throbbing
tingling

14. Clinical Practice Guidelines: Pain
Management
• The goals of protocols is to help the primary
care provider manage patients with chronic or
persistent pain by providing guidance about
how to manage pain and guidance about
when to refer for specialized pain
management services

15. 15
WHO STEPWISE THERAPY
INVASIVE
THERAPY
Low potent Opioids
+non-opioids+/-
Adjuvants
Non-Opioid-
Analgesics+/-Adjuvant
I
II
III
IV
High potent
Opioids + non opioids+/-
Adjuvants
STEP 4
Spinal opiates
Nerve blocks
STEP 3
Morphine
Methadone, Oxycodone
Fentanyl
Pethidine
STEP 2
Codeine
Dihydrocodeine
Tramadol
STEP 1
Paracetamol
Non steroidal anti-inflammatory
drugs

16. PATIENT EDUCATION/ Pain Diary
• An accurate record of
your pain
– Pains interference
with activities like
sleep, work or
walking.
– Drugs side effects
– Other treatments
herbal etc used

17. Multidisciplinary Pain teams
• Multidisciplinary pain treatment provides
patients with an opportunity to achieve both
adequate pain relief and improved physical,
behavioral and psychological functioning.
• Physiotherapists, Occupational therapists,
Psychologists and Nurses are important team
members.
• An important factor in improving psychosocial
well-being of patients with chronic pain is to
enhance their self-efficacy and perceived ability
to control or manage their pain.

18. It is every health worker’s
responsibility
The advent of effective treatment algorithms
means that all nurses and physicians can provide
effective, high-quality pain treatment
• Pain assessment and treatment in the
uncomplicated patient should be integrated
into service delivery in all departments
• Specialists in palliative care or anaesthesiology
can be called on for complex cases
18

19. Pain at the End of life
• Pain relief should always be a top priority. If the
primary focus is on treating disease, even when
the prognosis is poor, get somebody else to
provide pain management.
• We are a Death denying society so patients tend
to suffer in our hands at the end. Pain medication
is reduced as the end gets closer and sometimes
stopped so that ? Death does not occur.
• We need to talk about death and reap the
benefits.

21. WHO pain Relief Program
WHO PAIN
RELIEF
PROGRAMME
Multidimensional assessment
Appropriate ladder Level
Oral drugs
Regular medication
Morphine/ strong opioid of choice
Consider adjuvant drugs
Drugs for breakthrough pain

22. PAIN ASSESSMENT
Description
Location
Duration
Characteristics
Mechanism Cause
Pathological Cancer
nociceptive (tissue) Non- cancer
Neuropathic (nerve) PAIN
Debility
Functional Treatment
Somatic muscle (e.g. cramp) Concurrent disorder
Visceral Muscle ( e.g. colic)
Non-Physical factors
Psychological
Social
Spiritual

23. History taking
• Is the pain limiting activity?
• What does the patient feel about
the pain?
• What are the expectations of
treatment?
• What are the patient’s fears?
• What are the patient’s previous
experience of pain and illness?

24. Examination

25. Investigations:
• What are you trying
to find out?

26. Pain score-Numeric pain rating scale
• Pain levels 0-10, explained verbally to the
patient in which 0 is no pain and 10 is the
worst possible pain.
• Patients are asked to rate their pain.
• Record the pain level to make treatment
decisions and follow-up.
Palliative Care for HIV/AIDS and Cancer
Patients in Vietnam, Basic Training
Curriculum: Harvard Medical School, Centre
for Palliative Care (2007)
26

28. Assessment of pain in cognitively
impaired patients
Use the following pointers:
 Vocalization e.g. groaning, crying.
 Changing body language e.g. fidgeting, guarding of a body
part
 Physiological changes, e.g.. Increased pulse rate, high
temperature and blood pressure.
 Behavioural changes e.g. confusion, refusing to eat,
anxiety.
 Physical changes e.g. skin tears, pressure areas sores and
contractures.

29. 29

30. How to treat pain?
In 1986,WHO developed a 3 step simple algorithm
as a guide to treat pain in cancer patients. The
WHO Analgesic Ladder
• It incorporates opioids, non- opioids and adjuvant
medicines.
• It is extremely effective.
• When the ladder is optimised,85-90% of patients
report excellent pain control.
IASP: Treatment of pain in low-resource settings (2010)
30

31. WHO 3-step Ladder
1 mild
2 moderate
3 severe
Morphine
Methadone
Fentanyl
Oxycodone
± Adjuvants±
NSAIDs/
paracetamol
Codeine
Dihydrocodeine
Tramadol
Betapyn
± Adjuvants±
NSAIDs/
paracetamol
ASA
Paracetamol /
Acetaminophen
NSAID’s
± Adjuvants
WHO. Geneva, 2008.

34. The big question is…..
How effective is the ladder even after
modification over years???
………First is to question about
your practice!!!

35. Morphine
Oral morphine is the gold standard in the treatment
of severe pain in cancer patients (Gordon et al,
1999).
WHO has placed oral morphine on the essential drug
list.
Due to its established effectiveness, availability,
familiarity to physicians, simplicity of administration
and relative cost.
Its short-half-life characteristic generally favour its
use because it is easy to titrate.

36. Morphine
Rectal morphine bio-availability is similar to the oral
route.
Reassure the patient about the safety and efficacy.
 Constipation occurs at least to 90% of patients and
2/3 develop N/V, Prescribe prophylactic laxatives and
antiemetics.
(Europian Journal of pain.vol 11,issue 8, November 2007,p.gs823-830.)

37. Initiating morphine
Starting dose 5-10mg 4hrly.
For opioid naive and elderly patients, or those with
renal impairment use smaller doses e.g. 2.5mg 4hrly
with close monitoring.
– if pain is not controlled, titrate dose by 25–50% every
24-48 hrs.
Reassess pain daily; this can be done over the phone.
Once pain is controlled, either continue regular
immediate relese dose or convert to a 12hrly modified-release
preparation.

38. Rescue dose
All patients on around-the-clock opioid regime
should be offered a “rescue dose”
(supplemental dose) given on “as-needed
basis” to treat pain that breaks through a
regular schedule= BTP

39. Break through pain:
• A transient flare-up of pain of moderate or severe
intensity arising on a background of a well
controlled pain.

40. Fentanyl patches:
• A potent opioid analgesic in a topical patch
lasting for 72hrs.

41. Indications of Fentanyl patches
• Second line opioid for moderate to severe
responsive pain.
• Pain that is stable.
• Patients unable to tolerate morphine/
diamorphine due to persited side effects.
• Poor compliance but supervised patch application
is possible.
http://www.palliativedrugs.com.

42. Adjuvant analgesics.
 Opioids are not the only “magic bullets” in pain
management.
Adjuvant drugs not primarily designed to control pain
but they do control pain.
Have independent analgesic activity for certain pain
types like neuropathic pain and pain syndromes e.g.
fibromyalgia.
E.g. anticonvulsant, antidepressants, steroids
Beating Pain, 2nd Ed. APCA (2012); Using
Opioids to Manage Pain, APCA (2010)
42

43. Golden Rules
43
by the mouth
by the clock
by the ladder
for the individual
Make it simple !
WHO Genf (1986)

44. Invasive analgesic techniques;
• Despite appropriate use of analgesia and non-drug
therapies, 8-10% of patients will still have uncontrolled
pain or unacceptable side effects or both.
• Such patients should be considered for some invasive
analgesic techniques e.g. a simple nerve block or a
regional or neuro destructive blocks.
• Hanks GW,Conn F,Chemy N,Hanna M,Kalso E,Mcquary HJ,et al.Morphine and alternative opioid in cancer
patients:The EAPC RECOMMENDATIONS.Br J. Cancer 2001:84:587-93

45. QUESTIONS AND COMMENTS