Clossing By 3 step ladder WHO cancer pain management, 90 % of cancer pain can be relief. Since cancer patients cannot be cured, our main task is to let them die free of pain with Iman

1. Pedoman Penatalaksanaan
Nyeri Kanker
A. Husni Tanra
Universitas Hasanuddin
Fakultas Kedokteran, Bagian Ilmu Anestesi
Ketua Program Studi Sp2 Ilmu Anestesi
Makassar
Dibawakan pada acara Simposium dan Workshop “ Mewujudkan Bebas Nyeri Kanker 2020”
Di RS Kanker “Dharmais” Jakarta, 2 November 2017

2. Objectives :
• What is Cancer pain ?
• Cancer pain assessment
• Cancer pain management using WHO 3
step ladder
• Available opioid in Indonesia.
• Clossing

3. What is cancer pain?

4. Just as Cancer is not 1 disease
Cancer Pain is not 1 entity

5. What is Cancer Pain?
(Introduced by Dr. Cicely Saunders 1967)
‘TOTAL PAIN’
is the sum of 4 components:
1. Physical noxious stimuli
2. Emotional discomfort
3. Interpersonal conflicts
4. Nonacceptance

6. PHYSICAL DISTRESSS
SOCIAL DISTRESS
EMOTIONAL
DISTRESS
SPIRITUAL
DISTRESS
(Biopsychosociospiritul Disesase)

7. Paracetamol
 adjuvants
Weak Opioid for
mild to moderate
pain
 Paracetamol
 adjuvants
Strong Opioid for
severe pain
(Morphine)
 Celecoxib
 adjuvants
Increasing pain
Three step ladder WHO
Multidisciplinary Approach

8. INTEGRATION OF OTHER INTERVENTIONS TO THE
WHO LADDER

9. Of all the symptoms caused by
Cancer
PAIN is the most feared

10. Pain so severe that it crushes the human spirit

11. Orang India

12. Orang barat

13. Orang Indonesia

14. Etiology of cancer pain
Major sources of pain:
 Cancer-related 93%
 Therapy-related 21%
 Coincidental causes 2%
Carenceni & Portenoy Pain 82:263-274, 1999

15. Causes of Cancer pain
• CANCER RELATED

16. Causes of Cancer pain
 CANCER RELATED

17. Causes of Cancer pain
 cancer related

18. Pain in the Cancer Patient
Due to cancer treatment:
 Cancer surgery – post-mastectomy,
post-thoracotomy pain
 Chemotherapy – peripheral neuropathy
enterocolitis
 Radiation therapy - mucositis, dermatitis
post-radiation fibrosis

19. Treatment related
 Post mastectomy
 Phantom pain
 Pain in the scar
 Pain in the arm
 DUE TO CANCER SURGERY

20. Treatment related
• FROM CHEMOTHERAPY

21. Treatment related
• RADIATION THERAPY
COBALT RADIATION BURN

22. Pain in the Cancer Patient
Non related to cancer:
 Herpes zoster ( acute or chronic)
 Mucositis
 Osteo arthritis
 Musculoskeletal pain
 Etc.

23. Non related to Cancer
Acute Herpes Zoster

24. Non related to Cancer
• OTHER FACTORS-Immunocompromised
state

25. Non related to Cancer
Mucositis

26. Non related to cancer
DUE TO OSTEOARTHRITIS

27. Kanker dan nyerinya
1/5 yang hanya 1 nyerinya
4/5 yang memiliki 2 atau lebih
1/3 memiliki 4 atau lebih nyeri
Nyeri kanker bukan hanya satu.

28. Key success in cancer pain
management is
• Evaluasi dan asesmen yang berulang-
ulang  “With attention to detail”
• Assessment- Treatment and
Reassessment.
• At least once a day.

29. Kenapa nyeri harus di ases sebelum
diobati?
• Karena nyeri itu adalah simptom/penyakit yang
tidak bisa dilihat (Pain is invisible disease).
• You must believe what ever patient says.
• Tujuan utama dari Asesmen nyeri adalah meng-
visualisasikan nyeri serta mengdiagnosenya:
A. Jenis nyerinya (type of Pain).
B. Intensitas nyerinya (intensity of pain)

30. A. Jenis nyeri kanker
1. Nyeri nosiseptif
• Nyeri somatik
• Nyeri Viseral
2. Nyeri neuropatik
3. Gabungan keduanya (mixed pain)
4. Breakthrough pain
 Incident pain
 End of dose failure

31. Around-the-Clock
Medication
Breakthrough pain
Over Medication
Breakthrough Pain

32. 1. Nyeri Nosiseptif
• Nyeri konstan
• Tajam
• Lokalisasinya jelas
• Sakit kalau digerakkan
Contohnya
 Nyeri tulang karena
metastase.
 Kerusakan jaringan lunak
 Dinding torak
Nyeri Somatik nosiseptif

33. 1. Nyeri Nosiseptif
• Nyeri konstan
• Terasa kram
• Lokalisasinya tdk jelas
• Kadang ada nyeri rifer
Contohnya
– Karsinoma pangkreas
– Hepatoma, setelah kapsunya
meregang.
– Obstruksi usus (kolorektal)
Nyeri viseral nosiseptif

34. 2. Nyeri Neuropatik
• Nyeri neuropatik adalah nyeri akibat adanya
kerusakan , lesi atau disfunsi dari SS saraf
perifer atau sentral.
• Umumnya pasien menyatakannya sebagai
nyeri yang lain dari biasanya.
• Paling sering drasakan sebagai nyeri yang
terbakar, seperti memegang es, kontak listrik
atau seperti tertusuk-tusuk.

35. 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

36. B. Intensitas Nyeri Kanker

37. B. Intensitas Nyeri
None Mild Moderate Severe
Faces
Numerical
Categorical
No Pain
Ruler Scale

38. • Valid up to now 
more than 30 years ago.
• First Multimodal-
Analgesia application.
• MA was first initiated
by Henrik Kehlet 1993
• “Opioid Sparing effect”
has not yet well known.
1986

39. 1. World Health Organization. Cancer pain relief: with a guide to opioid availability. 2nd ed. Geneva:The Organization;1996.
2. National Comprehensive Cancer Network (NCCN) GuidelinesTM Ver. 2.2011: Adult Cancer Pain
Pain management:
WHO 3 steps ladder vs NCCN 2 steps Guidelines
WHO 1986
NCCN 2011

40. What ever the Ladder do you use, WHO or NCCN
5 essential concepts,
must be apllied:
1. By mouth
2. By the clock
3. By the ladder
4. By individual
5. With attention to
detail .
By this pharmacotherapy about 90% of cancer pain can be relieved

41. Analgesics for cancer pain should be given1
By the mouth
By the clock
By the ladder
For the individual
With attention to detail
1.World Health Organization. Cancer Pain Relief: With a Guide to Opioid Availability. World Health Organization; 1996.

42. Dr. Res. Anestesi, menerangkan tentang By the Clock.

43. Successive change
By the Ladder
Strong opioids
Step III
For moderate to severe pain,
Strong Opioid analgesics
± Non-opioid analgesics
± adjuvant analgesics
APAP/NSAIDs ± adjuvant analgesics
Step I
Non-opioid analgesics
± adjuvant analgesics
APAP/NSAIDs ± adjuvant analgesics
For mild to moderate pain,
Mild Opioid analgesics
Codeine or
Tramadol
Step II
± Non-opioid analgesics
± adjuvant analgesics
Pain
Pain
Painlevel
Paracetamol = APAP(Acetyl Para Amino Phenol)
Courtesy by Dr. S. Hattori
Cancer Institute Hospital in Tokyo
Seiji Hattori

45. With attention to detail
We need to do careful comprehensive assessment and reassessment.
Why? Cancer pain is dynamic porgressive pain specially at end life

46. Principles of Analgesic Prescribing
WHO Analgesic Ladder 1986 By this pharmacotherapy
about 90% of cancer pain can be relieved.
• Paracetamol
• NSAID or COXIB
•Adjuvants
• Paracetamol
• NSAID or COXIB
•Weak Opioid
(Codeine,or Tramadol)
•Adjuvants
• Paracetamol
•NSAID or COXIB
•Strong Opioid
(Morphine, Fentanyl,
Hydromorphon
Oxycodone)
•Adjuvants
STEP 1
STEP 2
STEP 3

47. Cancer Pain
NSAIDs,
Adjuvant drugs
Opioids
PO・Trans dermal
Neurolysis
Interventions by IVR
Opioid Injections
（PCA)
SC・IV・Epidural・Intrathecal
Radiation, Rehabilitation,
Bisphosphonates,
Fentanyl patch
Oxycodone
Morphine
JMS i-fuosr PLUS
Only 10% need intervention pain management

48. Analgesik
Non-opioid, Opioid dan Ajuvan
• “Opioid “
(Kerja sentral)
– Opioid Kuat
– Opioid lemah (taramadol,
Ckodein)
• Adjuvants
– Antidepressants
– Anticonvulsants
– Gabapentinoid
– 2 agonist
– Local Anesthestics
– Ketamin
“ Non-Opioid ”
(Kerja perifer)
• Parasetamol
• NSAIDs
• COX-2

49. 1. Non-Opioid
 Paracetamol
• Paling aman asal tidak lebih 4 g/24 jam
• Bisa dikombinasi dengan NSAID atau COXIB.
 NSAID non-selektif
• Ibuprofen atau Ketoprofen
• Paling lemah efek sampingnya
 COXIB
• Celecoxib
• Yang paling aman dari yang ada.
!!! Kalau menggunakan Steroid jangan dikombinasi dengan NSAID atau COXIB

50. Ibuprofen
Ketoprofen
Diclofenac
Meloxicam
Nimesulide
Celecoxib
Rofecoxib
Valdecoxib
Acetosal
Ketorolac
Indomethacin
Piroxicam
non-
selective
COX
inhibitor
preferentially
COX-2
selective
inhibitor
COX-2
selective
inhibitor
COX-1
selective
inhibitor
preferentially
COX-1
selective
inhibitor
COXIB
analgesic
anti-inflammatory
Less GI side effects
More GI side effects
NSAID Non-Selective vs COXIB

51. What is Opioid?

52. 2. Opioid
Senyawa yang biasa besifat agonis terhadap  and K
reseptor
Opioid Lemah
(agonis parsial)
• Kodein
• Tramadol
Opioid Kuat
(agonis penuh)
1. Morphine
 tab IR atau Syrup IR
 MST continus tablet
2. Fentanyl iv, patch
(transdermal) once in
3days
3. Hydromorphone tab
once daily.
4. Oxycodone
• tab IR, CR. and iv. .

53. 1. Codeine Phosphate
• Merupakan opioid lemah yang alami
• Memiliki kekuatan 1/10 dari Morfin
• Hasil metabolik melalui major pathway: Codeine-6-glucuronide
(merupakan parent drug yang memiliki efek analgesik minimal.)
• 2-10% diubah menjadi Morfin via minor pathway tapi menghasilkan
penyumbang analgesik utama dari kodein.
• 9% Caucasians lacked P450 cytochrome isoenzyme
• Bioavailability: 40% PO
• Onset of action: 30-60 min for analgesia
• Dose: 30-60mg q4h + paracetamol
• Very constipating, mild nausea and vomiting

54. 2. Tramadol
• Merupakan opioid lemah yang sintetis yang kekuatannya 1/10 Morfin
• Menghabat re-uptake baik nor-adrenaline maupun serotonin.
• Dimetabolik di hati menjadi O-demethyltramadol yang kekuatannya
2-4X lebih poten dari tramadol sendiri.
• Bioavailability: 75% PO
• Onset of action: 30min
• 50-100 mg q6H, maximum 400mg /day
• High nausea/vomiting; less constipating
• Cautions: epilepsy, raised ICP, severe renal or liver impairment, in
patients taking medication that lower seizure thresholds eg. TCA and
SSRI

55. 3. Morphine
• “Natural opioid”
• “Gold standard” for opioid agonist
• Widely available in multiple forms: oral pill
and liquid, pills, parenteral
• Histamine relies
• Hydrophilic

56. 4. Fentanyl
Routes of Administration  I.v and transdermal
• Lipophilic tinggi
• iv Rapid onset 3’ duration 30-45 ‘
• Transdermal duration of action 72 transdermal
• 80 – 85% plasma protein bound
• 90 % metabolized in the liver to inactive metabolites
Other properties
100 X potensi analgesiknya dengan morfin
10 X potensi analgesiknya dengan hydromorphone
*high efficacy for mu 1 receptors.
*most effective opiate analgesic

57. Fentanyl
• Indication of Fentanyl :
 morphine intolerance
 renal failure
 bowel obstruction
• Transdermal patches: 25, 50, 75, 100 mcg/hr
• 25 mcg/hr = 60 – 90 mg po morphine
• Slow onset 16-24 hours to peak analgesia, so additional
analgesia required at first and offset 12-24 hours
• Patches should not be used in opioid naïve patient

58. 5. Hydromorphone
• Synthetic “sister” of morphine
• Potency is 5 X morphine
• Widely available in multiple forms: available in
Indonesia long acting form, once daily.
• More rapid onset and shorter half life
• Less histamine release than morphine
• Hydrophilic

59. 6. Oxycodone
• Semi-Synthetic opioid from thebaine, is the
“cousin” to morphine
• Act on both in mu and kappa receptors
• Bioavailability 60 -87 % compare to Morphine
only 15-40 %.
• Oxycodone has 45 % protein binding
• Potency is 1.5-2X morphine
• Available in Indonesia tab IR and iv, include
long acting Tab CR q 12h.

60. Dialemma Opioid di Indonesia
• Semua opioid long acting yang slow release
yang harganya lebih mahal, tersedia di kota-
kota besar.
• Tapi opioid short acting yang Immediate
release yang harganya murah justru tidak,
yang merupakan fondasi untuk titrasi.
• Opioid adalah obat yang harus diberi secara
titrasi.

61. Opioid apa yang dibutuhkan di
Indonesia untuk mengatasi nyeri
kanker?
Morphine IR (Immediate Release)
Liquid (syrup) or
Tablet

63. Morphine for free for cancer
patient

66. Adjuvant Drugs
• Steroid (dexamethason)
• Antidepressant (tricyclic)
• Anticonvulsant (gabapentin&pregabaline)
• 2 agonist (Clonidine)
• Local Anesthetic.
• Ketamine ( Good and useful for end life cancer pain patint)

67. She was so exhausted and very depressed

69. She die after taking care for more than 2 years

70. Clossing
• By 3 step ladder WHO cancer
pain management, 90 % of
cancer pain can be relief.
• Since cancer patients cannot be
cured, our main task is to let
them die free of pain with Iman.

71. SEKIAN
Terima Kasih Banyak
Semoga Ada Manfaatnya