CME presentation made on 10th Nov 2012. Discusses a Radiation Oncologist's perspectives of cancer pain management, shortcomings of WHO pain ladder, ASTRO guidelines for metastatic bone pain.
CME presentation made on 10th Nov 2012. Discusses a Radiation Oncologist's perspectives of cancer pain management, shortcomings of WHO pain ladder, ASTRO guidelines for metastatic bone pain.
Pain is the production (out put ) of the brain.
Pain is invisible disease, we can’t see it like other disease, such as struma, fracture or blind.
What you have to do is to believe what ever the patient says.
Pain is what ever the patient says it is
Pain is invisible diseases, but is real for patient.
Pain definition, Pain pathways, pain modulation, the endorphin system, Types of Pain, current trend of Drugs used for pain management. New Drugs for pain
Pain is the production (out put ) of the brain.
Pain is invisible disease, we can’t see it like other disease, such as struma, fracture or blind.
What you have to do is to believe what ever the patient says.
Pain is what ever the patient says it is
Pain is invisible diseases, but is real for patient.
Pain definition, Pain pathways, pain modulation, the endorphin system, Types of Pain, current trend of Drugs used for pain management. New Drugs for pain
Pharmacological Pain Control in Emergency Department.pdfReza Aminnejad
Pain occurs in more than half of ED patient. Analgesia is often sub-optimally addressed or reassessed in a significant number of patients. A combination of non-pharmacologic and pharmacologic (opioid and non-opioid) analgesics modalities can enhance the quality of pain management.
a detailed description of pain and therpaeutic options available and clinical assessment of pain, approach to the patient with pain, assessment of intensity of pain, nsaids and opioids, tca. WHO pain ladder, chronic opioid therapy
To improving postoperative pain management, we need to;
- Always applies multi-modal analgesia. (get the advantages of multimodal analgesia)
- Implementation of the existing EB regarding the use of non-opioid + opioid on as needed basis.
- Use available specific evidence for optimizing multimodal pain management procedure (PROSPECT Web site).
The key to a successful Acute Pain Service is not so much the use of sophisticated drugs and high technology equipment, but an excellent organisational structure and well trained medical and nursing personnel.
Pharmacology of drugs for pain management important
Route of drugs administration change pharmacodynamic and pharmacokinetic of the drug must be explore to enrich our modality in pain management
Postoperative pain management not resolved completely still a problem for most of the physician involved in this area and the patients
Paracetamol iv as a single analgesic is very safe analgesic, but only for mild and moderate pain.
It can be combined with many analgesic or adjuvan drugs to provide strong analgesic for postoperative pain.
So, it can be the basic regiment for Multimodal Analgesia.
Because of its safety it can be the choice for high risk surgical patient
HISTORY OF 3-STEP LADDER WHO
1980 – WHO establishes Cancer Control Programme
Cancer prevention
Early diagnosis with curative treatment
Pain relief and palliative care
1986 – ” Cancer Pain Relief “ published by WHO
Step Ladder WHO
Updated on 1996
Worldwide acceptance protocol
Today, worldwide consensus favouring its used for management of all pain associated with serious illness
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Basavarajeeyam - Ayurvedic heritage book of Andhra pradesh
Principles in cancer pain management = j ansen 2014
1. PRINCIPLES IN CANCER PAIN
MANAGEMENT
DRADJAT SUARDI
Ketua PP Perhimpunan Onkologi Indonesia
Ketua PP Masyarakat Paliatif Indonesia
Ketua Tim Kanker RSHS/FK UNPAD
Ketua Tim Paliatif RSHS/FK UNPAD
2. Objectives
Factors that induced cancer
pain
Advantages dan
disadvantages of each
analgesic
Understanding opioid as
a drug for cancer pain
Cancer pain management
To know &
understand
3. OUTLINES
• Overview of cancer pain
• Overview of pain treatment
• Managing cancer pain
– Approach in cancer pain management
• Persistent/baseline pain
• Breakthrough pain
– Opioid in cancer pain
• Opioid phobia
• Advanced formulation in opioid for cancer
pain– practical usage
• Related side effect
– Guidelines of cancer pain management
4. All AC, Huyce LI, Pain Cancer and older adults 199
Ahmedzi S. New approaches to pain control in patients with cancer Eur Journal of Cancer 1997
CANCER PAIN
• PAIN is the symptom most commonly associated with
cancer
– severity increases with the progression of the disease
• 60-90% with advanced cancer report significant pain
• Often a mixed pattern:
– Nociceptive
– Neuropathic
– Cancer specific pain / tumour effects
– Post surgical pain
– Chemotherapy induced pain
• Pain control is a vital component of cancer management
Cancer survivors
5. CANCER ASSOCIATED PAIN
Cancer pain may be induced by:
• Infection AND/ OR Inflammation
• Poor circulation
• Invasion to bone, nerve or other organs
• Psychological or emotional problems
6. 6
International Narcotics Control Board; World Health Organization population data
Pain & Policy Studies Group (PPSG), University of Wisconsin
7. OUTLINES
• Overview of cancer pain
• Overview of pain treatment
• Managing cancer pain
– Approach in cancer pain management
• Persistent/baseline pain
• Breakthrough pain
– Opioid in cancer pain
• Opioid phobia
• Advanced formulation in opioid for cancer
pain– practical usage
• Related side effect
– Guidelines of cancer pain management
8. Tramadol +
Paracetamol
Analgesic classification adapted
from WHO Ladder
- Fentanyl
-COX-2
inhibitor/NSAID
-Aspirin
-Paracetamol
No need to start
from 1st step if the
pain is already
severe
Move to the next
step if there is no
response or the
pain score doesn’t
decreased
10. Paracetamol
Advantages • Does not produce end-organ toxicity
commonly seen with NSAIDs on the
gastrointestinaltract, kidney and
cardiovascular
• Lack the CNS and opioid-related side
effects
Disadvantages • Lacks antiinflammatory effect
• If used as single drug, its analgesic
potency is less than that of NSAIDs
• Less potent analgesic effect as compared
to NSAIDs
• Has a dose-related hepatotoxicity (in
high dose)
Hardman JG, Limbird LE, Gilman AG. Goodman & Gilman’s The Pharmacological Basis of
Therapeutics. McGraw-Hill Professional; 11th ed: Oct 2005
11. NSAID/COX-2 inhibitors
Advantages • Show antiinflammatory effect
• Lack the CNS and opioid-related side
effects
Disadvantages • Gastrointestinal side effects
(dyspepsia, hemorrhage, ulcer)
• Renal perfusion
• Blockade of platelet function
• Fluid and sodium retention
• Hypertension
• Risk of cardiovascular events
(stroke, MCI)
Hardman JG, Limbird LE, Gilman AG. Goodman & Gilman’s The
Pharmacological Basis of Therapeutics. McGraw-Hill Professional; 11th ed:
Oct 2005
12. Opioids
Advantages • Strong analgesic effect
• Do not produce end-organ toxicity
commonly seen with NSAIDs on the GI
tract, kidney and cardiovascular
• Relatively safe when used in
appropriate doses and when
monitored effectively
• No ceiling effect (strong opioid)
Disadvantages • Opioid related side effects:
nausea, vomiting, constipation,
drowsiness, dizziness, respiratory
depression, tolerance ,risk of abuse
Hardman JG, Limbird LE, Gilman AG. Goodman & Gilman’s The
Pharmacological Basis of Therapeutics. McGraw-Hill Professional; 11th ed:
Oct 2005
13. Pain treatment based on severity and
presence of inflammation
Inflammation
No
Inflammation
• NSAID or
coxib or
aspirin
• Paracetamol
and (NSAID
or coxib or
aspirin)
Paracetamol
• Weak opioid ±
NSAID or coxib
• Combination of
weak opioid
and
paracetamol ±
NSAID or coxib
Combination of
weak opioid and
paracetamol
Strong opioid ±
NSAID or coxib
Strong opioid
± Adjuvant (antidepressant, corticosteroid, α-2 adrenergic
agonist, neuroleptic, anticonvulsant) if needed
Mild Moderate Severe
Developed by Cancer Pain Management Advisory Board member based on WHO ladder
14. Why opioid for severe pain ?
Rapidly titrate short-acting opioid
15. OPIOID OPTIONS
• As part of multimodal therapy
• IV opioids (morphine, fentanyl)
• Immediate release oral opioid (morphine)#
• Sustained release opioids
– Oral : morphine, oxycodone*, hydromorphone*
– Transdermal : fentanyl, buprenorphine*
# very limited availability in Indonesia
* Not yet available in Indonesia
16. Opioid Characteristics
Codeine 8-9% of Caucasians and up to 40% of Asian people are CYP2D6 poor
metabolizers, and do not experience effective analgesia with codeine.
Tramadol Atypical opioid: additional non-opioid mechanism which inhibits re-uptake of
serotonin and norepinephrine
Morphine Chronic renal disease may be more affected by M3G and M6G metabolite
Fentanyl IV Transdermal/patch
Less constipation
Less likely cause nausea/delirium
Less competition for liver enzymes: drug interactions less likely
Tiny amounts of fentanyl reach liver so safe in patients with liver
dysfunction
Safe in renal dysfunction compared to other opioids
Fewer side effects from interactions with other opioid receptors in CNS
72-hour supply of fentanyl in patch and skin
for around-the-clock analgesia with no peaks
and troughs
No first-pass effect of liver: small amounts of
fentanyl needed for analgesia
Weak opioid
Strong opioid
17. Schnitzer. Anaesthesiology. 1996;20(S12):13
Paracetamol and tramadol
complimentary pharmacokinetics
Paracetamol
Paracetamol/Tramadol
Tramadol
0
1
2
3
4
0 2 4 6 8 10
Time
(hours)
Paracetamol/
Tramadol
Para-
cetamol
Tramadol
Painrelief
• Rapid onset of
action of
Paracetamol
• Long-lasting
effect
of tramadol
Medve RA, Wang Julia, Karim . Tramadol and Acetaminophen for dental pain. Anesth prog 48:79-81. 2001
Ho ML, Chung CY, Wang CC et al. Efficacy and safety of tramadol/acetaminophen in the treatment of breakthrough pain in cancer patients. Saudi Med J.
2010 Dec;31(12):1315-9.
18. Combination of tramadol-
paracetamol
• Advantages:
– Have multiple sites of action
– Produce a synergistic effect dose reduction is
applicable side effect are less than single components
– Not associated with peptic ulcer, hypertension, CVA, and
renal damage
• Disadvantage:
– Spectrum of side effect includes those from paracetamol
and tramadol as well
18
Ho ML, Chung CY, Wang CC et al. Efficacy and safety of tramadol/acetaminophen in
the treatment of breakthrough pain in cancer patients. Saudi Med J. 2010
Dec;31(12):1315-9.
19. NCCN (National Comprehensive Cancer
Network) Guidelines
• Converting from short-
acting to long-acting
opioids when 24-h opioids
requirement is stable
• Used immediate-release
opioids for breakthrough
pain
– 10–25% (1/6) of 24-h dose*
– Increase rescue dose
proportional to long-acting
*See in case study for detail
20. Barriers to Cancer Pain
ManagementBarrier %
• Inadequate pain assessment 76
• Patient reluctance to report 62
• Patient reluctance to opioids 62
• Physician reluctance 61
• Inadequate staff knowledge 52
• Inadequate nurse knowledge 38
• Excessive state regulations 18
• Lack of access to professional methods 12
• Lack of psychological support services 11
• Lack of equipment 6
• Lack of neurodestructive services 5
• Lack of access of a wide range of analgesics 3
Ann Internal Med 1993
21. Why “Around-the-clock” (ATC)
approach
• Cancer pain is continuous
• Baseline pain in cancer pain is defined as average
pain intensity experienced for 12 hours or more
during a 24-hour period
• ATC dosing should be used when pain itself is ATC
(continuous) or present for 12 or more hours each
day
• Therefore , ATC is a mainstay approach in cancer
pain
22. Drug C Monophasic Extended Release (q24h)
Current Paradigm for the
Relief of Chronic Pain
Pain
Increased Pain Intensity
In overall treatment needs “Around-the-clock”
management with limited “breakthrough pain”
Drug B Biphasic Controlled Release (q12h)
Drug A Immediate Release (q4h)
Time
Gupta S, Sathyan G. J Pain Sympt Manage 2007;33(2 Suppl):S19-24.
24. BREAKTHROUGH PAIN
• Defined as transitory exacerbation of pain in
a patient who has relatively stable and
adequately controlled baseline pain (rapid
onset, brief flare of severe pain despite
regular analgesia).
• Common in cancer patients
• Despite around the clock treatment regimen,
patients have approximately 4 episodes/day
Portenoy RK, Hagan NA : Breakthrough pain: definition, prevalance & characteristics. Pain 1990;41:273–281.
25. BREAKTHROUGH PAIN
• In 43% patients, pain reached peak intensity within
3 min
• Mean duration was about 30-40 min
• Immediate released, short-acting analgesic is an
ideal option for breakthrough pain (IV/IM, IR-Oral,
suppositoria, buccal*)
*not yet available in Indonesia
Portenoy RK, Hagan NA : Breakthrough pain: definition, prevalance &
characteristics. Pain 1990;41:273–281.
26. Breakthrough Pain Treatments
• Characteristic of analgesic required for
breakthrough pain:
– Strong opioid
– Immediate release formulation
– Rapid onset time
– Most direct routes
• Buccal / Mucosal / inhaled
• Morphine is preferred in breakthrough pain
treatment
27. OUTLINES
• Overview of cancer pain
• Overview of pain treatment
• Managing cancer pain
– Approach in cancer pain management
• Persistent/baseline pain
• Breakthrough pain
– Opioid in cancer pain
• Opioid phobia
• Advanced formulation in opioid for cancer
pain– practical usage
• Related side effect
– Guidelines of cancer pain management
28. Opioid formulations for cancer pain
• Sustained release formulations
– oral: MST, oxycodone*, hydromorphone
– transdermal: fentanyl, buprenorphine*
• New lower dosage permits ‘start low-go slow’
strategy to reduce side-effects
• Effective in nearly all types of pain including
neuropathic pain
*not yet available in Indonesia
29. Pain patient :
• Not out of control with
medication
• Medications improve quality of
life
• Aware of side effects
• Concerned about medical
problems
• Will follow agreed treatment
plan
• Has medications left over from
previous prescriptions
Differences between a pain patient and
addicted patient
Addicted patient :
• Out of control with medications
• Medications decrease quality
of life
• Wants medication despite side
effects
• In denial about medical
problems
• Does not follow treatment plan
• Does not have medication
remaining and always has ‘a
story’
Heit HA. The truth about pain management: The difference between a pain patient and an addicted
patient. Eur J Pain 2001; 5(suppl A): 27–29.
30. Drug
Equianalgesic
oral dose
Starting
oral dose
Adults ≥ 50 kg Adults ≤ 50 kg
Morphine 30 mg q3-4 h 15-30 mg q3-4 h 0.3 mg/kg q3-4 h
Codeine 130 mg q3-4 h 60 mg q3-4 h 1 mg/kg q3-4 h
Hydromorphone 5 - 7.5 mg q3-4 h 6 mg q3-4 h 0.06 mg/kg q3-4 h
Hydrocodone* 30 mg q3-4 h 10 mg q3-4 h 0.2 mg/kg q3-4 h
Levorphanol* 4 mg q6-8 h 4 mg q6-8 h 0.02 mg/kg q6-8 h
Meperidine 300 mg q2-3 h Not recommended Not recommended
Oxycodone* 20 mg q3-4 h 10 mg q3-4 h 0.2 mg/kg q3-4 h
Oral Opioid Analgesics
Hardman JG, Limbird LE, Gilman AG. Goodman & Gilman’s The Pharmacological Basis of
Therapeutics. McGraw-Hill Professional; 11th ed: Oct 2005
*not yet available in Indonesia
31. Switching
Commonly employed in cancer pain management
for:
• Tolerance causing rapid / high dose escalation
• Suspected opioid induced hyperalgesia
• Intolerable side effects
Dosage usually commenced at 30-40% less than
dose calculated from equivalence table
Hypothesised that incomplete cross tolerance and
differing opioid intracellular effects responsible for
benefit of substitution.
32. Oral and parenteral opioid equivalences and relative
potency of drugs as compared with morphine based
on single dose studies
Opioid agonists Parenteral
dose
Oral dose Factor (IV to
PO)
Duration of
action
Codeine 130 mg 200 mg 1.5 3-4 h
Fentanyl 100 mcg - - 1-3 h
Morphine 10 mg 30 mg 3 3-4 h
Tramadol - 50-100 mg - 3-7 h
Hydromorphone* 1.5 mg 7.5 mg 5 2-3 h
Levorphanol* 2 mg 4 mg 2 3-6 h
Oxycodone* - 15-20 mg - 3-5 h
Oxymorphone* 1 mg 10 mg 10 3-6 h
Hydrocodone* - 30-45 mg - 3-5 h
*not yet available in Indonesia
33. Recommended dose conversion from other opioid
to transdermal Fentanyl
Transder
mal
Fentanyl
(mcg/h)
Morphine
(mg/d)
Codeine
(mg/d)
Oxycodone*
(mg/d)
Hydromorphone*
(mg/d)
IV/SC Oral IV/SC Oral Oral IV/SC Oral
25 20 60 130 200 30 1.5 7.5
50 40 120 260 400 60 3 15
75 60 180 390 600 90 4.5 22.5
100 80 240 520 500 120 6 30
*not yet available in Indonesia
IV = intravenous
SC = subcutaneous
O = oral
34. Opioid side effects
• Initial
–Nausea and vomiting
–Dizziness
–Somnolence
–Pruritis
–Sweating
–Urinary retention
• Late
–Constipation
35. Principles to minimize
the side effects of opioid
• Frequently the side effects are transient, but may
require evaluation and management
• Adverse events, such as constipation, should be
anticipated and treated aggressively and
prophylactically with a stimulant laxative and/or stool
softener.
• ‘Pre-emptive’ use of:
• anti-emetics; laxatives; opioid antagonists
• Haloperidol low dose (1-1.5 mg po every 6-8 hours), proven
to be better than metoclopramide and ondansetron
NCCN Clinical Practice Guideline in Oncology. Adult cancer pain. 2010. www.nccn.org
36. Principles to minimize
the side effects of opioid
• Maximize non-opioid and non pharmacologic
intervention to limit opioid dose and treat side
effects
• Consider opioid rotation if side effects persist
• Multisystem assesment
• Recognize that side effects may be from other
treatments or cancer itself
37. Constipation
If constipation
develops
Preventive measures
-Prophylatic medications
-Maintain adequate fluid and dietary
fiber intake
-Exercise if feasible
If constipation
persists
-Asses cause and severity
-Rule out obstruction
-Treat other causes
-Titrate stool
softener/laxatives
-Consider co-analgesics to
allow reduction of opioid dose
-Reasses cause and severity
-Check for impaction
-Consider other agent (Mg(OH)2, bisacodyl,
lactulose,sorbitol)
- Saline, or tap water enema
-Consider use of prokinetic agent
-Consider neuraxial analgesics
38. Nausea
If nausea
develops
Preventive measures :
Prophylatic with antiemetic agents are highly recommended for
patients with prior history of opioid induced nausea
If nausea persists
> 1 week
-Asses for other causes of
nausea
-Consider haloperidol or
metoclopramide (as needed
regimen)
-If nausea persist administer
antiemetics around the clock for
1 wk, then change as needed
-Reasses cause
and severity
-Consider
opioid rotation
If nausea persists
after trial of several
opioids
-Reasses cause and
severity
-Consider neuraxial
analgesics or
neuroablative
techniques
39. Managing severe pain in cancer patient*
• Assesment for severe cancer pain:
Give IV drip morphine 10 mg/ 24 hours for opioid naive
patients and 15 mg/ 24 hours for opioid tolerant patients
Re-asses efficacy and side effects at 2 hours
If the pain score is unchanged, patient can be given morphine
bolus 10% from total dose every 2 hour, repeated 10 times at
maximum
If the pain score↓, maintain the IV morphine dose
Calculate the 24-hour total opioid requirement and continue
the same dose as needed over the initial 24 hours for the next
day
Based on the 24 hours total IV morphine dose requirement,
IV morphine should be converted to oral morphine immediate
or sustained released then converted to opioid patch as
indicated (see conversion table)
Opioid naive includes patients who are not chronically receiving opioid analgesic on a daily basis
Opioid tolerant includes patients who are chronically receiving opioid analgesic on a daily basis
*modified based on experience from Advisory Board Member of Cancer Pain Management
40. Pain management in opioid naive patients
For ALL pain
levels
Severe
Pain score 7-10
**
•Recognize and treat
analgesic side effects
•Consider adding co-
analgesic for spesific
pain syndrome
•Provide psychosocial
support
•Provide patient and
family education
•Optimize
nonpharmacologic
• See **AND
•Rapidly
titrate
short-acting
opioid
• Begin
bowel
regimen
Moderate
Pain score 4-6
• See **
AND
•Titrate
short-acting
opioid
•Begin
bowel
regimen
Mild
Pain score 0-3
• See **AND
• Consider NSAID or
paracetamol without opioid if
patient is not on analgesics
•Consider titrating short-
acting opioid
•Begin bowel regimen
Reevaluate pain at each
contact and as needed to
meet patient goals for
comfort and function
NCCN Clinical Practice Guideline in Oncology. Adult cancer pain. 2010. www.nccn.org
42. Pain score ≥ 4
Oral peak effect (60 min) IV bolus (peak
effect 15 min)
Dose 5-15 mg oral short-acting
morphine sulfate or equivalent
Reasses efficacy and side effects at 60 min
↑ dose by 50-
100%
Pain score
unchanged or ↑
Pain score ↓
to 4-6
Pain score ↓ to 0-3
Repeat same
dose
Continue at
current effective
dose as needed
over initial 24 h
After 2-3
cycles,
consider IV
titration
and/or
subsequent
management
and
treatment
See detail in
next slide
NCCN Clinical Practice Guideline in Oncology. Adult cancer pain. 2010. www.nccn.org
43. Pain score ≥ 4
Oral peak effect
(60 min)
IV bolus (peak effect 15 min)
Dose 2-5 mg IV morphine
sulfate or equivalent
Reasses efficacy and side effects at 15 min
↑ dose by 50-
100%
Pain score
unchanged or ↑
Pain score ↓
to 4-6
Pain score ↓ to 0-3
Repeat same
dose
Continue at
current effective
dose as needed
over initial 24 h
After 2-3
cycles, for
subsequent
management
and treatment
NCCN Clinical Practice Guideline in Oncology. Adult cancer pain. 2010. www.nccn.org
44. Pain management in opioid tolerant patients
For ALL pain
levels
Severe
Pain score 7-10
**
-Provide
psychosocial
support
-Provide
patient and
family
education
• See **AND
• reevaluate opioid
titration
•Reevaluate working
diagnosis with a
comprehensive pain
assesment
•Consider spesific pain
syndrome problems
•Consider pain
specialty consultation
•Reevaluate co-
analgesics as indicated
Moderate
Pain score 4-6
• See **AND
• Continue opioid
titration
• Consider spesific
pain syndrome
problems
• Consider pain
specialty
consultation
• Continue co-
analgesic titration
Mild
Pain score 0-3
• See **AND
• Continue opioid
titration
• reassess and
modify regimen
to minimize side
effects
•Co-analgesics as
needed
NCCN Clinical Practice Guideline in Oncology. Adult cancer pain. 2010. www.nccn.org
45. SUMMARY
• Pain is prevalent, underestimated, debilitating
• Pain is the most common symptom of cancer
– Effective management of moderate to severe cancer
pain requires treatment with opioids
– Cancer pain management is an important factor in
maintaining Quality of Life
• Safe and effective opioid analgesics are available
– However, careful pain assesment and drug titration are
needed
Rich BA. Ethics of opioid analgesia for chronic noncancer pain. Pain Clinical Updates. Dec 2007