Importance Of Controlling Cancer Pain In Adults

Pain control merits high priority for two reasons. First- unrelieved pain causes unnecessary suffering. Pain diminishes activity, appetite, and sleep; it can further weaken already debilitated patients. The psychological effect of cancer pain can be devastating. Patients with cancer often lose hope as pain emerges, believing that pain heralds the inexorable progress of a feared, destructive, and fatal disease. Chronic, unrelieved pain can lead patients to reject active treatment programs, and when their pain is severe or when they are depressed. Second- Besides mitigating suffering, pain control is important because, even when the underlying disease process is stable, uncontrolled pain prevents patients from working productively, enjoying recreation, or taking pleasure in their usual role in the family and society. It is not only for those with advanced disease, but also for the patient whose condition is stable and whose life expectancy is long. Effect of cancer pain on quality of life. Physical Decreased functional capability. Diminished strength, endurance. Nausea, poor appetite. Poor or interrupted sleep. Psychological Diminished leisure, enjoyment. Increased anxiety, fear. Depression, personal distress. Difficulty concentrating. Somatic preoccupation (totally engrossed with the perception and occurrence of pain). Loss of control. Social Diminished social relationships. Decreased sexual function; affection. Altered appearance. Increased caregiver's burden. Spiritual Increased suffering. Altered meaning. Reevaluation of religious beliefs. Three-step analgesic ladder. (W.H.O.) for pain. Step 1 - For mild pain - Non-opioid + Adjuvant (Opioids are painkillers derived from the opium poppy plant,) Pain persisting or increasing Step 2 -Opioid for mild to moderate pain + Non-opioid + Adjuvant Pain persisting or increasing Step 3 - Opioid for moderate to severe pain + Non-opioid + Adjuvant Goal - freedom from cancer pain Initial pain assessment; expectations from your doctor ABCDE Asks about pain regularly Assesses pain systematically Believes the patient and family in their reports of pain and what relieves it. Chooses pain control options appropriate for the patient, family and setting. Delivers interventions in a timely, logical and coordinated fashion. Empowers patients and their families Enables them to control their course to the greatest extent possible. Assessment of pain intensity and character. Onset and pattern - when did your pain start? How often does it occur? Has its intensity changed? Location - where is your pain? Is there more than one site? Description - What does your pain feel like? What words would you use to describe your pain? Intensity - on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine, how much does it hurt right now? How much does it hurt at its worst? How much does it hurt at its best? Aggravating and relieving factors - what makes your pain better? What makes your pain worse? Previous treatment - what types of treatments have you tried to relieve your pain? Were they and are they effective? Effect - how does the pain affect physical and social function? Pain intensity scales   0 __ 1 __ 2 __ 3 __ 4 __ 5 __ 6 __ 7 __ 8 __ 9 __ 10           No pain Mild pain Moderate pain Severe pain Very severe pain Worst possible pain   Common Cancer Pain Syndromes. Many intractable pain problems involve neurologic structures (structures containing nervous tissue). Bone Metastases. Epidural Metastases/Spinal Cord Compression. (Epidural refers to the space outside the duramater, which is the outer most thick layer covering the brain and the spinal cord.) Metastases to the Skull (spread of cancer to the skull from a different part of the body.) Plexopathies - Cervical brachial and lumbosacral plexi can be sources of intractable pain in cancer patients. (plexi, which is plural for plexus, means a bundle of nerves. Cervical and lumbosacral refer to the neck and lower back regions respectively). Peripheral Neuropathies - Peripheral nerves (nerves running from the spinal cord to other parts of the body) can be compressed or infiltrated by tumor or constricted by fibrosis (which is a process in which excessive fibrous tissue, the tough, stringy tissue which connects and supports body parts, is produced) which in rare instances is a complication of radiation treatment. They may also be damaged by neurotoxic (therapy poisonous to nerves) chemotherapy or by cutaneous incisions (cuts in the skin) and the retraction (pulling)of tissues during surgery. Common cancer pain syndromes due to peripheral nerve injury. Tumour infiltration of peripheral nerve. Postradical neck dissection. Postmastectomy pain (after removal of a breast). Postthoracotomy pain (after surgery in the chest cavity). Postlimb amputation pain (after removal of a limb). Post nephrectomy pain (after removal of a kidney). Chemotherapy induced peripheral pain. Radiation induced peripheral nerve tumours. Cranial neuropathies. Acute postherpetic neuropathy (after infection by the herpes zoster virus). Common causes of abdominal pain: Obstruction of small or large bowel. Occlusion of blood flow to visceral organs (e.g. liver, kidney, large and small bowel). Thrombosis and engorgement of splenic or renal veins (blockade and swelling of these very large blood vessels) Omental metastasis (spread of cancer from another area to the omentum, which is a fatty flap like fold hanging over some of the organs in the abdomen) Volvulus of the small intestine (twisting of the small intestine over itself). Infectious or chemical peritonitis (inflammation of the peritoneum, the sac like structure containing most of the organs in the abdomen) Metastasis or lymphomatous liver distention. (spread of cancer to the liver from another place, or distension of the liver with lymph, which is a clear, watery fluid containing lymphocytes , which are cells which fight infection) Assessment of mucositis. Examine lips and all mucosal surfaces for number, size and location of lesions. Pain intensity is usually related to the degree of tissue damage. Include assessment of local oedema and erythema as well as preexisting periodontal disease that may also be painful. Ask patient to identify painful or burning areas, even if there is no apparent tissue damage, these may become involved later. Culture suspicious lesions to rule out concomitant infection (bacterial, viral, and fungal) that may intensify pain and delay healing. Evaluate patient's ability to swallow (including oral analgesics) and restrict oral intake if necessary. An essential principle in using medications to manage cancer pain is to individualize the regimen to the patient. Three major classes of drugs are used alone, or more commonly in combination to manage pain in the cancer patient: NSAIDs and Acetaminophen (APAP). Opioid analgesics. Adjuvant analgesics. The simplest dosage schedules and least invasive pain management modalities should be used first. The FIVE essential concepts in the WHO approach to drug therapy of cancer pain are: By the mouth. By the clock. By the ladder. For the individual. With attention to detail. The first step in this approach is the use of acetaminophen, aspirin or another NSAID for mild to moderate pain. When pain persists or increases, an opioid such as codeine or hydrocodone should be added (not substituted) to the NSAID. Pain that is persistent, or moderate to severe at the outset, should be treated by increasing opioid potency or using higher dosages. Advantages and disadvantages of pain therapies:   Advantages Disadvantages Oral Analgesics Acetaminophen Aspirin NSAIDS Additive when combined with opioids Ceiling effect to pain relief. Widely available Side effects, gastritis, renal toxicity, bleeding Additive when combined with opioids Many are expensive Oral opioids Effective both for localized & generalised pain Side effects may limit use Ceiling only by side effects Many drugs to choose from Sedative and anxiolytic Easy to take by patient Some are inexpensive They are prescription drugs Long acting, controlled release available Associated with stigma and fear Transdermal Opioids (fentanyl) Long duration of action. Some effects not quickly reversed. Strong opioid for outpatients. Difficult to minify dose. Easy to use. Slow onset. Provides continuous administration. Additional drugs required for acute. pain. Can be used by patient. Expensive. Rectal opioids Easy to use when oral not available   Not widely accepted Other opioid suppositories available for morphine intolerant patients. Side effects limit use Can Be Administered By Patient. Slow onset Less expensive than SC or IV infusions Contraindicated with low blood counts (risk of infection, bleeding) Subcutaneous infusion Provides rapid relief without IV access Limited volume 2-4 ml/hr Induration at site Morphine or hydromorphone can be used thus at home Skilled nursing and pharmacy support Patient controlled Infusion pump expensive Intravenous Rapid pain relief Infection of veins All opioids can be given by this route Skilled nursing required No limit of infusion volume Expensive infusion pump -recurring disposables Pca mode permits patient control EpiduralIntrathecal, intra-cerebro ventricular Pain not responding to less invasive measures Tolerance may occur soon Infections Pruritus and urinary retention Contraindicated in spinal cord compression Special expertise required, careful monitoring Expensive infusion pump, fees and disposables Local anaesthetics may be added to spinal opioids Regional neurolytic blocks Effective with certain diagnosis (e.g. Pancreatic cancer) Risk of postural hypotension. Bowel and bladder incontinence and leg weakness Irreversible May be useful for movement related abdominal pain refractory to drugs Special expertise required Helps reduce dosage of systemic drugs for local pain Expensive Ablative neurosurgery May be useful for movement related lower refractory to drugs 6 months duration of pain relief for cordotomy is 50% Quick onset of pain relief Irreversible Percutaneous cordotomy can be done under local anaesthesia Requires expertise Reduces dosage of systemic drugs Expensive Corticosteroids Effective with inflammation - bone pain Prolonged use produces adrenal suppression Can produce cytotoxic effects in some tumours Risk of gastritis Can be given oral or iv Decrease cell mediated immunity and increase risk of infection May increase appetite, produce euphoria May produce psychosis Decrease pain with CNS and spinal cord tumours May mask infections Anticonvulsants Peripheral pains, specially shooting pain. May increase sedation Monitoring required for side effects, idiosyncrasy, bone marrow suppression Antidepressants Useful in neuropathic pain and pain caused by surgery, chemotherapy or nerve infiltration May increase sedation Anticholinergic side effects Promotes sleep taken at bed time CNS, CVS, hepatic toxicity limit use Hydroxyzine In high doses additive to opioids. High doses respiratory depression, not reversed by nalaxone. May be useful for opioid induced nausea and vomiting. Significant sedation. Radiation therapy Directly treats tumour, useful for bone metastasis With multiple fractions may give prolonged discomfort to patients Fast onset of pain relief Single dose may suffice in some Widely available mode Can treat multiple disease sites Myelosuppression may occur with previous chemotherapy Relaxation, imagery, biofeedback, distraction and reframing May decrease pain without drug side effects Patient must be motivated to use self-management strategies Useful adjunct Increases patients sense of control Inexpensive and acceptable Professional teaching required for training Patient education Effective in pain management Requires professional time to teach pain management regimens Multiple teaching aids available. Self care in treatment and side effects Psychotherapy, hypnosis Useful to reduce pain and anxiety Requires skilled therapist Cutaneous stimulation (superficial heat, cold, massage) May reduce pain, inflammation, muscle spasm Heat may increase bleeding and oedema after acute injury Adjuvant to other therapy Easy, low cost and can be administered by patients or families Cold is contraindicated in ischaemic tissues Acupuncture May give pain relief without side effects Requires skilled therapist Can be used as adjunct Peer support groups Helps in coping with pain Nil Increases self control Provides support for families Religious counselingPrayer Increases patients coping skills Nil Provides spiritual and emotional comfort Drugs such as codeine or hydrocodone are replaced with more potent opioids (usually morphine, hydromorphone, methadone, fentanyl, or levorphanol). Medications for persistent cancer-related pain should be administered on an around-the-clock basis, with additional as-needed doses, because regularly scheduled dosing maintains a constant level of drug in the body and helps to prevent a recurrence of pain. Patients who have moderate to severe pain when first seen by the clinician should be started at the second or third step of the ladder. Adverse effects of NSAIDs that may appear at any time include: Renal failure. Hepatic dysfunction. Bleeding. Gastric ulceration Dosing data for acetaminophen (APAP) and NSAIDs Drug Usual dose for adults and children > 50 kg body wt. For adults and children <50kg body wt. Acetaminophen and over-the-counter NSAIDS Acetaminophen 650 mg q 4 h 975 mg q 6 h 10-15 mg/kg q 4 h 15-20 mg/kg q 4 h (rectal) Aspirin 650 mg q 4 h975 mg q 6 h 10-15 mg/kg q 4 h 15-20 mg/kg q 4 h (rectal) Ibuprofen 400-600 mg q 6 h 10 mg/kg q 6-8 h (caution in children) Prescription NSAIDS Choline salycilate 870 mg q 3-4 h   Fenoprofen 300-600 mg q 6 h   Ketoprofen 25-60 mg q 6-8 h   Ketorolac tromethamine 10 mg q 4-6 h to a max of 40mg/day   Magnesium salycilate 650 mg q 4 h   Meclofenamate sodium 5-100 mg q 6 h   Mefenamic acid 250 mg q 6 h   Naproxen 250-275 mg q 6-8 h 5 mg/kg q 8 h Sodium Salicylate 325-650 mg q 3-4 h   Parenteral NSAIDs Ketorolac tromethamine 60 mg initially, then 30 mg q 9 h intramuscular dose not to exceed 5 days   Opioids. Opioids are the major class of analgesics used in the management of moderate to severe pain because of their effectiveness, ease of titration and favorable risk to benefit ratio. .Opioid analgesics are classified as full agonists, partial agonists, or mixed agonist-antagonists, depending on the specific receptors to which they bind and their intrinsic activity at that receptor. Full agonists include morphine, hydromorphone, codeine, oxycodone, hydrocodone, methadone, levorphanol and fentanyl. They do not have a ceiling to their analgesic efficacy and will not reverse or antagonize the effects of other opioids within this class given simultaneously. Side effects include constipation, nausea, urinary retention, confusion, sedation and respiratory depression. Buprenorphine is a partial agonist. Mixed agonist-antagonists in clinical use include pentazocine, butorphanol tartrate, dezocine and nalbuphine hydrochloride. Patients receiving full opioid agonists should not be given a mixed agonist-antagonist because doing so may precipitate a withdrawal syndrome and increase pain. Morphine is the most commonly used opioid for moderate to severe pain because of its availability in a wide variety of dosage forms. Meperidine may be useful for brief courses (e.g. few days) to treat acute pain, generally should be avoided in patients with cancer. Meperidine should not be used if continued opioid use is anticipated. Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with psychological dependence ("addiction"), manifested as drug abuse behaviour. The presence of opioid tolerance and physical dependence does not equate with addiction. Dose equivalents for opioid analgesics in opioid-naïve adults and children >50kg Drug Approximate equianalgesic dose Usual starting dose for moderate to severe pain   Oral Parenteral Oral Parenteral Oipioid Agonist (care with renal or hepatic insufficiency) Morphine 30 mg q 3-4 h repeat round the clock dosing60mg q 3-4h(single or intermittent dosing) 10 mg q 3-4 h 0.3 mg/kg q 3-4 h 0.1 mg/kgq 3-4 h Morphine - Controlled release 90-120 mg q 12 h       Hydromorphone 1.5 mg1.6 q 3-4 h 1.5 mg1.6 q 3-4 h 0.06 mg/kgq 3-4 h 0.015 mg/kgq 3-4 h Levorphanal 4 mgq 6-8 h 2 mg q 6-8 h 0.04 mg/kgq 6-8 h 0.02 mg/kgq 6-8 h Meperidine 300 mg q 2-3 h 100 mg q 3 h   0.75 mg/kgq 2-3 h Methadone 20 mg q 6-8 h 10 mg q 6-8 h 0.1 mg/kg0.2 q 6-8 h 0.1 mg/kg0.2 q 6-8 h Combination opioid/NSAID preparations Codeine (with aspirin or acetaminophen) 180-200 mgq 3-4 h 130 mgq 3-4 h 0.5-1mg/kgq 3-4 h   Hydrocodone (with others) 30 mgq 3-4 h   0.1 mg/kgq 3-4 h   Oxycodone (with others) 30 mgq 3-4 h   0.2 mg/kgq 3-4 h   Because many patients have persistent or daily pain it is important to use opioids on a regular schedule rather than only "as needed". Around the clock administration of analgesics allows each dose to become effective before the previous dose has lot its effectiveness. A patient should be given "as-needed" doses for the first 24 to 48 hours when a new drug is started to define the best daily dosing requirements for that individual patient. Oral. The oral route is the preferred route of analgesic administration because it is the most convenient and cost-effective. When patients cannot take medications orally, other less invasive routes such as rectal or transdermal routes should be tried. Rectal - The rectal route may be used when patients have nausea or vomiting or are fasting either preoperatively or post operatively. The rectal route is contraindicated if there are lesions of the anus or rectum. Transdermal - Transdermal administration bypasses GI absorption. Fentanyl is currently the only opioid commercially available in a transdermal form in four patch sizes and provide delivery of fentanyl at 25,50,,75 or 100 µg/hour; therefore, there is flexibility in drug dosing. The maximum recommended daily dose is 300 µg /hour. Patients requiring larger doses should be switched to an equianalgesic dose of an oral or subcutaneously administered opioid. Nasal - Butorphanol, which is rapidly taken up by the vascular nasal mucosa. The major indication for its use is acute head ache. This drug is not recommended for routine use in cancer pain treatment. Intravenous or Subcutaneous: (Intramuscular administration of drugs should be avoided because this route can be painful and inconvenient, and absorption is not reliable). Patients who may benefit from continuous infusions of opioids include: Those with persistent nausea and vomiting. Those with severe dysphagia or swallowing disorders. Those with delirium, confusion, stupor, or other mental status changes that make oral administration contraindicated because of concerns about pulmonary aspiration in an unprotected airway. Those on high doses of oral medications necessitating numerous tablets. Those who experience undesirable side effects in relation to each dose of an 'as needed' medication. Those who require rapid incremental doses of analgesia. Intraspinal - Analgesics may be administered intraspinally when pain cannot be controlled by oral, transdermal, subcutaneous or intravenous routes because side effects such as confusion and nausea limit further dose escalation. Documentation of the failure of maximal doses of opioids and coanalgesics administered through other routes should precede consideration of intraspinal analgesia. Furthermore, this route requires experience, meticulous technique, significant family and professional support systems, and sophisticated follow up, which are not available in all settings. The main indication for the long term administration of intraspinal opioids is intractable pain in the loser part of the body. Intraventricular-beneficial for recalcitrant pain due to head and neck malignancies and tumors (e.g. superior sulcus tumors, breast carcinoma) that effect the brachial plexus. Small maintenance doses of morphine (less than 5mg daily) are needed to achieve maximal comfort. Requires the placement of a ventricular catheter connected to a subcutaneous (e.g. Ommaya) reservoir for intermittent administration. Management of side effects. Constipation - This is a common problem associated with opioid administration. Tolerance to the constipating effects of opioids does not occur. Increase in fiber consumption and the use of a mild laxative such as milk of magnesia. A stimulating cathartic drug e.g. bisacodyl, standardized senna concentrate, or hyperosmotic agents (e.g. lactulose or sorbitol). Oral laxatives can be taken at bedtime and rectal suppositories can be used in the morning if needed. Stool softeners or emollient laxatives, e.g. docusate, are of limited usefulness because of colonic resorption of water from the forming stool. They should not be used as sole regimen but may be useful when given in combination with stimulant laxatives to ease defecation, especially in bedridden patients. Sedation. Transitory sedation is common when opioid doses are increased substantially, but tolerance usually develops rapidly, reducing the opioid in each dose and increasing the dosage frequency. General comments and cautions regarding the use of opioid analgesics. Opioids are drugs of choice for severe cancer-related pain. Opioids do not have an analgesic ceiling effect, and therefore dose can be treated to achieve maximum. Constipation is an almost universal complication of opioid use, so all patients should receive prophylactic stimulant laxative therapy unless otherwise contraindicated (e.g. chronic diarrhea). Sedation is a frequent side effect of initial opioid use. However, tolerance develops soon in most patients. Respiratory depression rarely occurs except in opioid naïve patients and those with significant pulmonary disease. True hypersensivitity reactions to opioids are rare. If patients experience such reactions, it is often possible to administer an opioid from another subclass safely The subclasses are: Phenanthrene derivatives; morphine, codeine Hydromorphone, oxycodone, phenylpiperidine, derivatives, meperidine Fentanyl, Diphenylheptane derivatives; methadone. The use of opioid antagonists such as naloxone can immediately reverse all opioid effects including analgesia. Such reversal results in acute withdrawal, which may be complicated by excruciating pain and seizure. Therefore, opioid antagonists are never recommended to reverse non-life-threatening respiratory depression or hypotension, they should be titrated cautiously. Oral is the preferred route of administration, except for patients who cannot undertake or tolerate oral medications. When given in appropriate doses, oral opioids are as efficacious as parenteral opioids. Rectal and transdermal dosage forms are available and effective non-invasive alternatives when oral medication is not possible. Rectal suppositories are contraindicated if lesions of the rectum or anus are present. Repetitive intramuscular and subcutaneous (SC) injections should be avoided because they are painful and absorption is inconsistent. Intravenous (IV) administration may be used when less invasive routes are ineffective or unavailable. IV opioids may be given by bolus or continuous administration (including PCA) Patient Controlled Analgesia; however, they require careful monitoring during titration. Inappropriately excessive dosing may carry significant risk of respiratory depression, especially in opioid-naive patients or those with underlying pulmonary pathology. Low volume continuous SC infusion may also be used if venous access is not established. IV or SC -PCA provides a good steady level of analgesia. It is widely accepted by patients but requires special infusion pumps and staff education. May not be appropriate for patients with altered mental status or agitation. Epidural and intrathecal opioids provide good analgesia, when suitable. These routes have significant risk of respiratory depression, which may be delayed, necessitating careful monitoring. Special preservative free drug formulations are necessary for these routes of administration. Nausea and Vomiting. Metoclopramide, prochlorperazine, chlorpromazine , haloperidol, Scopolamine, hydroxyzine. Respiratory Depression Naloxone should be given cautiously. Naloxone titration, when indicated for the reversal of opioid-induced respiratory depression, should be given incrementally in doses that improve respiratory function but do not reverse analgesia. Adjuvant Drugs Corticosteroids - provide a range of effects including mood elevation, anti-inflammatory activity, antiemetic activity, and appetite stimulation. .Reduce cerebral and spinal cord edema, management of elevated intracranial pressure, tumor induced spinal cord compression, reducing pain due to perineural oedema. Undesirable effects such as myopathy, hyperglycemia, weight gain and dysphoria may occur during prolonged steroid therapy. Adjuvant analgesic drugs for cancer pain. Drug Approximate adult daily dose range Route of administr-ation Type of pain Corticosteroids Dexamethasone 16-96 mg Oral, I.V. Pain associated with brain metastases and epidural spinal cord compression Prednisone 40-100 mg Oral Antidepressants Amitryptyline 25-150 mg Oral Neuropathic pain Doxepin 25-150 mg Oral Imipramine 20-100 mg Oral Trazadone 75-225 mg Oral   Neuroleptics Methotrimeprazine 40-80 mg I.M. Analgesia, sedation, antiemetic Antihistamines Hydroxyzine 300-450 mg I.M. Adjuvant to opioids, complicating symptoms -anxiety, insomnia, nausea Local Anaesthetics/antiarrhythmics Lidocaine 8mg/kg I.V./S.C. Neuropathic pain Mexiletine 450-600 mg Oral Tocainide 20 mg/kg Oral Psychostimulants Dextroamphetamine 5-10 mg Oral Improve opioid analgesis, decrease sedation Methylphenidate 10-15 mg Oral Bisphosphonates and Calcitonin Nonpharmacologic Management: Physical and psychological Modalities Physical Modalities Cutaneous stimulation, exercise, immobilization, Transcutaneous Electrical Nerve Stimulation(TENS) and acupuncture. Cutaneous Stimulation. - includes the application of superficial heat (thermotherapy) and cold cryotherapy). Other methods, such as massage, pressure and vibration, may help patients to relax or distract them from their pain. Usually can be easily taught to the patient or family caregiver. In view of the lack of research findings that clearly contraindicate this use of superficial heat, it is recommended that it be used for pain control in patients with cancer. Exercise: position change or exercise as a self-initiated strategy for pain relief. Patients should be encouraged to remain active and participate in self care when possible. Families should be taught a simple routine of range-of-motion exercises and massage to minimize discomfort and preserve muscle length and joint function. During acute pain, exercise should be limited to self-administered range of motion. Prolonged immobilization should be avoided whenever possible to prevent joint contracture, muscle atrophy, cardiovascular deconditioning, and other untoward effects. Counterstimulation. Transcutaneous Electrical Nerve Stimulation (TENS) - TENS is a method of applying controlled, low-voltage electrical stimulation to large, myelinated peripheral nerve fibers via cutaneous electrodes for the purpose of modulating stimulus transmission and relieving pain. Acupuncture - this is a neurostimulatory technique that treats pain by the insertion of small, solid needles into the skin at varying depths, typically penetrating the underlying musculature. Patients who choose to have acupuncture for pain management should be encouraged to report new pain problems to their health care team before seeking palliation through acupuncture. Psychosocial Interventions - giving patients information about pain and its managemenand helping patients to think differently about their pain are both cognitive techniques, restoring the patient's sense of self control, personal efficacy, and active participation in his/her own care. Psychosocial interventions should be introduced early in the course of illness so that patients can learn and practice these strategies while they have sufficient strength and energy. Relaxation and Imagery - Mental relaxation, physical relaxation, simple focused-breathing exercises, progressive muscle relaxation, meditation, and music-assisted relaxation. Distraction and Reframing. Patient Education Patients should be told that: The use of opioid analgesics will not lead to addiction. Tolerance to opioid analgesics can be dealt with by upward dosage adjustments. Many patients worry that, if they complain of pain, their health care providers might not think of them as good patients. Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan. Psychotherapy and Structured Support. Hypnosis Peer Support Groups - Programs of self help and mutual support of patients with cancer, visitor programs to offer practical help for patients at home, enroll survivors of any type of cancer and their relatives. Association of Laryngectomees, Ostomy Associations. Religious Counseling. Non-pharmocologic interventions. Invasive therapies. With rare exception, non-invasive analgesic approaches should precede invasive palliative approaches. Radiation Therapy. The desired dosage of radiation should be administered in the fewest fractions possible to promote patient comfort during and after treatment. Bone Metastases. Indications for the radiation of bone metastases include pain relief and the prevention or promotion of healing of pathologic fractures. Pain relief with Localized Radiation Therapy - radiation is commonly administered to a localized bone metastasis. Wide Field Radiation Therapy - Hemibody irradiation which can treat multiple disease sites, is particularly appropriate for diffuse bone pain. Radiopharmaceuticals - several radiopharmaceuticals have been used therapeutically. Iodine 131 used for the treatment of multiple bone metastases from thyroid cancer. Phosphorous-32-orthophosphate has provided partial or complete relief of pain in about 80 per cent of patients with bone metastases from breast and prostate carcinoma. Plexopathy - painful nerve compression or infiltration by a malignant tumor can sometimes be alleviated by radiation therapy. Palliation radiation can be administered to any location of symptomatic primary or metastatic disease. Brachytherapy - endobronchial and bile duct tumors, the intracavitary treatment of cervical and endometrial cancer, and interstitial implants in unresectable tumors with catheters or radioactive seeds. Anesthetic Techniques Nerve Blocks When a patient is painfree after neurolysis, opioids should not be stopped abruptly, lest a withdrawal syndrome be provoked. Neurolytic blockade of peripheral nerves should be reserved for instances in which other therapies (palliative irradiation, TENS, pharmacotherapy) are ineffective, poorly tolerated, or clinically inappropriate. Catheter Placement for Drug Delivery. Neurosurgery - include neuroblation, implantation of drug infusion systems and neuroaugmentation. Neuroblation. Peripheral Neurectomy. Dorsal Rhizotomy - selective ablation of the dorsal nerve root reduces nociceptive perception in the affected area and spares motor function. Anterolateral Cordotomy (Spinal Tractotomy) - this is an ablative procedure aimed at the pain-conducting tracts in the anterolateral quadrant of the spinal cord. Commissural Myelotomy - disrupts pain-conducting fibers as well as a polysynaptic pain pathway that runs through the center of the spinal cord. Hypophysectomy - Surgical and chemical (stereotactic transsphenoidal)hypophysectomy are similar procedures that each offer a 40 to 70 per cent likelihood of pain relief. Neuroaxial Opioid Infusion - in properly selected patients, intraspinal or intraventricular infusions of opioids have the advantage of producing profound analgesia without motor, sensory, or sympathetic blockade. Surgery - operations for the curative excision or palliative debulking of a tumor have the potential to reduce pain, improve prognosis and even to achieve long-term, symptom-free survival. Surgical Management of Pain due to Primary or Metastatic Tumor. When surgery is palliative because the tumor is unresectable, pain control is frequently the operative indication, surgeons should use techniques to limit the development of chronic neuropathic pain such as nerve sparing incisions, avoidance of ischemia and careful dissection around nerves. The oncologic surgeon should be familiar with the interactions of chemotherapy, radiation therapy, and surgical interventions so that iatrogenic complications may be avoided or anticipated (e.g. multiple fistulas resulting from bowel resection performed after radiation. The second principle is that even outstanding radiotherapy generally will not improve an inadequate surgical procedure. The third principle is that local tumor recurrence is not always the harbinger of disseminated disease. Some patients with local recurrence can still be cured depending on their underlying disease and may be best served by a second resection aimed at cure, perhaps incorporating radiotherapy, rather than a less aggressive palliative procedure solely for pain control. The fourth principle is that the timing of a surgical intervention for pain control is important. Surgical pain control may be maximized if undertaken before the onset of symptoms. Pain as a Consequence of Operation - the surgeon should recognize and treat characteristic pain syndromes that follow specific surgical procedures (e.g. mastectomy, nephretomy etc.) Procedure-Related Pain. General Considerations. Treat anticipated procedure-related pain prophylactically. Patients benefit from predictability as to time, frequency, and clustering of procedures with an identified block of time when no procedures are to be performed, barring emergencies. Be attentive to the environment and to privacy. Cold or crowded rooms or beepers on machines can escalate distress. Manage preexisting pain as well as possible. Psychological preparation of the patient and family - discuss with the child and parents what can be expected and how the child might respond. Procedural considerations For procedures that will be repeated, maximize treatment for the pain and anxiety of the first procedure to minimize anxiety before subsequent procedures. Ensure the competency of the person performing the procedure. Minimize delays to prevent escalation of pain and anxiety. Nonpharmacologic interventions - the presence of a parent is a source of great comfort for the child. Parents should be taught what to do, where to be, and what to say to help their child through the procedure. Parents should not be asked to restrain the child during the procedure. For adults, the presence of a supportive friend or relative may be helpful. Pharmacologic agents for management of procedural pain. Local anesthetics. Opioids - 0.03 to 0.05 mg per kg of morphine every 5 minutes for children, weigh less than 50 kg or 2 to 4 mg of morphine every 5 minutes for adults and children >50 kg. Intravenous fentanyl may be used in small doses. Benzodiazepines - orally, intravenously, transmucosally. Barbiturates - no analgesic effects, used with analgesics. Sedation for Procedural Pain: When conscious sedation is used, at least one health care professional who is well trained in airway management and advanced life support should be available. During such procedures, a health care professional not involved in performing the procedure or restraining the patient should monitor the patient. Additional Pain Management Strategies for Lumbar Puncture and Bone Marrow Aspiration. Local anesthetics are used. Benzodiazepine, supplementation with opioids is helpful for some patients., for bone marrow aspirations, local anesthesia, conscious sedation with benzodiazepines, opioids. Elderly patients Elderly patients are often under-treated for cancer pain. Attitudes of health care professionals, the public and patients toward pain can impede appropriate care; because many people consider acute and chronic pain to be a part of normal aging. The elderly should be considered an at-risk group for the under-treatment of cancer pain because of inappropriate beliefs about their pain sensitivity, pain tolerance, and ability to use opioids. Elderly patients, like other adults, require aggressive pain assessment and management. Depression in patients with Cancer Pain: Psychological symptoms of depression; dysphoric mood, hopelessness, worthlessness, guilt, and suicidal ideation. A history of familial depression or of previous depressive episodes. Makes this diagnosis more probable. Psychostimulants are most helpful. Suicide and Cancer Pain. Few patients with cancer commit suicide, but poorly controlled pain places them at increased risk. Suicide risk factors in cancer patients with pain. Depression Poorly controlled pain Previous controlled pain Previous suicide attempt(s) Family history of suicide Delirium Substance abuse Prior psychiatric diagnosis (depression)