EIFEL FAHERI

Principles of Cancer Management

Survival symptom control
& pain mangement
Analgesic theraphy
Multidiscipline team
Psychososial Support
Spesific educational

NCCN 2015

IASP Council on October 28, 2010)

Pain : Sensory and emotional experience,

associated with actual and potential tissue
damage

Cancer Pain

Annals of Oncology 21 (Supplement 5): v257v260, 2010

people experience
pain (spread)
At the time of
diagnosis

65-85 %
30-40 %

treated
successfully

90 %

systematic review of the literature : half of cancer patients were under-treated

not adequately treated in a significant percentage of patients : 56% to 82.3%.

Pain - ASCO curriculum .Cancer.Net. 2011

 Fatigue
Weakness
Shortness of breath
Nausea
Constipation
Sleep disturbances
Depression
Anxiety
Mental confusion
Pain - ASCO curriculum .Cancer.Net.

generation of pain in response to

tissue injury
Nociceptive
signals
noxious
stimulation

central nervous
system

Transformation
Perception
( clinical pain experience)

Neuropathic

Nociceptive

Transduction Transmission
Nociceptive pain can be classified as somatic (for example, muscles, joints) or less
often visceral (internal organs). Because of the high concentration of nociceptors in
somatic tissues, chronic somatic pain is typically well localized and often results
from degenerative processes (such as arthritis)
Neuropathic pain: Pain caused by a lesion or disease of the somatosensory nervous
system
Cohen and Mao. BMJ 2014;348:f7656

Pain Control

Pain Management

Comprehensive Pain
Assesment

NCCN 2014

10

Comprehensive Pain Assesment

Type
History
Intensity
Location
Referral pattern

NCCN 2014

Radiation of pain
Factor
exacerbate
Current pain
management
Respon at
theraphy

11

Classification of neuropathic and nociceptive pain

Cohen and Mao. BMJ 2014;348:f7656

12

Comprehensive Pain Assesment

Type
History
Intensity
Location
Referral pattern

NCCN 2014

Radiation of pain
Factor
exacerbate
Current pain
management
Respon at
theraphy

13

 Onset
Duration
Course

14

Comprehensive Pain Assesment

Type
History
Intensity
Location
Referral pattern

NCCN 2014

Radiation of pain
Factor
exacerbate
Current pain
management
Respon at
theraphy

15

Visual Analogue Scales (VAS)

Verbal Rating Scale (VRS)

Numerical Rating Scale (NRS)

Annals of Oncology 23 (Supplement 7): vii139vii154, 2012

16

Self completed by the respondent

line perpendicular
Using a ruler
Range of scores from 0100
no pain (04 mm), mild pain (544), moderate pain (4574 mm), and
severe pain (75100 mm)

Hawker et al. Arthritis Care & Research Vol. 63, No. S11, November 2011, pp S240

17

Numeric Rating Scale

Numeric version of VAS

Respondent selects a whole number (010 integers)
Best reflects the intensity of their pain
Scores range from 010
Minimal language translation difficulties support the use
of the NRS

Hawker et al. Arthritis Care & Research Vol. 63, No. S11, November 2011, pp S240

18

Wong-Baker FACES Pain Rating Scale

Face 0 is very happy because he doesnt hurt at all

Face 1 hurts just a little bit
Face 2 hurts a little more
Face 3 hurts even more
Face 4 hurts a whole lot
Face 5 hurts as much as you can image
for persons age 3 years and older
1. National Cancer Institute
2. National Initiative on Pain Control

19

Nonverbal Pain Indicators (CNPI)

Score a 0 if the behavior was not observed. Score a 1 if the behavior occurred even briefly during activity or at rest. The
total number of indicators is summed for the behaviors observed at rest, with movement, and overall. There are no clear
cutoff scores to indicate severity of pain; instead, the presence of any of the behaviors may be indicative of pain,
warranting further investigation, treatment, and monitoring by the practitioner

20

(-)

an Oncology emergency

Pain
(+)

an Oncology emergency
Bone fracture
Metastases
Obstruction

NCCN 2015

21

Comprehensive Pain Assesment

Type
History
Intensity
Location
Referral pattern

NCCN 2014

Radiation of pain

Factor
exacerbate
Current pain
management
Respon at
theraphy

22

Comprehensive Pain Assesment

Type
History
Intensity
Location
Referral pattern

NCCN 2014

Radiation of pain
Factor
exacerbate

Current pain
management
Respon at
theraphy

23

PRINCIPLES OF PAIN MANAGEMENT IN

PATIENTS WITH CANCER
Pain is a subjective experience
Patients should be given information and instruction
about pain
Successful pain management involves
comprehensive assessment, individualised treatment
planning and regular review
Treatment start at the level of the WHO analgesic
ladder appropriate for the severity of the pain
moderate to severe cancer pain receive a trial of
opioid analgesia
Continuous pain --- "breakthrough pain".
Multiprofessional team
1.General Palliative Care Guidance for Control of Pain in Patients with Cancer
2003

24

Gambar. Algoritma tatalaksana nyeri pada kanker

25

By the Ladder
analgesics given per the W.H.O three step ladder

Fraser heakth. Hospice Palliative Care, Clinical Practice Committee, November

26

W.H.O Principles

By mouth.
By the clock.
By the ladder
For the individual
Use of adjuvants
Attention to detail

Hospice Palliative Care, Clinical Practice Committee, November 24, 2006

27

By the Mouth
oral route is the route of administration of
choice

Fraser heakth. Hospice Palliative Care, Clinical Practice Committee, November

28

By the Clock
analgesic medications for moderate to severe
pain should be given on a fixed dose schedule,
not on an as needed basis

Fraser heakth. Hospice Palliative Care, Clinical Practice Committee, November

29

Selected non-opioid analgesics (WHO step I)

Substance

Widely available forms and

strengths

Time to
onset (min)

Caution

Maximal daily
dose (mg)

Acetaminophe
n
(paracetamol)

Tablets, suppositories
5001000 mg

1530

Hepatotoxicity

4-6 x 1000

Acetylsalycic
acid

Tablets 5001000 mg

1530

GI toxicity, allergy,
platelet inhibition

3x1000

Ibuprofen

Tablets 200400600 mg; tablets

800 mg modified release; topical
gels

1530 + 20

GI and renal toxicity

4 x 600 ; 3 x
8000 modified
release

Ketoprofen

Tablets 2575 mg; tablets

100150200 mg modified release

+ 30

GI and renal toxicity

4 x 75 ; 2 x 200

Diclofenac

Tablets 255075 mg; tablets

100 mg modified release

30-120

GI and renal toxicity

4 x 50 ; 2 x 100

Mefenamic
acid

Capsules 250500 mg

+ 30

GI and renal toxicity

4 x 500

Naproxen

Tablets 250375500 mg

+ 30

GI and renal toxicity

2 x 500

Jost & Roila. Annals of Oncology 21 (Supplement 5): v257v260, 2010

30

Selected opioids for mild to moderate pain

(WHO level II)
Substance

Widely available
forms and
strengths

Relative
effectiveness
compared with
oral morphine

Duration of
effectiveness
(h)

Maximal
daily dose
(mg)

Starting dose
without
pretreatment
(mg)

Dihydrocodeine

Modified release
tablets
6090120 mg

0,17

12

240

60-120

Drops 100 mg/ml,

capsules
50 mg

0,1-0,2

2-4

400

50-100

Modified release
tablets
100150200 mg

12

12

400

50-100

Tramadol

Jost & Roila. Annals of Oncology 21 (Supplement 5): v257v260, 2010

31

1. What should I do before prescribing an opioid?

assessment to understand the pain problem

identify patients at risk ofopioid misuse or addiction

setting function-improvement and pain-reduction goals with

the patient

Informed consent by reviewing with the patient

2. How do I titrate the opioid dose?

Start with a low dose, increase gradually and monitor opioid effectiveness,
i.e., an improvement in function or a reduction in pain intensity of at least 30%.
Track the daily dose in morphine equivalents and flag the watchful dose.
Recognize the optimal dose
1) effectiveness: improved function or at least 30% reduction in pain intensity
2) plateauing: effectiveness plateaus
3) adverse effects/complications

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

32

3. What should I do to ensure patient safety?

pain-reduction goals set to monitor opioid effectiveness
Watch for aberrant drug-related behaviours that could signal opioid misuse
Assess factors that could impair cognition and psychomotor ability
Collaborate with pharmacists to improve patient education and safety
4. When do I stop the patients opioids?
Stop or switch opioids when side effects or risks are unacceptable or
opioid effectiveness is insufficient.
Discontinue opioids with a tapering protocol avoid sedativehypnotic drugs, especially benzodiazepines, during the taper

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

33

Selected opioids for moderate to severe pain (WHO

step III: may be combined with step I medication)
Substance route

Relative effectiveness
compared with oral morphine

Maximal daily
dose

Starting dose without

pretreatment

Morphine sulfate oral

20-40 mg

Morphine parenteral

5-10 mg

Oxycodone oral
Hydromorphone oral

1,5-2

20 mg

7,5

8 mg

Fentanyl transdermal
Buprenorphine oral
Buprenorphine
intravena

12 ug/h
75

4 mg

0,4

100

3 mg

0,3-0,6

Buprenorphine
transdermal

140 ug

Methadone oral

17,3 35 ug/h
10

Nicomorphine oral

20 mg

Nicomorphine
parenteral

20 mg

Jost & Roila. Annals of Oncology 21 (Supplement 5): v257v260, 2010

34

 Morfin
Mulai dengan dosis 5-10 mg setiap 4 jam.
(hati-hati usila dan gangguan ginjal)

Diamorfin

Pasien yang (-) menerima sediaan oral.

Dosis : morfin total /3
Breakthrough analgesia : 1/6 dosis 24 jam.
Breakthrough dpt diulang tiap 30 dg penilaian
The NATIONAL MARROW DONOR PROGRAM operates the Be The Match Registry.

35

 Fentanyl patch (Durogesic)

Biasanya tidak cocok untuk pasien dengan nyeri
tidak terkontrol
Gunakan untuk nyeri stabil
Pertimbangan yang kesulitan rute obat oral
Pertimbangan pada terdapatnya efek samping
dengan opiod lain.
Pasien lebih suka patch.

36

Common and Manageable Side Effects

confusion
dry mouth
hyperalgesia
pruritus
sexual dysfunction

constipation
dyspepsia
nausea
sedation*
tiredness

dizziness
headache
vomiting
sweating
drug tolerance

* It is critical for successful OT to make sure patients are aware of common side effects

These side effects may often be diminished

- by low starting doses
- slow titration rates
- modifying the dosage regimen
- treating side effect symptoms
- patient education at the outset of therapy
- rotating the type of opioid
2010 VA/DoD Clinical Practice Guideline for the Management of Opioid

37

2010 VA/DoD Clinical Practice Guideline for the Management of Opioid

38

2010 VA/DoD Clinical Practice Guideline for the Management of Opioid

39

Efek samping opioid

Konstipasi : laxative + stimulant
Mual dan muntah : metoclopramid 3x10 mghaloperidol 1,5-3 mg.
Sedasi
Mulut kering : permen karet tanpa gula

40

Opioid toxicity and its management

Symptoms and
signs:
- persistent
drowsiness
- pinpoint pupils
- Confusion
- Agitation
- Hallucinations
- Myoclonic jerks
- Cognitive
impairment
- Respiratory
depression

Management
reduce the dose of opioid
adequate hydrati
treat the agitation /confusion
e.g.haloperidol 1.5-3 mg orally
or SC

General Palliative Care Guidance for Control of Pain in Patients with Cancer

41

Do not take Morphine Sulfate Oral if you

allergic to morphine
having an asthma attack or have severe asthma,
trouble breathing,or lung problems
have a bowel blockage called paralytic ileus

The NATIONAL MARROW DONOR PROGRAM operates the Be The Match Registry.

42

For the individual

the dosage must be titrated against the particular patients pain

Fraser heakth. Hospice Palliative Care, Clinical Practice Committee, November

43

Use of adjuvants
to enhance analgesic effects
to control adverse effects of Opioids
to manage symptoms that are contributing
to
the patients pain (anxiety, depression or
insomnia).

Fraser heakth. Hospice Palliative Care, Clinical Practice Committee, November

44

Non pharmacologic treatment

After adaptation from NCCN 2005

45

THANKYOU

The NATIONAL MARROW DONOR PROGRAM operates the Be The Match Registry.

46

Tatalaksana Nyeri
STEP 3: NYERI BERAT
OPIOD + A NON-OPIOID ADJUVANT
Drug options

First line : - Morphine p.o.

- Diamorphine
alternative opioids : - Fentanyl
- Hydromorphone
- Oxycodone
STEP 2: NYERI SEDANG
OPIOID NYERI RINGAN + SEDANG
+ A NON-OPIOID ADJUVANT
Drug options
- Codeine 60mg 6hrly
- Dihydrocodeine 60mg 6hrly

STEP 1: NYERI RINGAN

NON-OPIOID ADJUVANT
Drug options
- Paracetamol 1g qid
- NSAIDs

NYERI BERAT
Morphine adalah opioid oral pilihan. Jika rute oral tidak sesuai, opiod
parenteral menjadi pilihan.

NYERI SEDANG
Pasien dengan nyeri sedang harus menerima opioid lemah plus non-opioid.
Pertimbangkan kombinasi spt codein-parasetamol.

NYERI RINGAN
Pasien harus menerima NSAID atau parasetamol, dosis parasetamol 1 gram/ 6
jam.

PHARMACOLOGICAL MANAGEMENT

World Health Organisation Analgesic Ladder (1986)

47

48