Departments

Medical Departments

Pain Clinic

Diverses data bases

 

Table I : Assessment of bone pain
Physical examination
Neurological examination	Vital if cranial nerves palsy or back pain
Performance status	ECOG or Karnofsky
History of pain	Onset, progression, location(s), temporal pattern, aggravating and relieving factors, prior therapies, functional consequences, associated sleep disturbances
Evaluation of pain	Visual Analog Scale Descriptive Scale Numeric Scale
Laboratory tests	Liver and renal function
Radiological studies	X-Rays, CT Scan, MRI
Psychological evaluation	To rule out associated depression or anxiety
Lumbar puncture	If necessary, to avoid leptomeningeal involvement

Table II : NSAIDs in cancer pain
Oral route available
No coagulation disorder	Coagulation tests required
No active peptic ulcer
No active bleeding
Avoid long-acting molecule	To avoid long term side-effects
Favor short duration of treatment	Between 6 to 8 days (Treatment may be repeated)
Use a "well known" molecule	Adverse events of a "new" molecule may be under estimated

Table III: Recommended opioids for cancer pain (Adapted from Lossignol 1998)
Drug	Route	Equianalgesic dose (mg)°	Starting dose (mg)	Duration of effect (hr)	Agonist/ Antagonist	Comments
Codeine	PO, IM	100	60 (PO)	4	Agonist	Not superior to NSAIDs / Constipation
Tramadol	PO (+ SR), IM, IV, Rectal	100	50 (PO)	4-6	Agonist	Amine re-uptake inhibition / equivalent to codeine but with less side effects
Morphine	PO (+ SR), IM, IV, SC, Rectal	30-60	10 (PO)	4-6	Agonist	First choice for moderate to severe cancer pain
Methadone	PO, IV, IM	10 (?)	1 – 5	8-10	Agonist	Not a first choice/ Useful in opioid rotation program/ Risk of drug accumulation/ 10 times more potent than morphine (?)
Fentanyl	TD, (IV,IM)	0.1 (?)	25 mcg	48-72 (TD)	Agonist	Potent opioid/ Transdermal system/ Share the same side effects with morphine/ Useful in opioid rotation program
Hydromorphone	PO (SR), IV, IM	5 –7.5	2	3 - 4	Agonist	High solubility / Useful in opioid rotation program

Potency relative to 10 mg of parenteral morphine; IV: intravenous; SR: sustained release; TD: transdermal Table IV: Guidelines for the use of opioids
Start with a short-acting molecule to titrate the pain	Morphine 5 mg (SC) or 10 mg (PO) every 6 hours ("Around the clock")
Evaluate side effects	Prevention of nausea (metoclopramide or haloperidol°Prevention of constipation (laxative regimen)
Favor oral medications	For long term treatment, move to sustained release preparations
Prescribe rescue –dose	One "rescue-dose" is about 10 % of the total daily dose
Use a diary to collect information on pain control/ pain relief	Use VAS, NS etc.
Educate the patient and family members	Prevent withdrawal, explain that toxicomany or respiratory depression is uncommon
Change from one opioid to an other when side effects are to though	Opioid rotation program

Table V: Co-analgesics
Amitriptyline	25 to 75 mg once a day
Carbamazepine	200 to 600 mg once a day
Clonazepam	0.5 mg once a day
Gabapentine	300 mg X 3
Biphosphonates	Various dosages
Methylprednisolone	Various dosages

Table VI: Pharmacological treatment of bone pain
1.Paracetamol	500mg 4 to 6 b.i.d
or NSAID – (COX-2 ?)
2.Oral morphine	10 mg 4 to 6 b.i.d.
or SC morphine	5 mg 4 to 6 b.i.d.
3. Co-analgesic medications according to pain characteristics
4. Consider radiation therapy, surgery or biphosphonates
5. Consider analgesia before any diagnostic procedures: CT Scan, MRI	Oral or SC morphine
6. Consider sustained released medications for long term treatment

Figure 1 : Pain assessment tools (Adapted from Koshy) Visual analog scale
No pain	Worst possible pain

No pain Worst possible pain Descriptive scale
No pain	Mild pain	Moderate pain	Severe pain	Very severe pain	Worst possible pain

Visual analog scale

0	1	2	3	4	5	6	7	8	9	10

Figure 2: The WHO ladder
		STEP III Strong opioids
	STEP II Weak opioids
STEP I Nonsteroidal Antiinflammatory drugs (NSAIDs) and paracetamol
Co-analgesics (antidepressants, anticonvulsants, etc)

 

Comments:
1) Step I medications may be associated with Step II/ III
2) Never associate Step II and Step III
3) Consider surgery and/or radiation therapy in each case
4) Prevent breakthrough pain with rescue medications

Other Articles:

- Pain Treatment
- Coanalgesics
- Resistant Pain

 

Person in charge : Dr. Lossignol Dominique