Dr G P Dureja

Professor and Incharge

Pain Management Clinic

All India Institute of Medical Sciences

New Delhi

 

Pain is among the most common symptom in cancer patients. It is estimated that globally 4 million cancer patients suffer pain  and for most of these patients, pain is not satisfactorily relieved. Of the one million people who get cancer in India every year, the vast majority is incurable at the time of diagnosis and is in need of pain and palliative care only.   Although developed countries have established government policies on   cancer pain management and terminal care; India still has no national policy on the care of terminal cancer patients or palliative care. There is an urgent need for fresh initiatives in this direction and  the Oncologists and Anaesthesiologists should take a lead in formulating a National Cancer Pain Relief Programme. Freedom from pain  ,suffering and access to palliative care should be seen as a right of every cancer patient.

 

Over the period of past 15 years, new treatment modalities have been evolving for managing both acute and chronic pain including cancer pain.  With personal experience of attending to over 8000 acute and chronic pain patients every year at a premier referral hospital of the country, we find that pain management has come a long way and the pain treatment continuum too has been ever expanding.  Relief of cancer pain is possible : the protocols for pain treatment have to be laid down keeping in view the problems of our patients. The key points are simplicity and low cost of the technology used to manage pain and other symptoms. A judicious use of available NSAIDs, Opioids, chemotherapy, radiotherapy,palliative surgery, neurolytic blocks and Advanced interventional pain management modalities can be adopted to minimise or eliminate the pain and improve the quality of life of terminally ill patients. .

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 How well do we as a medical community manage cancer pain? What are the basics when initiating morphine therapy? What are some of the newer approaches available today? This lecture attempts to answer these questions by discussing the barriers to effective pain management, offering guidelines for quantifying pain levels, and describing appropriate administration of nonopioid, opioid, and adjuvant medications.

 

Chronic or recurrent pain affects one third of all patients with cancer and 60% to 90% of those with advanced cancer. The prevalence rate in children with cancer is lower because of the higher proportion of hematologic malignancy; those with solid tumors, however, often have the same kinds of chronic pain as their adult counterparts.  The Eastern Cooperative Oncology Group (ECOG) used the Outpatient Pain Needs Assessment Survey to evaluate the adequacy of pain relief in 1,308 outpatients with metastatic cancer. The patients were asked to rate the presence and severity of pain during the week before a scheduled appointment. Of these patients, 871 (67%) had pain or took analgesics during the week and 475 (36%) had pain severe enough to impair function. Among 597 patients who took analgesics, 250 (42%) reported that they were not given adequate analgesic therapy.

 Magnitude of problem

?                    Ten lakh new cancer patients every year in India.

?                    60-80% of patients present in advanced stage, hence incurable.

?                    60% cancer patients require pain management and palliative care.

?                    40% receive inadequate treatment for pain management with a poor quality of life in terminal stages.

?                    Only 28% receive palliative care.

 

What are the barriers to adequate analgesia in cancer patients? In certain cases, patients themselves create barriers. Some are reluctant to report pain because it may reflect disease progression. Some may have cultural or religious influences that cause them to value suffering. Some are concerned that if they take pain medicines too soon, the drugs may not work later if pain increases. Many patients fear addiction. Finally, some may feel that drugs such as morphine are only for patients who are dying. These concerns can all be addressed with accurate information.

The treatment of cancer pain leads to addiction in less than 1% of patients who have no history of drug addiction . Addiction is a psychological and behavioral syndrome characterized by loss of control over drug use and compulsive, continuous use despite harmful side effects. Persons addicted to opioids crave the psychic effects of these drugs. In a large prospective study, only four cases of iatrogenic addiction could be identified among 11,882 patients with no history of addiction who had received opioids in the hospital setting .

Physicians may create barriers to effective pain management. An ECOG study of university and community medical oncologists, hematologists, surgeons, and radiation therapists explored the most significant barriers to adequate pain management. Over half of all respondents rated one of the following as an important barrier: inadequate pain assessment, patient reluctance to report pain, patient reluctance to take opioids, physician reluctance to prescribe opioids, or inadequate staff knowledge about pain management.

 

?                    Lack of awareness among health care workers, policy makers and public that treatment for cancer pain management is available.

?                    Lack of financial resources, health care delivery systems and trained personnel.

?                    Fear among treating physicians of psychological dependence and drug abuse of opioids.

?                    Strict legal provisions for accessibility to opioids.

?                    Lack of will to formulate national policy for cancer pain relief and palliative care.

 

 

Cancer Pain Management Guidelines

 

Although developed countries have established government policies on pain, cancer pain and terminal care; developing countries such as India and other Asian and African countries still have no national policy on the care of terminal cancer patients or palliative care.. There is an urgent need for fresh initiatives in this direction and the Oncologists and Anaesthesiologists should take a lead in formulating a National Cancer Pain Relief Programme. Freedom from pain, suffering and access to palliative care should be seen as a right of every cancer patient.

 

In the cancer population, pain is associated with both psychologic distress and functional impairment.  The impact on mood, function, and quality of life may be related to many facets of pain, including its severity, temporal relations, and meaning.  The relationship between severity and impact has been well characterized by a recent survey.  It demonstrated that pain rated from 1 to 4 on a 10-point scale had a generally mild impact on function; pain of this severity adversely affected overall enjoyment of life.  Pain rated 5 and 6 on a 10-point scale had a moderate impact on function, and pain rated 7 or greater had a severe impact.

 

 For over 3 decades, World Health Organization (WHO) has taken a lead in establishing a consensus for a scientifically valid method of relieving cancer pain that is relatively simple, inexpensive and easy to apply at community level, known as the WHO ?Three step Analgesic Ladder? method. Data from prospective surveys suggest that 70% of patients with cancer pain could attain adequate relief from the systematic administration of the drug therapies endorsed by the World Health Organization (WHO).  Unfortunately, this potential success rate is not achieved in routine practice settings.  In a recent survey of ambulatory cancer patients, a pain management index was devised to assess the degree to which analgesic therapy is consistent with WHO guidelines; according to this measure, more than 40% of patients were undertreated.  Among other factors, undertreatment was associated with minority status, female sex, and history of substance abuse.

 

 

Assessment of cancer pain and related problems

A detailed history and thorough general physical examination is undertaken when the patient is enrolled in the Pain clinic. The intensity of pain is measured on visual analog scale (VAS) and other components of pain like somatic, neuropathic, visceral or sympathetically maintained pain are measured by different scales such as the impact of pain on the quality of life (QOL score) of patient and treatment patient has already received is also noted. It is also necessary to evaluate the affective, behavioural and social disturbances (MMPQI). Severity of pain determines the strength of analgesics required, and the type and cause of pain will influence the choice of adjuvant analgesic and interventional modalities to be chosen.

During the period of treatment all the patients are continuously monitored for the efficacy of treatment and for the need of modification of treatment. The parameters used are

 

?                    Visual analogue scale (1-10)

 

?                    Performance scale

a.    Activity of daily living score ? the domains covered are

-                      Eating

-                      Dressing

-                      Writing

-                      Use of household items

b.    Quality of life scores (SF 36) ? the domains covered are

-                      Physical

-                      Role ? physical

-                      Bodily pain

-                      General health

-                      Vitality

-                      Social functioning

-                      Role ? emotional

-                      Mental health

-                       

For the purposes of research and study documentation eastern cooperative oncology group and Karnofsky rating performance scale and World Health Organization quality of life score is used.

 

 

Table 1 : Eastern cooperative oncology group (ECOG)performance scale and Karnofsky rating

 

ECOG PS grade rating	Description	Karnofsky
0	Fully active, able to carry all pre-disease activity without restriction	100
1	Restricted physical strenous activity, but ambulatory and able to carry out work of a light or sedantary nature (light house work office work)	80-90
2	Ambulatory and capable of all self care but unable to carry out any work activities: up and about >50% of working hours	60-70
3	Capable to limited self care, confirmed to bed or chair > 50% of waking house	40-50
4	Completely disabled, cannot carry on any self care, totally confined to bed or chair	>30

There are certain basic principles and approaches that have been described to pain management in cancer patient, although each patient needs to have treatment plans tailored to his individual problems. The basic principles to cancer pain management are:

 

?                    Treatment of cancer : surgery, radiation, chemotherapy.

?                    Modulation of central perception of pain : analgesics, antidepressants, anxiolytics, disruption of nociceptive transmission within the CNS : neuroaxial analgesia, neuroablation.

?                    Palliative care

?                    Immobilization ? rest, cervical collar etc.

 

 

Relief of cancer pain is possible: the protocols for pain treatment have to be laid down keeping in view the Indian perspective. The key points are simplicity and low cost of the technology used to manage pain and other symptoms. A judicious use of available NSAIDs, Opioids, chemotherapy, radiotherapy and Neurolytic blocks can be adopted to minimise the pain and improve the quality of life of terminally ill patients. Systemic opioid therapy is widely accepted as a first line approach to management of moderate or severe chronic cancer pain.  World Health Organization (WHO) advocates the use of the analgesic step ladder and predicts a favourable outcome in about 80% of patients.  In clinical practice, this rate of success is not realized, largely because of under treatment and multifactorial aetiology of pain syndromes in advanced cancer patients.  Some patients would also have intolerable side effects of oral  opioids forcing them to abandon the use of these drugs.  These patients are poorly responsive to opioid therapy and must be considered for alternative analgesic strategies.  Pain clinicians should be able to identify poor responsiveness and pursue clinical approaches that may improve outcome

 

Advantages of WHO 3 step Ladder

?                    Effective pain relief can be achieved in 75-80% of patients of cancer.

?                    It is simple to use.

?                    Assessment of cancer pain & related problems

 

Disadvantages of WHO 3 step Ladder

?                    It gives minimal emphasis on regional nerve blocks which are very suitable for the patients who are travelling long distances in search of treatment and regular follow up is difficult.

?                    Puts a lot of emphasis on opioid treatment inspite of known fact that opioids are not widely and easily available particularly oral morphine.

 

Neurolytic sympathetic procedures for pain conditions due to pancreatic and pelvic cancers should be intended as adjuvant techniques to reduce the analgesic consumption and not as a panacea, given that multiple pain mechanisms are involved. Neurolytic  blocks such as coeliac plexus blockade is the preferred method for managing pain caused by neoplastic infiltration of upper abdominal viscera, including pancreas, liver and stomach. This blocks relieves  pain by 50 ?90% in such patients with relief lasting from 1 to 12 months.  Pancreatic pain is more amendable to sympathetic blocks than pain due to pelvic cancers.

 

The role of neuroablative techniques for somatic and neuropathic pain of cancer of often debatable. However chemical neurolysis and pituitary ablations have been reported to relieve diffuse and multifocal pain syndromes. Transdermal fentanyl citrate also provides a new option for pain management and as a adjuvant for managing sever cancer pain.

 

Intrathecal drug delivery implantable systems play a major role in managing cancer pain in patients with a long life expectancy. Intrathecally administered opioids such as morphine and alpha adrenergic agonist such as clonidine provide a comprehensive and complete relief of pain and suffering in select group of patients.  The quality of life achieved after such interventions is far superior to other methods and patient can achieve complete independence in a very short span of time.  However, the only drawback of this technique is its cost which is prohibitive and beyond the reach of a common individual.

 

Years of experience in a large referral institution indicates that cancer pain treatment is a continuum starting with physical therapy and neuropsychology techniques escalating to NSAIDs, weak narcotics, strong opioids and finally advanced interventional techniques and operative interventions.  After diagnosis and evaluating the level of pain, selection of method with the best chance for optimal reduction of pain with the least occurrence of side effects, is indicated.  Numerous nonpharmacological approaches may be considered such as chemical neurolysis, neurostimulatory methods, intrathecal opioid delivery systems, rehabilitative (e.g. an arthrosis in a patient with painful limb) and psychological (e.g., cognitive) interventions for control of pain.  Although linked conceptually, the scope of these therapies is obviously very broad and there are substantive differences in their indications and implementation.  The choice of therapy must integrate the type of pain, its function, the overall disease burden of the patient and psychological aspects of cancer.  As a general rule, if opioid analgesics are not sufficient, interventional therapies and other surgical management should be considered.The World Health Organization (WHO) guidelines for cancer pain reduction procedures, ignores physical medicine, neuropsychology, neurolytic interventions and advanced interventions, completely in favour of exclusive reliance on pharmacological modalities.  This critical omission is due to the lack of equipment and personnel trained in such disciplines in under developed and developing countries.