Pain and cancer patients


Every doctor, sooner or later encounters in cancer patients with cancer pain, this problem very frequent and enormously important health and social care. The first step is to see if the pain is:

Intense
visceral
somatic
neuropathic
mixed.
Cancer Facts and Figures!

14 million people suffer from cancer in the world
Overall 8% of all causes of death depends on the cancer.
23% of the causes of death in Europe depends on the cancer.
Are diagnosed annually about 7 million new cancer cases and 5 million people die because of this.
Not all cancer patients suffer from pain: This symptom is present in 30-40% of all cases.

. What is cancer pain?

Cancer pain can be regarded as a twofold phenomenon: the patient perceives the pain, but the evil lives, because just think of people living in manera heightens the experience of pain! I apologize for the sick suffering, but it is so! How many people love to make love with violence! Living the pain becomes cause for excitement! The terminally ill, however, lives on as a source of suffering and pain that is a function of its degree of culture, moral tone delll'umore, expectation of recovery. So pain is "The pain of living" or "total pain". Contributes to this feeling of discomfort arising from the loss of role in family, society, work, fatigue, hopelessness, anxiety, fear of death, weakness, lack of money and assistance! In the face of the euro and pensions of starvation of cancer patients!



Cancer pain depends on:

direct involvement by the cancer of the nervous structures (eg compression for swelling of nerve endings, myelopathy)
complications of antineoplastic therapy,
physiological and biochemical changes associated with malignancy
inflammation (eg. post-radiation, post chemotherapy, herpetic inflammation)
pain after surgery
embolism and venous thrombosis
bedsores
vertebral collapse and compression of nerve roots
post-chemotherapy side effects (headache, migraine, neuritis)
Objectives of the practitioner and internist simple.

· Convince himself and the patient that the pain can be defeated!

· What care is therefore possible and necessary!

· What can be fought with more drugs and sedatives in order to increase the hours of sleep and rest of the patient.

Medication


General Criteria
The administration of analgesics in cancer pain should follow some basic principles. They must be observed methodically in order to obtain good therapeutic results. We must not leave room for improvisation and inventive individual.

The basic principles are:
initially administered a 'loading dose', ie a dose-dependent high.;
Released drug recommended by WHO;
preference for oral or sublingual;
individualized doses used, eliminate insomnia;
if necessary, set two analgesics with different mechanisms of action;
choose the drug based on the intensity of pain;
avoid placebo;
prevent and detect side effects.
Each of these key points are discussed below.

SEQUENTIAL APPROACH
According to WHO, is now widely accepted, cancer pain must be addressed through the use of sequential three drug classes successors to each other, according to a progression step.

· For the first NSAIDs

Opioids · children

Opioids · more.



Must begin with fans, add other adjuvant drugs (eg. Amitriptyline, benzodiazepine sedatives etc.) then smaller and then imaggiori opioids. Is always preferable to the oral route and the dose and time must be respected, especially opioids.

NSAIDs

The nonsteroidal antiinflammatory drugs (NSAIDs) represent a heterogeneous series of compounds. Were traditionally classified with conditions such as: anti-rheumatic, pain-antifebbrili, reliever. They also wrongly called analgesics 'weak or light'. In fact, some of them, such as ketorolac, have an analgesic effect that is close to or less equivalent to opiates. Their mechanism of action is common and the origin of analgesia was due to:

inhibition of prostaglandin synthesis;
neuronal membrane hyperpolarization;
inhibition of lysosomal enzymes;
depressed levels of oxidizing substances released in the formation of prostaglandins.

The actions for which NSAIDs are classically exploited are three: analgesic, antipyretic and antiphlogistic. The analgesic action is predominantly in peripheral location and exactly at the level of nociceptors. The antipyretic action consists of inhibition of prostaglandin biosynthesis in the hypothalamic thermoregulatory center. The anti-inflammatory action is not entirely clear. Prostaglandins, in addition to proinflammatory activity, increase the action of biological mediators of inflammation such as histamine and leukotrienes.




Name
Trade Name
Average dose in mg/24 h

Lysine acetylsalicylate
Flectadol
900x4

Acetylsalicylic acid
Aspirin
1000x4

Mefenamic acid
Lysalgo
250x3

Diclofenac
Voltaren
50x3

Diflunisal
Dolobid
500x3

Ibuprofen
Brufen
300x4

Ketoprofen
Orudis
100x3

Ketorolac tromethamine
Tora-Dol / Lixidol
30x4

Metamizole
Painkillers
500x3

Naproxen
Naprosyn
500x2

Nimesulide
Aulin
200x2

Paracetamol
Efferalgan
500x4

Piroxicam
Feldene
20x1




.... Major side effects of NSAIDs!

Eye on the gastric and duodenal ulcers! Protection should always be used with antacids or gastric ie pump inhibitors or anti-H2 (eg omeprazole, pantoprazole, ranitidine)

By interfering with platelet aggregation, they should be administered with caution in cancer patients with coagulation problems or fewer platelets.

Opioids

The drugs are derivatives of opium use old and proven effectiveness. These substances are also called analgesics opioid analgesics more, narcotics, morfinosimili.
Morphine is the founder and is the benchmark in the evaluation of analgesic its other congeners. They represent a stage, almost always obliged, in the treatment of cancer pain. Their potent analgesic activity is due to interaction with opioid receptors located in certain areas of the CNS and spinal cord along the sensory pathways of pain. At this level, similar to endorphins (a type of morphine normally produced by the body), they trigger mechanisms of elimination and modulation of painful sensations, coming as keys in the lock of pain and bloccandola.I different pharmacological profile of the individual opioids ( intensity of action, duration of action, side effects) can be explained precisely by the presence of several varieties of different receptors and the ability of each drug morfinosimile to interact with individual receptors.

They are divided into drugs that act on opioid receptors in three groups according to the activity:

pure agonists (eg morphine)
agonist-antagonists (eg buprenorphine)
pure antagonists (eg naloxone).
Pure agonists and agonist-antagonists, while sharing a powerful analgesic activity should never be prescribed at the same time as, competing with the same receptor, reduce the therapeutic effect. In addition to the note and powerful anti-pain opioids produce certain other actions and side effects such as:

tranquilizing action
respiratory depression
attenuation of the stimulus of cough
miosis
nausea and vomiting (central effects)
hypertonia of smooth muscle (constipation, impaired urination).

Opioids are used when the use of NSAIDs did not give a satisfactory effect.
The rule that you always use, however, at first, minor analgesics, is absolute.
The choice of medication should take particular account intensity of pain as well as in life, whereas the use of narcotics is not necessarily tied to a short life expectancy. The secret to start analgesia with opioids is to achieve effective blood concentration and to maintain this level. Once a satisfactory degree of analgesia, it must be maintained with regular doses fixed time. Contraindications to the use of opioid drugs are severe hepatic insufficiency, renal failure, respiratory failure and bowel obstruction. The common phenomena that occur during treatment are tolerance (in cancer pain appears slowly) and physical dependence.
Tolerance is the need for increasing amounts of drug to achieve the same analgesic effect. This is a normal reaction to opioids and is a constant phenomenon in chronic therapy. It is established not only to analgesia but fortunately also to other effects such as respiratory depression.
Physical dependence is an alteration of physiological conditions characterized by symptoms of opioid withdrawal when stopping chronic administration or administering narcotic antagonists (eg naloxone).
Morphine is the standard for all narcotic analgesics (Table 1, Law 685).



.. Italy is one of Europe which is used less morphine mainly due to ignorance about its therapeutic qualities and the persistence of some unfounded prejudices.

morphine does not necessarily respiratory depression;
morphine does not always generate a psychic dependence, especially if given orally;
morphine does not establish a rapid and uncontrolled tolerance;
administration of morphine does not dysphoric phenomena;
morphine does not affect the quality of life.

For the oral morphine is recommended in cancer pain, as the most advantageous. Also used if there are barriers to use of oral, that are intravenously and epidural.

Controlled release oral morphine

For some years in Italy you can take advantage of controlled release morphine in discoid, already widely used in other countries. Such preparation is able to achieve a nearly constant plasma concentration of morphine. 40% of the morphine contained in discoid becomes available within one hour of providing and 80% in about 4 hours. Even for this formulation is the speech of the marked variability of the dosage necessary to obtain analgesia from one patient to another, linked to the individual response to drug. The advantages can be summarized as follows:

is easy to administer (12 hours)
eliminates the inconvenience of the dose at night,
is well accepted by nursing staff,
the patient can take without the intervention of others.
no-effect roof so you can increase the dosage until they are needed.
Currently, the slow-release morphine for the advantages over other dosage forms is becoming a standard.
Despite this, unfortunately, Italy is one of Europe where you use less morphine in cancer pain. We start with a dosage of 10-20 mg every 12 hours and increased gradually up to 200 mg per day and beyond. The total number of milligrams to be administered can be reached easily by combining various dosage discoid on the market (10, 30, 60, 100 mg).

Side effects of morphine

The prevention and the rule of the side effects of morphine is crucial to the success of therapy.



Constipation controlled by suppositories, lactulose and enemas (eg Fleet enema)

Nausea and vomiting controlled by ondansetron or metoclopramide (eg Zofran and Plasil)



And 'present with discrete frequency, but shows tolerance after prolonged use. The

Sedation and drowsiness These effects may also be due to catch up with lost sleep from the patient, previously, for the pain.

Respiratory depression

And 'potentially the most serious side effect but for which tolerance develops rapidly.
Treatment of severe cases consists of the administration of small doses of an antagonist, naloxone (Narcan), which are rapidly solving the problems. Respiratory depression is not affected by the use of buprenorphine and naloxone can be cured with a respiratory analeptic, doxapram on (Doxapril).



Among opioids tramadol smaller stands that boasts 20 years of clinical experience. And 'a centrally acting analgesic, synthetic, group dell'aminocicloesanolo with agonist properties on opioid receptors and their effects on noradrenergic and serotonergic neurotransmission. Compared to other opioid agonists (morphine, pethidine), it shows a lower incidence of cardiorespiratory depression and reduced potential for addiction. Tramadol administered orally, parenterally or rectally has been demonstrated to be good '


Drug
Specialty
Via
Average dose

Tramadol
Contramal
os, im, iv
100 mg/6h

Codeine
-
os
30-60 mg/4-6h

Morphine controlled release
MS Contin-- Skenan
os
20-200 mg/12h

Morphine
-
os
5-40 mg/4h

Morphine
-
sc or im
1/3-1/4 doses orally

Morphine
-
continuous IV
0.04 to 0.07 mg / kg / h

Buprenorphine
Temgesic
sl
0.2 to 0.4 mg/6-8h

Buprenorphine
Temgesic
im
0.3 to 0.6 mg/6-8h

Buprenorphine
Temgesic
v
ditto


DRUGS adjuvant, ie to assist.

Benzodiazepines

They are also called minor tranquilizers. Among the four typical effects: muscle relaxant, anticonvulsant, sedative and anxiolytic that is what is better utilized in cancer. The abolition of anxiety leads, consequently, a greater relaxation that facilitates sleep. May be given an evening dose of 5-10 mg diazepam orally. The common side effects of benzodiazepines include weakness, headache, altered vision, dizziness, nausea, vomiting and diarrhea.

Tricyclic antidepressants

And 'This is another category of drugs commonly used in controlling cancer pain. Indeed less than a third of patients with cancer pain suffer from concomitant depression. The three major actions for which tricyclic antidepressants may be used are:

mood elevation,
analgesic activity in tumors with nerve damage,
sedation.
The amitriptyline is given in a single dose in the evening dosage varies from 10 to 25 mg. This dosage may be increased gradually to 50-75 mg.
Side effects of anticholinergic type: dry mouth, tachycardia, abnormal vision, urinary retention, with a variable incidence and severity depending on the medications.

Anticonvulsants
The anticonvulsants such as carbamazepine (Tegretol °), may be particularly useful in the treatment of certain types of pain-related nerve damage. This drug can be alleviated or eliminated the pain associated with neoplastic invasion of nerves, neuropathy, with some central pain syndromes or syndromes of pain postamputazione.
The initial dose of carbamazepine is 100 mg per day and continue in increments up to a maximum of 400 mg.
The most common side effects are nausea, vomiting, dizziness and drowsiness.

Corticosteroids
These drugs can be used in the treatment of cancer pain for their analgesic activity, anti-inflammatory, such as stimulating the appetite and improve mood.
They are particularly used in specific clinical situations such as:

spinal cord compression,
headache by increased intracranial pressure,
to increase the distension of the liver in liver tumors
or control of some symptoms:
anorexia,
malaise,
night sweats.
Are given dexamethasone 4 mg three times daily or prednisolone 10 mg three times daily, which should be reduced after a week at a maintenance dose.



Other therapeutic modalities

A limited number of patients not responding to analgesic therapies base mentioned above so it is necessary to use specialized techniques invasive.
Even if the practitioner is not interested in person to these methods is important that he know at least briefly what are the key.
Very popular in previous years neurolytic techniques and spinal neurosurgical techniques for the control of cancer pain are having a decline of interest to organizational difficulties, either because they do not always completely effective, because it is irreversible. Among the invasive techniques, which for years has established itself, for its ease of availability of continuous epidural analgesia management. It is placed in the dorsal or lumbar epidural space, a small catheter (the size of a needle injection) through which are administered daily doses of appropriate local anesthetic and / or opioids such as morphine and buprenorphine. The advantages of this technique are essentially these:

drugs are administered in small quantities, directly on pain pathways,
it is a reversible technique
is a fairly simple procedure, although restricted to a specialist in pain therapy.
A continuous epidural analgesia are best managed when implementing the whole system and its subcutaneous cateterino access drilling, which are not visible, but noticeable to the touch. In practice, the patient receives doses of the drug by injection under the skin which is arranged access cateterino connected to the epidural space. 'S facility is run by experienced personnel in hospitals and in 30 minutes and with minimal discomfort to the patient, not requiring hospitalization.
The regular supply of long-term local anesthetic such as ropivacaine (Naropina °) or less in addition to opioids are easily managed by nurses or even family members adequately trained. Alternatively supplies are possible even within a week days by using the infuser °, which is a cheap and disposable elastomeric continuous infusion of medication.


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