1. Nursing Instruction
  2. Overview
  3. Hematology and Oncology

[Major points]

  1. “Pain” is one of the most common symptoms among cancer patients. Introduction for  different types of pain relief medications.
  2. The principles of pain relief medicaiton usage.
  3. The management of pain relief medicaiton side effects.
What is cancer pain？
“Pain” is one of the most common symptoms among cancer patients. Cancer pain could be related to tumor compression, obstruction or metastases. Meanwhile, the patient‘s psychological status, such as stress, depression and anxiety, resulting from confronting cancer diagnosis could worsen the feeling of pain.
 
The principles of pain relief for cancer patients:
The principles of cancer pain relief is offering continuous and effective analgesics, with tolerable side effects and improving the patient’s quality of life.
  1. According to The World Health Organization (WHO) Clinical Pain Management Guideline, clinicians should select appropriate analgesics and adjuvant medications based on patients’ severity of pain while pain control. The severity of pain could be divided into three levels: mild, moderate, and severe.
    1. Mild cancer pain ( pain scale of 1 to 3): Administer medications from the first step of the pain management medication ladder. The first choice is to start pain relief with non-opioid analgesics.
    2. Moderate ( pain scale of 4 to 7) to severe ( pain scale of 8 to 10) cancer pain: Administer medications from the second and the third step of the pain management medication ladder to ensure achieving satisfactory pain control. Opioid analgesics are used primarily, and sometimes combining with anticonvulsants, anxiolytics, antidepressants, antiepileptic drugs, muscle relaxants, or steroids. If the pain persists or gets worse, oral or intravenous opiates are added or converted to the equivalent dosage of transdermal patch as needed.
  2. Appropriate route of administration: Oral administration is the choice of priority. Intravenous administration and Subcutaneous injection are recommended only when patients need to relieve pain immediately.
  3. Keep the right time or interval of taking medications: To maintain the serum concentration, the patients should take medications continuously and regularly to gain persistent pain control.
 
The common types of medications for cancer pain:
  1. Non-opioids: Acetaminophen and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) (e.g., Diclofenac, Celebrex and Naproxen) are most common and effective for mild cancer pain and bone pain.
  2. Weak opioids: Codeine and Tramadol are useful for mild to moderate cancer pain.
  3. Strong opioids: For moderate to severe cancer pain, morphine and oxycotin are the drugs of choice which can be replaced with an equivalent dosage of Fentanyl transdermal patch as needed.
  4. Anticonvulsive drugs: Gabapentin and pregabalin are the drugs can treat neuropathic pain.
The managements of side effects :
 
The side effects below could all be treated and prevented. Therefore, do not worry about taking analgesicss.
  1. Gastrointestinal (GI) bleeding: Some non-opioids can cause gastrointestinal  bleeding. It can be prevented by combining antacids usage. 
  2. Constipation: It is a common side effect of opioids and can be prevented by increasing physical activities, drinking more water, taking high-fiber diet and fruits, or taking stool softeners regularly.
  3. Nausea and vomiting: They usually happen when taking opioids initially, and would not last longer. Preemptive anti-emetics can be administered.
  4. Drowsy: Opioids should be withheld temporarily and keep observating conscious and side effects. If symptoms persist, the dosage of analgesicss should be decreased.
  5. Bradypnea (slow breathing): Closely monitor conscious and respiration. Naloxone may be given if it’s necessary.
  6. Delirium: Doctors will rule out the possibilities of poor liver function, poor renal function or dehydration. And use psychiatric drugs to control symptoms.
  7. Psychological dependence: It is rarely occur if used correctly as directed by order.
  8. Allergy: Skin itch and rash may occur and can be relieved by antihistamines.
 
Precautions in daily living:
  1. Take medicine regularly and do not stop taking medication by yourself. 
  2. Keep a pain diary: make detail notes about the pain characteristics, location,  frequency, and the conditions of taking analgesicss. Discuss with your doctor at follow-up visit and find the most suitable treatment mode.
  3. To prevent constipation, take foods with rich fibers like vegetables and fruits, drink much more water, do proper exercise, and use stool softeners as prescribed.
  4. Nausea, vomiting and drowsiness may occur. If no improvement and slow breathing occurs, please seek medical advice immediately. 
  5. Combine other non-pharmacological methods for pain relief, such as relaxation techniques,massage, music therapy, watching TV, those can be distracted to relieve pain.
 
Referances
  1. Deng, G. (2019). Integrative medicine therapies for pain management in cancer patients. Cancer Journal, 25(5), 343-348.https://doi.org/10.1097/PPO.0000000000000399
  2. Ramanjulu, R., Thota, R., Ahmed, A., Jain, P., Salins, N., Bhatnagar, S., Chatterjee, A., & Bhattacharya, D. (2020). Indian society for study of pain, cancer pain special interest group guidelines on pharmacological management of cancer pain (Part I). Indian Journal of Palliative Care, 26(2), 173-179. https://doi.org/10.4103/0973-1075.285692
  3. Ramanjulu, R., Thota, R., Ahmed, A., Jain, P., Salins, N., Bhatnagar, S.,  Chatterjee, A., & Bhattacharya, D. (2020). Indian society for study of pain,cancer pain special interest group guidelines on pharmacological management of cancer pain (Part II). Indian Journal of Palliative Care,26(2), 180-190. https://doi.org/10.4103/0973-1075.285693
  4. Swarm, R. A., Paice, J. A., Anghelescu, D. L., Are, M., Bruce, J. Y., Buga, Sorin. & Greenlee, H. (2019). Adult cancer pain, version 3.2019, NCCN clinical practice guidelines in oncology. Journal of the National     Comprehensive Cancer Network, 17(8), 977-1007.https://doi.org/10.6004/jnccn.2019.0038 
  5. World Health Organization. (2018). WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and olescents https://apps.who.int/iris/bitstream/handle/10665/279700/9789241550390-eng.pdf
 
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