Clinical Practice Guidelines on Cancer Pain Control
Ospital ng Maynila Medical Center
Satisfactory
control of cancer pain for all clients consulting OMMC.
Every
year, at least 90% of admitted cancer patients have achieved pain score of 3 or
less prior to discharge (or death).
How should cancer pain be
managed (general guidelines)?
Management starts
with a definite diagnosis of cancer (nature and extent) and whether the cancer
is associated with pain or not.
If the cancer
pain is present, the nature (physical, mental or in combination), cause
(invasion, obstruction, compression), type (somatic, visceral, neuropathic),
and severity (mild, moderate, severe) should be determined as accurately as
possible.
Treatment of
cancer pain is primarily directed towards the cancer itself (curative goal as
much as possible, if not, palliative goal) in the hope that resolution of the
pain will just follow. However, when treatment of the cancer is deemed not
feasible for one reason or another, then the objective of treatment should
focus on the relief of the cancer pain.
The treatment
modalities for cancer pain include non-pharmacologic, pharmacologic, and
interventional therapies, singly or in combination. The choice of a specific treatment regimen will be dependent on
the comprehensive diagnosis of the cancer and the cancer pain (see above) and
its track records of success in resolving a specific cancer situation.
Below are some
general guidelines in the selection of treatment modalities:
1.
Since
practically all patients with cancer will have various degrees of anxiety and
depression, in other words, mental pain, psychotherapy and psychosocial support
should be integrated into the treatment of the physical pain all throughout the
course of management.
2.
Selection of a
specific treatment regimen should be made after an objective and systematic
comparison of the benefit, risk, cost, and availability data on the different
options.
3.
All patients
should be given opportunities to make informed consent or refusal for all
recommended treatment regimen.
What are methods of pain assessment to be
used? What is the preferred method?
The two methods
are the verbal scoring system using numeric rating scale and the visual analoque system using faces scale.
The simplest
method is the verbal scoring system using numeric rating scale and should be
used as much as possible.
The faces scale
can be used when the numeric rating scale cannot be used. However, for communication purposes, the
assessment using faces scale should be converted to its equivalent in the
numeric rating scale.
The numeric
rating scale has a score of 0 to 10 with 0 signifying no pain at all and 10,
most severe pain. Mild pain has a score
of 1-3; moderate pain, 4-6; severe pain, 7-10.
A pain control monitoring record will be used. (See attached
form).
Pain score is made on admission, just prior to, during, and
after treatment, and at least 2 days prior to discharge for admitted
patients.
There should be complete and continual daily monitoring and
recording of pain score while the patient is confined and continued at home by
the patient and his guardians. Average
pain score and the most severe pain score per day should be noted down.
Patient and his guardians should be trained and empowered to
fill-up the pain control monitoring record.
What is the protocol on pharmacologic
therapy in cancer pain control?
The protocol
recommended by DOH will be adopted with some modifications.
2-step analgesic
ladder.
BY THE MOUTH as
much as possible
BY THE CLOCK
-
regular basis (every 4 hours or every12 hours for sustained
release preparation)
-
dose gradually increased until comfortable
-
next dose should be given before the effect of the previous
one has fully worn off
-
first and last
doses of the day “anchored” to the patient’s waking and bedtimes
-
at night time,
drugs should be given at a larger dose at bedtime so as to enable the patient a
continue night sleep
BY THE LADDER
-
1st step – non-opioid analgesics (paracetamol,
nsaids)
-
2nd step - morphine
For
mild pain
1st step – non-opiod
analgesics, paracetamol
If pain persists or increases, 2nd
step – non-opioid analgesics, nsaids
If pain persists or increases with 2nd
step, 3rd step – opiod analgesics,
morphine tablets
Moderate
pain
1st step – non-opiod analgesics
, nsaids
If pain
persists or increases, 2nd step – opioid analgesics, morphine
tablets
For severe pain
1st
step - opiod analgesics – morphine tablets
If pain persists or increases, 2nd step – increase dosage
Adjuvant pharmacologic therapy is added as needed.
Prophylactic pharmacologic therapy to combat side effects of
analgesics is added as needed.