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,
1st step – non-opiod analgesics
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.