European options and recommendations for cancer ... - OECI
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European options and recommendations for cancer ... - OECI

European options and recommendations for cancer ... - OECI European options and recommendations for cancer ... - OECI

oeci.eu
01.06.2013 Views

6 OECI PaIn thEraPy Abstract Cancer-related pain is a major issue of healthcare systems worldwide. The reported incidence, considering all stages of the disease, is 51%, which can increase to 74% in the advanced and terminal stages. For advanced cancer, pain is moderate to severe in about 40–50% and very severe or excruciating in 25–30% of cases. Pain is both a sensation and an emotional experience. Pain is always subjective; and may be affected by emotional, social and spiritual components thus it has been defined as “total pain”. From a pathophysiological point of view, pain can be classified as nociceptive (somatic and visceral), neuropathic (central, peripheral, sympathetic) idiopathic or psychogenic. A proper pain assessment is fundamental for an effective and individualised treatment. In 1986 the World Health Organisation (WHO) published analgesic guidelines for the treatment of cancer pain based on a threestep ladder and practical recommendations. These guidelines serve as an algorithm for a sequential pharmacological approach to treatment according to the intensity of pain as reported by the patient. The WHO analgesic ladder remains the clinical model for pain therapy. Its clinical application should be employed only after a complete and comprehensive assessment and evaluation based on the needs of each patient. When applying the WHO guidelines, up to 90% of patients can find relief regardless of the settings of care, social and/or cultural environment. This is the standard treatment on a type C basis. Only when such an approach is ineffective are interventions such as spinal administration of opioid analgesics or neuroinvasive procedures recommended. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Cancer pain; Assessment; Pharmacological therapy; Opioids

OECI PaIn thEraPy 1. General information 1.1. Introduction According to World Health Organization (WHO) projections, there will be 15 million new cases of cancer by 2020 [1]. These statistics suggest that cancerrelated pain may be a major issue of healthcare systems worldwide. The research network of the European Association of Palliative Care (EAPC) performed a survey of 3030 cancer patients from 143 palliative Care Centers in 21 European countries with the aim to evaluate the intensity of pain and the use of the different analgesic drugs [2]. The investigators assessed 32% of the patients as having moderate or severe pain. According to the literature, most patients with advanced cancer have at least two types of cancer-related pain which derives from a variety of aetiologies [3,4]. Sixty-nine percent of patients rate their worst pain at a level that impaired their ability to function [5]. Unfortunately the high incidence of unrelieved cancer-related pain is still a problem notwithstanding the published indication on the treatment of cancer pain. In a recent study carried out to evaluate the prevalence, management, and relief of pain during the last 3 months of life of a representative sample of dying cancer patients in Italy, the caregivers interviewed reported that 82.3% of patients experienced pain, and that in the 61% the pain was very distressing [6]. According to the International Association for the Study of Pain (IASP), pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” [7]. Pain is both a sensation (conscious awareness of a noxious stimulus) and an emotional experience (intense feelings of displeasure resulting in a pattern of reactive behaviour). Pain is always a subjective sensation; it is what the patient says it is [7] and may be affected by emotional, social and spiritual components [8] thus it has been defined as “total pain”. The perception of the intensity of pain is not proportional to the type or to the extent of the tissue damage but is dependent on the interactions between nociceptive and non-nociceptive impulses in ascending pathways, as well as the activation of descending paininhibitory systems. Cancer pain may be acute, chronic, episodic (Table 1). From a pathophysiological point of view, pain can be classified as nociceptive (somatic and visceral), neuropathic (central, peripheral, sympathetic) idiopathic or psychogenic [9,10]. Table 2 shows the semantic descriptors of neuropathic pain according to the IASP [7]. In cancer patients, pain is a direct result of the tumour in 75–80% of cases, is caused by anticancer treatments in 15–19% of patients and is unrelated to cancer and its treatments in 3–5% [11]. This coincidental pain has a variety of causes, for example it may be related to debility, decubitus (nociceptive), or post-herpetic neuralgia (neuropathic-peripheral and central). Pain may also be a consequence of the diagnostic procedures used in cancer treatment. Numerous distinct acute and chronic cancer pain syndromes (Table 3) have been recognized and described [11,12]. A proper pain assessment is fundamental for an effective and individualised treatment. Poor pain assessment is the greatest barrier to effective cancer pain management [13]. As pain is a subjective perception, objective measurement is not Table 1 Temporal classification of pain. Acute pain follows injury to the body and generally disappears when the body injury heals. It is usually due to a definable nociceptive cause. It has a definite onset and its duration is limited and predictable. It is often associated with objective physical signs of autonomic nervous system activity. Acute pain may also indicate a progression of disease and is often accompanied by anxiety. Chronic pain is due to the progression of the disease and is rarely accompanied by signs of sympathetic overactivity and the site and the intensity may vary over the time. Chronic pain may be accompanied by changes in personality, lifestyle, and functional abilities and by symptoms and signs of depression. Chronic pain with overlapping episodes of acute pain (i.e. breakthrough pain) is probably the most common pattern observed in patients with ongoing cancer pain. This indicates the necessity for intermittent changes in therapy. Furthermore, the appearance of acute pain, or progression of a previously stable chronic pain, is suggestive of a change in the underlying organic lesion and often requires clinical re-evaluation. Breakthrough pain (episodic pain) is defined as transient flares of severe or excruciating pain in patients already being managed with analgesics. It arises in 64% of cancer patients with a median duration of 30 min (range 1–240). The most frequent causes of breakthrough pain are as follows: an insufficient amount of opioids taken at regular intervals; incident pain due to the patient’s moving, swallowing, or coughing; bowel distension, exacerbation of the neuropathic pain, or the onset of some other pains. The usual therapeutic approach in treating breakthrough pain is the administration of an opioid rescue dose equivalent to 5–10% of the total daily opioid intake concurrently with the regularly scheduled drug. Table 2 Semantic descriptors of neuropathic pain [7]. Allodynia: Pain caused by a stimulus which normally does not provoke pain. Causalgia: Continuous burning pain, allodynia and hyperpathia in succession or a traumatic nervous lesion; disturbed vasomotor functions are often intercurrent, as well as, later on, disturbances to trophism. Central pain: Pain associated with a lesion of the central nervous system. Dysesthesia: Unpleasant sensation of tingling, stabbing or burning whether spontaneous or provoked hyperesthesia: increase in sensitivity to specific stimuli. Hyperalgesia: Increased response to a stimulus which is normally painful. Hyperpathia: Painful syndrome characterised by increased reaction to a stimulus, especially a repetitive stimulus. Paresthesia: Abnormal sensation, either spontaneous or evoked. 7

6<br />

<strong>OECI</strong> PaIn thEraPy<br />

Abstract<br />

Cancer-related pain is a major issue of healthcare systems worldwide. The reported incidence, considering all stages of the<br />

disease, is 51%, which can increase to 74% in the advanced <strong>and</strong> terminal stages. For advanced <strong>cancer</strong>, pain is moderate to<br />

severe in about 40–50% <strong>and</strong> very severe or excruciating in 25–30% of cases.<br />

Pain is both a sensation <strong>and</strong> an emotional experience. Pain is always subjective; <strong>and</strong> may be affected by emotional, social <strong>and</strong><br />

spiritual components thus it has been defined as “total pain”.<br />

From a pathophysiological point of view, pain can be classified as nociceptive (somatic <strong>and</strong> visceral), neuropathic (central,<br />

peripheral, sympathetic) idiopathic or psychogenic.<br />

A proper pain assessment is fundamental <strong>for</strong> an effective <strong>and</strong> individualised treatment.<br />

In 1986 the World Health Organisation (WHO) published analgesic guidelines <strong>for</strong> the treatment of <strong>cancer</strong> pain based on a threestep<br />

ladder <strong>and</strong> practical <strong>recommendations</strong>. These guidelines serve as an algorithm <strong>for</strong> a sequential pharmacological approach<br />

to treatment according to the intensity of pain as reported by the patient.<br />

The WHO analgesic ladder remains the clinical model <strong>for</strong> pain therapy. Its clinical application should be employed only after a<br />

complete <strong>and</strong> comprehensive assessment <strong>and</strong> evaluation based on the needs of each patient. When applying the WHO guidelines,<br />

up to 90% of patients can find relief regardless of the settings of care, social <strong>and</strong>/or cultural environment. This is the st<strong>and</strong>ard<br />

treatment on a type C basis. Only when such an approach is ineffective are interventions such as spinal administration of opioid<br />

analgesics or neuroinvasive procedures recommended.<br />

© 2008 Elsevier Irel<strong>and</strong> Ltd. All rights reserved.<br />

Keywords: Cancer pain; Assessment; Pharmacological therapy; Opioids

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