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Pain Management

Introduction:

Pain is an unpleasant multidimensional sensory and emotional experience associated with actual or potential tissue damage or described in relation to such damage.
Pain is seen with 50-70% of cancer patients.Out of these 50-80% are not satisfied by pain relief.
Pain is often associated with tachycardia, hypertension, hyperventilation and facial grimacing.
Pain is subjective.
Survival is linked to symptom control and proper pain management improves the quality of life.

Route of pain transmission

Chemical/ thermal/ mechanical stimuli

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Release of chemical mediators such as arachidonic acid metabolites

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Activation of peripheral receptors

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Transmission of signals through unmyelinated A-delta and C fibres

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Enter spinal cord via dorsal root ganglion

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Modulation of pain signals

(Influencing substances include- Glutamate, aspartate, substance P, calcitonin gene related peptide, GABA, Glycine, adenosine, bombesin, somatostatin, VIP)

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Ascend in one of the two contralateralspinothalamic tracts

Always try to diagnose the cause of pain.

History: Site, onset, duration, intensity, quality, radiation, exacerbating and relieving factors

Causes	Investigations (Other tests to be done based on differential diagnosis)
Backache: Spina bifida, scoliosis, spondylosis, spondylolisthesis, trauma, antero-posterior imbalance, leg length discrepancy, pyogenicosteomyelitis, tuberculosis, rheumatoid arthritis, brucellosis, ankylosingspondylitis, prolapsed disc, primary bone tumor, secondaries in spine, multiple myeloma, psychogenic, Rieter disease, psoriasis, ulcerative colitis, renal calculi, prostatitis, sickle cell anemia, leukemias, pyelonephritis, muscle spasms, Referred pain: Esophagitis, myocardial infarction, peptic ulcer, pancreatitis, cholecystitis, diverticulitis, aortic aneurysm, ovarian tumor, dysmenorrhea, retroperitoneal neoplasms Drugs: Steroids, methysergide	X Ray- Lumbosacral spine- AP and Lateral MRI- Whole spine screening
Abdominal Pain: Constipation, acid peptic disease, CBD stone, cholecystitis, pancreatitis, Ca head of the pancreas, renal stone, pyelonephritis, ureteric calculus, acute cystitis, appendicitis, salpingitis, ectopic pregnancy, torsion of ovarian tumor, PID, dysmenorrhea, retained products of conception, irritable bowel syndrome, subarachnoid hemorrhage, lead poisoning, amebic colitis, diverticulitis, intestinal obstruction, bacillary dysentery, enteritis, Crohn disease, porphyria, parasitic infestation, aortic aneurysm, ischemic gut injury, endometriosis, twisted ovarian cyst, peritonitis, mesenteric lymphadenitis, splenic rupture, acute hepatitis, liver abscess, basal pneumonia, myocardial infarction, torsion testis, diabetic keto acidosis, HS purpura, hypercalcemia, uremia, functional	USG Abdomen with pelvis CT- Abdomen (Pain and contrast) S. Amylase and Lipase X Ray erect abdomen Surgical reference if there is distended abdomen/guarding-rigidity/ absence of bowel sounds/ feculentvomitus/ absolute constipation/ multiple air fluid levels in X Ray/ history of amenorrhea
Headache: Intracranial bleeding, Migraine, cluster headache, post traumatic, hypertension, giant cell arteritis, tension headache, nasal problems, sinusitis, ocular problems, aural problems, dental problems, trigeminal neuralgia, cervical problem, intracranial tumor/ abscess, post lumbar puncture, pseudotumorcerebri, uremia, heat prostration, TM joint arthritis, idiopathic intracranial hypertension, psychogenic	CT/MRI Brain ENT-Opthal-Dental-Neurology opinion
Pain in Neck/ Shoulder Trauma, disc prolapse, rheumatoid arthritis, ankylosingspondyltis, meningitis, primary/metastatic tumor in spine, osteomyelitis, angina, tendinitis, bursitis, rotator cuff tear, periarthritis, subdiaphragmatic irritation, Pancoast tumor	CT Neck
Chest Pain: Myocardial infarction, angina, pericarditis, mediastinitis, mitral valve prolapse, aortic dissection, pulmonary embolism, pulmonary hypertension, right ventricular strain, pleuritis, tracheobronchitis, pneumonia, esophageal reflux, esophagitis, cervical disc prolapse, myalgia, costochondritis, diseases of shoulder/spine/ribs, trauma, breast disorders, neurocirculatory asthenia, skin problems, herpes zoster	ECG 2D Echo CT Chest with pulmonary angiogram Cardiac enzymes If angina suspected: Tab. Sorbitrate- 5mg- Sublingual stat and SOS Tab. Aspirin- 150mg- Stat Tab. clopidogrel- 300mg- Stat

Pain specific to hematology patients:

Procedure related- Bone marrow aspiration, PICC line insertion, post lumbar puncture headache
Therapy related-
- Myopathy, Myalgia- Ex: Steroid induced
- Oropharyngealmucositis
- Osteoporosis
- Peripheral neuropathies Ex: vincristine, thalidomide etc
- Post herpetic neuralgia
- Visceral pain syndromes: Typhlitis, hemorrhagic cystitis, enteritis, mucositis
Disease related:
- Bone pain: Bone marrow expansion/ infiltration by malignancy
- Bone infarct or necrosis
- Lytic lesion and compression fracture
- Hemarthrosis
- Visceral pain: Tumor involvement, splenomegaly, lymphadenopathy
- Headache: Meningial infiltration, infection, bone metastasis, primary tumor
- Neuropathic pain: Paraproteins with antimyelin properties, amyloid infiltration
- Peripheral nerve compression, spinal cord compression

Symptomatic treatment:

Mild:
- Paracetamol- Not more than 4gm/day
- NSAIDs- Avoid if there is thrombocytopenia/ bleeding disorder/ risk of renal toxicity
Moderate:
- Tramadol
Severe:
- Opioids:
  - Morphine: Oral- 20-30mg- 3-4 times a day (Oral 10mg= SC/IV 5mg)
    - IV- 0.05mg/kg/hr
    - 10% of total 24hr dose is given as loading dose (0.12mg/kg)
    - Maintain continuous infusion and monitor pain of the patient. Titrate the dose as per the pain. If pain persists/there is breakthrough pain, give one more bolus of double the previous dose
    - Use round the clock dosing schedule to avoid peaks and valleys in serum analgesic levels.
    - There is no maximum opioid dose- Give whatever required to relieve the pain, except when respiratory rate is <12/min
    - When changing to oral morphine give TDS dose. PO dose is 2 times the parenteral dose.
    - When planning to stop- Taper over 10 days and stop. Abrupt discontinuation may result in tachycardia, hypertension, diaphoresis, nausea, vomiting, abdominal pain, psychosis and hallucinations
  - Fentanyl
  - Oxycodone
  - Methadone
- Add laxatives always, as narcotics lead to constipation
- Educate patient and family about dosing and side effects

Other treatment options:

Transdermal patches:
- Fentanyl-
  - Dose- 25mcg/hr patch is equal to 50mg oral morphine/ 17mg IV Morphine
  - Delivers lipophilicfentanyl into the fat containing areas of skin.
  - Drug diffuses continuously from patch's reservivor through a rate control membrane and reached the systemic circulation.
  - Onset of pain relief starts at 12hrs, hence liberal pain rescue must be provided for 1st 24 hrs.
  - Naloxone may be given if features of toxicity develop.
  - New patch is applied every 48-72hrs.
  - Side effects include allergy due adhesive, opioid side effects.
  - Avoid in patients with sepsis, acute pain with marked fluctuating opioid requirements, chachectic patients, patients with significant dermatological problems
- Buprenorphine
  - 10-20mcg/hr
  - Should be applied once a week
  - Can cause QTc prolongation
Adjuvant therapies
- Antidepressants: Amitryptaline (50-100mg HS)
- Anticonvulsants: Carbamazepine, Pregabalin (100mg-TDS), Gabapentin (100-300mg- HS)
- Corticosteroids (Dexamethasone)- Useful in case of bone metastasis, nerve compression, increased intracranial pressure, obstruction of hollow viscus
- Local anesthesia
  - Lidocaine patches
  - Nerve block
- Bisphosphonates and calcitonin: Useful in bone metastasis/ lytic lesions in myeloma
- Radiation therapy-
  - For painful bony lesions, spinal cord compression, bulky lymphadenopathy
  - Single fraction of 8Gy or 20gy in 5 fractions
  - Radiopharmaceuticals: Strontium chloride (89Sr), Somarium 153 lexidronan
- Surgery
  - Vertebroplasty: Bone cement, usually polymethylmethacrylate is injected into vertebral body
  - Kyphoplasty: Balloon is inserted into vertebral body followed by inflation and deflation, before cement is added.
- Non-pharmacological measures
  - Education, reassurance, psychological support
  - Hypnosis
  - Cognitive behavioral techniques including spiritual counseling
  - Cutaneous techniques: Acupuncture, massage, vibrations, application of cold/heat
  - Cutaneous ointments- Capsaicin, Volini spray/gel
  - Transcutaneous electrical nerve stimulation

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