Aprox 10-lakh new cancer patients are diagnosed in every year in India & most of them are in advanced stage who need only pain management.
Most of these patients complains of inadequate management of pain by their physicians, accepting it as their destiny. But more than 90% of this pain can be managed nicely & adequately.
A Recent Case History:
This patient of about 55 years lady suffering from lung cancer with mets and severe pain in back, shoulder and hip.
She was prescribed different analgesics including morphine, fentanyl patch and many other medications without any success.
This patient was tried with 1mg intrathecal morphine at upper lumber area with excellent pain relief and taken for intrathecal pump implantation. 1mg morphine is equivallent to 300mg oral morphine without side effects of large oral morphine.
We implanted fixed flow tricumed pump of 40 ml reservoir. Now patient is enjoying excellent pain relief.
Article on Cancer Pain Management beyond WHO Ladder
Cancer pain: is it treatable? Facts & Fictions
Some facts about cancer pain:
• 10 lakh new cancer patients are diagnosed every year in India.
• 60% are diagnosed in advanced stage, so require only pain management and palliative care.
• 30%-50% have pain at the time of diagnosis.
• 70% to 90% have severe pain when the disease is advanced.
• 40% die with severe pain.
• 60%-80%complains of inadequate pain relief by their physician.
• 30% are not relieved by medicine treatment alone, so require interventional pain management.
• More than 90% cancer pain can be adequately controlled.
From the above statistics it is seen that cancer pain is inevitable at some stage of the disease, but at the same time 90% of the cancer pain are curable by some means or other.
What are the reasons then for inadequate cancer pain control? Why most of the cancer patients are suffering from cancer pain at some stage of the disease?
The most important reason is lack of awareness. Lack of awareness exists among: 1.health care workers (including doctors), 2.policy makers and 3.public (patients and their relatives) that cancer pain can be cured or controlled. There are other reasons also, like: lack of financial resources, lack of infrastructure, lack of adequately trained personnel who can perform interventional pain management; fear among treating physician about medicine dependency, and medicine abuse, and of course non-availability of opioids due to legal restriction.
Why the cancer pain must be properly controlled?
Apart from being excruciating and intolerable in nature there are other reasons to control the cancer pain.
• Cancer pain is curable; at least it can be controlled.
• Psychological effects of cancer pain can be avoided. (anxiety, depression, lack of sleep, anger, suicidal attempts)
• Precipitation of diseases like diabetes, hypertension can be avoided.
• Meaningful and productive social life can be lived.
• Effective pain control can prolong life.
• Relatives also relieved from constant worries.
What are the ways to treat the pain?
The methods of treatment of cancer pain are many like:
1. Pharmacotherapy (treatment with oral or injectable pain killer medicines) with analgesics (opioid & non-opioid); co-analgesics (anti-depressant & anti- convulsant) and others.
2. Interventional pain management(IPM)
WHO recommendations: (same protocol is applicable for the other kinds of pain too)
• 3 stage analgesic ladder (Pharmacotherapy).
• 1st stage- NSAIDs +/- NSAIDs
• 2nd stage-Weak opioid +/- NSAIDs
• 3rd stage-strong opioid +/- NSAIDs
• Interventional pain management (IPM) in 4th stage +/- NSAIDs.
What are the indications of IPM in cancer patients?
• Severe pain that is expected to persist
• Failure of analgesic medicine treatment
• Non-availability of morphine
• Limited life expectancy
• Well localized pain
• Pain is not multi-focal in origin
• Pain is of visceral or somatic in origin
• Coexisting or preexisting problems curable with IPM
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Types of IPM in cancer patients
• Neurolytic procedures.
• IPM done in non-cancer pains.
• Advanced interventional pain management.
What is neurolysis?
It is a procedure (a type of IPM) by which nerve fibres carrying nociception (pain sensation) is irreversibly destroyed to obtain permanent pain relief.
Methods of neurolysis:
Neurolysis can be done by applying neurolytic agents like: phenol, alcohol, hypertonic saline, glycerin, butamben, ammonium sulfate, chlorocresol etc on particular nerve fibres. or by some other methods like: cryoneurolysis (neurolysis by applying cold), radiofrequency ablation (neurolysis by applying heat), neurectomy (neurolysis by operation).
These are little costly, but excellent option to take care of cancer pain. Best is intrathecal morphine pump.