Palliative Care – 3 – pain 1

Palliative Care PART – 3

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)

Question:  Last time we covered important concepts of palliative care as a whole. 1. Palliative care, or also called “Best Supportive Care” covers cancer patients in all stages, not just those in very advance stages. Even patients who are cured, may have need for pain control or disabilities or psychological issues. 2. All healthcare workers and family members have been delivering this type of care. However formal training or exposure improves working on some specific aspects. 3. Every  doctor does not need to be an expert in every aspect. But just like for other branches, they need basic knowledge, ability to detect more difficult issues, and know when and who to refer if required.

We started discussion on pain management, commonest cancer related symptom.

Ans: Yes cancer pain is top on the list of patient’s mind. And it is important for everyone to have basic knowledge, to be able to help patients. Let us go over some of the important points:

1. WHO concept of analgesic ladder. Start with good doses of paracetamol, up to 3 g per day i.e. 6 tablets of 500 mg each. Add NSAIDs like ibuprofen, diclofenac as combination or separate drug, again in adequate doses e.g. Diclofenac 2 to 3 times per day of 50 mg each.
2. Add tramadol or codeine if available, if above is insufficient. Many doctors and patients stop first level of medicines if it is insufficient to control pain and then go to next level. Instead, it is better to continue paracetamol and NSAIDs in most cases, and add next level of medicines, Since first level medicines do provide some relief in most patients. Also, many medicines provide partial or good relief for few hours, but not for very long. In such cases, adding more options allows patients to titrate pain control better, and have more options for dosing throughout the day. For example, when a patient says “this medicine is not working”, most of them mean that it is not providing relief for whole day. If you ask them carefully, in most cases, they will say that yes drug reduces pain by about 20-50% or even more, but pain comes back in 3-4 hours or in 8-12 hours. In such cases, you should continue first level i.e. combination of paracetamol and diclofenac for example, and add tramadol after 4 hours. That means now patient has first combination working for 4 hours, followed by tramadol working for another 4 hours. Tramadol can be given as 50-100 mg every 8-12 hours as required.

If both drugs are given every 8 hours, alternate, then patient has a painkiller every 4 hours available to him. And as per need, he can titrate. Such optimum use allows fairly good pain management in many patients, without going to opioids or need for pain specialist.

• Side effects of analgesics are important but frequently over emphasized. Many patients continue to suffer because of this fear. For example, concerns related to kidney or liver injury, addiction etc. Short term use of NSAIDs is rarely a concern, if baseline creatinine is normal. Same way liver injury from short term high dose use is rarely a concern. Addiction to non opioids does not happen. Even with opioids, it is extremely rare in cancer patients. Out of misconceptions, patients try to preserve effective pain medicines for future use. Hence many a times, they take less than prescribed doses.
• Some patients may develop “gastric upset”. It is reasonable to prescribe a PPI or ranitidine for prevention. Tramadol is not tolerated by some patients, leading to significant nausea, or dizziness. Such patients need alternate drugs. But most patients have no such issues.
• Different patients respond differently to various analgesics, in terms of both pain control and side effects. Some patients may have excellent pain relief with a single agent, such as tramadol or NSAID, and some need more medicines. Over time, however, they may still need additional pain medicines or switch to next level, especially if there cancer is progressively worse. Alternatively, patients who get better cancer control over time, do need to reduce or even come off the pain medicines.
• Never guarantee excellent pain control with any one medicine. But reassure patients that you have multiple options for pain control. If one is insufficient, you have more. And that there are expert formally trained pain specialists too in case I cannot adequately control your pain. In many cases, treating oncologists are sufficient experts in pain management.
• Bone metastases related pain is better controlled by NSAIDs in most cases, compared to other options. Hence NSAIDs are preferred first agent in such cases. Also, zoledronate or other bisphosphonate, or denosumab also helps reduce pain of bone metastases.

November 14th 2020.  

Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com