Alleviating Cancer Pain Toward Better Quality of Life 林至芃醫師 台大醫院麻醉部疼痛科科主任台大醫院麻醉部暨腫瘤醫學部合聘主治醫師台大醫學院醫學系臨床助理教授台灣疼痛醫學會秘書長 82 y/o male Newly diagnosed PC Initial presentation Back pain Shoulder pain Rapid progressed to Bed-ridden Pain!! 1
What is Your Initial Management? Majorly Bone Pain! Start with Acetaminophen / NSAIDs? Severe Pain -> Ultracet? Oh!! I know WHO analgesic ladder approach! Principles of Pain Management WHO 3-step Analgesic Ladder Step 3 Opioids for moderate-to-severe pain ± non-opioid ± adjuvant eg, morphine, hydromorphone, oxycodone, buprenorphine, fentanyl, methadone Pain persists or increases Step 1 Step 2 Opioids for mild-to-moderate pain ± non-opioid ± adjuvant eg, codeine, tramadol Non-opioids ± adjuvant eg, acetylsalicylic acid, ibuprofen, diclofenac, COX-2 inhibitors, paracetamol, metamizol, flupirtine World Health Organization. Cancer pain relief: with a guide to opioid availability. 1996. 2
EAPC Recommendation- WHO Step II Opioids For pain inadequately controlled by paracetamol or NSAID addition of weak opioids or low dose strong opioids Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. Feb 2012;13(2):e58-68. 5 EAPC Recommendation WHO Step III Opioids Strong opioids by oral route: Morphine Oxycodone Hydromorphone Methadone (used only by experienced professionals) Strong opioids by transdermal route: Fentanyl Buprenorphine Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. Feb 2012;13(2):e58-68. 3
Continuous pain Reassess the diagnosis Review current dosing Increase dose 30% (min) Breakthrough pain Unpredictable pain Frequent episodes (> 4/day) Increase regular dose Otherwise. Incidental pain Only in certain circumstance Treat as breakthrough pain Treat prophylactically DO NOT adjust routine dose End-of-dose failure Breakthrough pain in a predictable window before the next dose Change the frequency of dose 極常見! Clinical Practice Guidelines for Cancer Pain Management Up Titration and Switching are the principle No Combination therapy! Finish Titration before considering Rotation! 4
Neuropathic pain After WHO Three Step Analgesic Ladder Refractory pain Failing to achieve analgesia Intolerable side effects 15% Adequate pain relief 85% 5
何時照會疼痛科? 沒有一定的標準 你覺得一天打多少靜脈嗎啡算有點多? 個人的建議 Fentanyl patch > 50-100 mcg/h MST 60 一天吃超過三顆 副作用很難處理 VS or 病人要求 6
NTUH Protocol Clinical judgment Performance status, life expectancy, localized, approachable Intraspinal medication >50% reduce pain Neuroablative procedure Short or not effective Spine augmentation Temporary or Permanent infusion IT medication Spinal cord stimulator Morphine conversion ratio 1:10 :100 :300 7
Decision-making in NTUH Epidural catheter or portacath need for focal local anesthetics Intrathecal catheter or portacath diffuse pain, epidural space obliterated by tumor or surgery Tunneling Epidural Catheterization <3 months 出不了院可能換管健保不給付 Up to 6 weeks use 8
IDDS Decision-making in NTUH Serial Single shot IT trial Epidural catheter trial if not good enough or clinically indicated IT catheter trial >50% pain relief <50% pain relief Implant pump Further medical mangement IDDS = Intrathecal M Pump 9
Nerve Blocks by? Lidocaine Bupivacaine 99.8% Alcohol Phenol 6-10% Bilateral Splanchnic neurolysis for Upper Abdominal Cancer Pain 10
肚子的神經阻斷後要注意甚麼? T9-T10 以下交感神經阻斷了 -> Hopotension, Hypovolemia -> 奇怪神經阻斷去好久, 有沒有甚麼問題? 常常 Lung 就在旁邊很難閃 這裡很多 Tumor 跟血管 回來臉紅紅的, 微燒, 有點昏? 4-8 小時 肚子反而絞痛得厲害 鴉片類藥物要不要調整? Thoracic Paravertebral Neurolysis for Chest wall syndrome 11
目前無法顯示此圖像 目前無法顯示此圖像 Classical Intrathecal Neurolysis by hypobaric Absolute Alcohol Percutaneous Balloon Kyphoplasty 2 months later 12
Take home messages Modified 2 Steps WHO guideline Opioid Titration and Rotation 更多的藥物可供選擇 Pain Psychology! Interventional Strategies 疼痛科是你可靠的夥伴 13