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*The professional part of this article is only for medical professionals to read and learn together! Cancer pain is a kind of pain that is often encountered in clinics or patients.
More than 80% of advanced cancers may be accompanied by pain.
The domestic diagnosis and treatment of cancer is far from enough.
Some have not been treated, and some have been treated with analgesia, but they have not achieved good results.
Today, let’s learn about "cancer outbreak pain" together.
What is cancer burst pain? Cancerous explosive pain: It refers to the transient aggravation of sudden pain spontaneously or triggered by some predictable or unpredictable factors under the premise that the background pain control is relatively stable and the analgesic drugs are fully used.
▍Characteristics of incidence In cancer pain patients, the incidence of cancer burst pain can reach 33%~95%.
The existence of cancerous outbreak pain not only seriously affects the daily activities of patients, leading to the decline of quality of life and treatment compliance, but also increases the expenditure of medical resources [1], and often indicates poor clinical prognosis and treatment of opioids.
Resist [2].
Cancerous burst pain is a kind of refractory cancer pain.
The onset of pain is unpredictable, the pathological mechanism is complicated, and any rescue drug has a lag.
▍Type event cancerous explosive pain (also called induced cancerous explosive pain): generally caused by predictable factors.
Spontaneous cancer burst pain (also called idiopathic cancer burst pain): refers to the pain that occurs without any specific activity or inducement, which is unpredictable.
▍Assessment methods At present, the most commonly used assessment tools in China are mainly one-dimensional assessments.
The tools include: 1.
Numericrating scales (NRS).
Oral questioning: "From the number 0 (painless) to 10 (the most severe pain), which one describes your pain?" Write the pain description circle: List the numbers 0-10, and let the patient use a pen to circle it.
The value of pain. Digital score scale pain grading: 0: no pain; 1-3: mild pain; 4-6: moderate pain; 7-10: severe pain 2.
Visual analogue scales (VAS).
Instructions for use: Give the above picture and inform the patient that the above facial expressions show the degree of pain.
The leftmost face means that there is no pain, and the degree of pain gradually increases from left to right, allowing the patient to point out facial expressions that can represent the degree of pain.
3.
Language ratings (verbal rating scales, VRS).
▍The diagnosis meets the following three criteria at the same time: the patient has persistent pain in the past 1 week, and the duration is> 12 h per day (background pain); the patient’s background pain is fully controlled in the past 1 week (digital pain score ≤ 3 points); The patient has transient pain aggravation (digital pain score ≥ 4 points).
Figure 4 Flow chart of diagnosis of fulminant cancer pain What is the treatment principle of fulminant cancer pain: The cause of treatment is very important.
▍Treatment for cancer disease itself.
Radiotherapy can reduce cancer bone metastasis pain and neuropathic pain caused by tumor compression; chemotherapy and endocrine therapy can reduce tumor damage or compression to tissues, internal organs, and nerves; for patients with intestinal obstruction Patients can be treated with palliative surgery, etc.
; for advanced tumors, when anti-tumor therapy cannot effectively control the tumor, it is extremely difficult to treat the cause, and timely symptomatic treatment is required.
▍For the treatment of pain itself [3] 1.
It is recommended to use patient-controlled analgesia (PCA): the medical staff will pre-set the dose of analgesic drugs according to the patient's pain and physical condition, and then hand it over The patient "self-management".
Indications: Dose titration of opioids for cancer pain patients; cancer pain patients with frequent outbreak pain; cancer pain patients with dysphagia or gastrointestinal dysfunction; analgesic treatment for dying patients.
Contraindications: Patients who are unwilling to receive PCA technical analgesia; those who are too old or too young and lack the ability to communicate and evaluate; those who are mentally abnormal; restricted activities and unable to control the buttons are relatively contraindications, and can be operated by medical staff or family members if necessary.
Common adverse reactions include bleeding, infection, catheter blockage or shedding, and excessive sedation.
2.
PCA technology and medication: generally administered by intravenous or subcutaneous route, commonly used clinical drugs include morphine and hydromorphone injections.
3.
Combined use of auxiliary analgesics according to the condition: such as antidepressants, anticonvulsants, non-steroidal anti-inflammatory drugs and acetaminophen, and glucocorticoids.
4.
According to the consideration of local target treatment methods: such as incident cancerous burst pain caused by bone metastasis, osteoplasty, local nerve lysis, and seed implantation can be used.
Drug treatment strategies for cancer outbreak pain ▍Application of opioid analgesics Oral route of administration: Oral immediate-release morphine tablets are still the most commonly used drugs for cancer outbreak pain with slow onset and longer duration.
It is recommended to use 10% to 20% of the daily background dose for the initial dose of cancerous explosive pain, and to gradually titrate it according to the analgesic effect and adverse reactions.
For incident cancerous explosive pain, because the pain is often predictable, oral fast-acting opioids can be given before the painful event occurs to prevent and alleviate incident cancerous explosive pain.
It is recommended to take immediate-release morphine tablets orally in advance for a period of ≥30 min (onset time), or 60 min (maximum analgesic effect).
For patients who have difficulty swallowing tablets, morphine sulfate oral solution can be used as an alternative medicine.
Intravenous route of administration: rapid onset (5 min) and high bioavailability (100%), usually limited to patients with severe pain in hospital, and change to other methods of administration after the patient's pain improves.
Subcutaneous injection and intramuscular injection: higher bioavailability (80%~100%), faster onset (10~15min).
Intramuscular injection of morphine will increase local irritation.
Long-term repeated use may have the risk of unstable absorption.
It is not recommended as a routine route of use.
Rectal route of administration: It is not recommended as a conventional route of administration.
It can be used for some patients with cancerous outbreak pain who have difficulty in oral administration. ▍Application of non-opioid analgesics Cancer pain is often compound pain.
According to WHO's analgesic principles, for patients with poorly controlled opioids alone, it is recommended to use non-opioid analgesics and anticonvulsants, antidepressants and other auxiliary drug.
Nervous-related cancer burst pain can be combined with anticonvulsant, antidepressant and other auxiliary drugs to improve the analgesic effect.
Intracranial hypertension and spinal cord compression caused by brain metastasis or meningeal metastasis and other related cancerous burst pain, dehydration drugs combined with glucocorticoid therapy can be considered.
For cancer patients with bone metastases, pain will appear quickly after activity.
The pain is related to bone destruction.
Bisphosphonate drugs should be added to the use of painkillers.
Cancerous burst pain caused by spasm of internal organs in the abdominal cavity can be treated with antispasmodic drugs.
▍The use of opioids for risk assessment and management of opioids is used for cancer pain patients.
Generally, there will be no problems of abuse and addiction.
However, considering that the rescue drugs for cancer outbreak pain are short-acting, strong-acting and highly fat-soluble Opioids, and often need to be used multiple times.
It is recommended that patients receiving short-acting opioids for the relief of cancer outbreaks should receive a risk assessment including drug metastasis and opioid-related abnormal behaviors.
Individualized management and risk assessment should be given to high-risk patients who meet the items in the table, and strengthened Health education for patients and their families.
Risk assessment tool: Before taking opioids: cancer pain patient screening and opioid application assessment (SOAPP-R) and opioid risk assessment tool (ORT).
During the use of drugs: the application of the Opioid Misuse Evaluation Form (COMM).
Table 1 References for the definition of abnormal behaviors related to opioids: [1] Andrew D, Alison B, GiovambattistaZ, et al.
Breakthrough cancer pain: an observational study of 1000 Europeanoncology patients[J].
Journal of Pain & Symptom Management, 2013 ,46（5）:619-628.
[2]Augusto C, Cinzia M, Ernesto Z,et al.
Breakthrough pain characteristics and syndromes in patients with cancerpain.
An international survey.
[J].
Palliat Med, 2004,18（ 3):177-183.
[3]Wang Kun, Jin Yi.
Expert consensus on refractory cancer pain (2017 edition)[J].
Chinese Journal of Oncology, 2017,44(16):787-793.
More than 80% of advanced cancers may be accompanied by pain.
The domestic diagnosis and treatment of cancer is far from enough.
Some have not been treated, and some have been treated with analgesia, but they have not achieved good results.
Today, let’s learn about "cancer outbreak pain" together.
What is cancer burst pain? Cancerous explosive pain: It refers to the transient aggravation of sudden pain spontaneously or triggered by some predictable or unpredictable factors under the premise that the background pain control is relatively stable and the analgesic drugs are fully used.
▍Characteristics of incidence In cancer pain patients, the incidence of cancer burst pain can reach 33%~95%.
The existence of cancerous outbreak pain not only seriously affects the daily activities of patients, leading to the decline of quality of life and treatment compliance, but also increases the expenditure of medical resources [1], and often indicates poor clinical prognosis and treatment of opioids.
Resist [2].
Cancerous burst pain is a kind of refractory cancer pain.
The onset of pain is unpredictable, the pathological mechanism is complicated, and any rescue drug has a lag.
▍Type event cancerous explosive pain (also called induced cancerous explosive pain): generally caused by predictable factors.
Spontaneous cancer burst pain (also called idiopathic cancer burst pain): refers to the pain that occurs without any specific activity or inducement, which is unpredictable.
▍Assessment methods At present, the most commonly used assessment tools in China are mainly one-dimensional assessments.
The tools include: 1.
Numericrating scales (NRS).
Oral questioning: "From the number 0 (painless) to 10 (the most severe pain), which one describes your pain?" Write the pain description circle: List the numbers 0-10, and let the patient use a pen to circle it.
The value of pain. Digital score scale pain grading: 0: no pain; 1-3: mild pain; 4-6: moderate pain; 7-10: severe pain 2.
Visual analogue scales (VAS).
Instructions for use: Give the above picture and inform the patient that the above facial expressions show the degree of pain.
The leftmost face means that there is no pain, and the degree of pain gradually increases from left to right, allowing the patient to point out facial expressions that can represent the degree of pain.
3.
Language ratings (verbal rating scales, VRS).
▍The diagnosis meets the following three criteria at the same time: the patient has persistent pain in the past 1 week, and the duration is> 12 h per day (background pain); the patient’s background pain is fully controlled in the past 1 week (digital pain score ≤ 3 points); The patient has transient pain aggravation (digital pain score ≥ 4 points).
Figure 4 Flow chart of diagnosis of fulminant cancer pain What is the treatment principle of fulminant cancer pain: The cause of treatment is very important.
▍Treatment for cancer disease itself.
Radiotherapy can reduce cancer bone metastasis pain and neuropathic pain caused by tumor compression; chemotherapy and endocrine therapy can reduce tumor damage or compression to tissues, internal organs, and nerves; for patients with intestinal obstruction Patients can be treated with palliative surgery, etc.
; for advanced tumors, when anti-tumor therapy cannot effectively control the tumor, it is extremely difficult to treat the cause, and timely symptomatic treatment is required.
▍For the treatment of pain itself [3] 1.
It is recommended to use patient-controlled analgesia (PCA): the medical staff will pre-set the dose of analgesic drugs according to the patient's pain and physical condition, and then hand it over The patient "self-management".
Indications: Dose titration of opioids for cancer pain patients; cancer pain patients with frequent outbreak pain; cancer pain patients with dysphagia or gastrointestinal dysfunction; analgesic treatment for dying patients.
Contraindications: Patients who are unwilling to receive PCA technical analgesia; those who are too old or too young and lack the ability to communicate and evaluate; those who are mentally abnormal; restricted activities and unable to control the buttons are relatively contraindications, and can be operated by medical staff or family members if necessary.
Common adverse reactions include bleeding, infection, catheter blockage or shedding, and excessive sedation.
2.
PCA technology and medication: generally administered by intravenous or subcutaneous route, commonly used clinical drugs include morphine and hydromorphone injections.
3.
Combined use of auxiliary analgesics according to the condition: such as antidepressants, anticonvulsants, non-steroidal anti-inflammatory drugs and acetaminophen, and glucocorticoids.
4.
According to the consideration of local target treatment methods: such as incident cancerous burst pain caused by bone metastasis, osteoplasty, local nerve lysis, and seed implantation can be used.
Drug treatment strategies for cancer outbreak pain ▍Application of opioid analgesics Oral route of administration: Oral immediate-release morphine tablets are still the most commonly used drugs for cancer outbreak pain with slow onset and longer duration.
It is recommended to use 10% to 20% of the daily background dose for the initial dose of cancerous explosive pain, and to gradually titrate it according to the analgesic effect and adverse reactions.
For incident cancerous explosive pain, because the pain is often predictable, oral fast-acting opioids can be given before the painful event occurs to prevent and alleviate incident cancerous explosive pain.
It is recommended to take immediate-release morphine tablets orally in advance for a period of ≥30 min (onset time), or 60 min (maximum analgesic effect).
For patients who have difficulty swallowing tablets, morphine sulfate oral solution can be used as an alternative medicine.
Intravenous route of administration: rapid onset (5 min) and high bioavailability (100%), usually limited to patients with severe pain in hospital, and change to other methods of administration after the patient's pain improves.
Subcutaneous injection and intramuscular injection: higher bioavailability (80%~100%), faster onset (10~15min).
Intramuscular injection of morphine will increase local irritation.
Long-term repeated use may have the risk of unstable absorption.
It is not recommended as a routine route of use.
Rectal route of administration: It is not recommended as a conventional route of administration.
It can be used for some patients with cancerous outbreak pain who have difficulty in oral administration. ▍Application of non-opioid analgesics Cancer pain is often compound pain.
According to WHO's analgesic principles, for patients with poorly controlled opioids alone, it is recommended to use non-opioid analgesics and anticonvulsants, antidepressants and other auxiliary drug.
Nervous-related cancer burst pain can be combined with anticonvulsant, antidepressant and other auxiliary drugs to improve the analgesic effect.
Intracranial hypertension and spinal cord compression caused by brain metastasis or meningeal metastasis and other related cancerous burst pain, dehydration drugs combined with glucocorticoid therapy can be considered.
For cancer patients with bone metastases, pain will appear quickly after activity.
The pain is related to bone destruction.
Bisphosphonate drugs should be added to the use of painkillers.
Cancerous burst pain caused by spasm of internal organs in the abdominal cavity can be treated with antispasmodic drugs.
▍The use of opioids for risk assessment and management of opioids is used for cancer pain patients.
Generally, there will be no problems of abuse and addiction.
However, considering that the rescue drugs for cancer outbreak pain are short-acting, strong-acting and highly fat-soluble Opioids, and often need to be used multiple times.
It is recommended that patients receiving short-acting opioids for the relief of cancer outbreaks should receive a risk assessment including drug metastasis and opioid-related abnormal behaviors.
Individualized management and risk assessment should be given to high-risk patients who meet the items in the table, and strengthened Health education for patients and their families.
Risk assessment tool: Before taking opioids: cancer pain patient screening and opioid application assessment (SOAPP-R) and opioid risk assessment tool (ORT).
During the use of drugs: the application of the Opioid Misuse Evaluation Form (COMM).
Table 1 References for the definition of abnormal behaviors related to opioids: [1] Andrew D, Alison B, GiovambattistaZ, et al.
Breakthrough cancer pain: an observational study of 1000 Europeanoncology patients[J].
Journal of Pain & Symptom Management, 2013 ,46（5）:619-628.
[2]Augusto C, Cinzia M, Ernesto Z,et al.
Breakthrough pain characteristics and syndromes in patients with cancerpain.
An international survey.
[J].
Palliat Med, 2004,18（ 3):177-183.
[3]Wang Kun, Jin Yi.
Expert consensus on refractory cancer pain (2017 edition)[J].
Chinese Journal of Oncology, 2017,44(16):787-793.
