Modern methods of pain relief in oncology
Pain is an integral symptom of cancer. In the final stages of the disease from tolerable, it gradually develops to a strong, painful and constant. Chronic pain syndrome aggravates the life of an oncologic patient, depresses not only physical, but also mental state. The issues of anesthesia in oncology are extremely relevant for patients and their relatives. Modern medicine has a wide arsenal of drugs and methods to combat the pain of cancer. In more than 90% of cases, pain syndrome can be stopped or its intensity reduced.
Let us take a closer look at how the correct anesthesia scheme is built and what is the basis for advanced methods to alleviate the state of cancer patients. Oncology and pain Pain is one of the first symptoms that indicates the progression of the malignant process in the body. If at the early stage of cancer no more than a third of patients complain of pain, then as the disease progresses, they are almost always spoken of.
Pain can cause not only the tumor itself, but also inflammatory reactions leading to smooth muscle spasms, joint damage, neuralgia and wounds after surgery. Information As a rule, pain in cancer appears in stages III and IV. However, sometimes it may not even be in critical conditions of the patient – this is determined by the type and location of the tumor. Facts are known when stage IV cancer of the stomach was asymptomatic.
A breast tumor may not cause pain – discomfort in such cases appears only when the metastases cover the bone tissue. Pain syndrome can be classified according to various criteria. So, according to the degree of intensity of pain can be weak, medium and strong, according to a subjective assessment – stabbing, throbbing, drilling, burning; in duration – acute and chronic. Let us dwell separately on the classification of pain by origin: Visceral – pain in the abdominal cavity without clear localization, long, aching. For example, pain in the back with kidney cancer. Somatic – pain in the ligaments, joints, bones, tendons: dull, poorly localized.
Classification of Pain
They are characterized by a gradual increase in intensity. Appear in the advanced stages of cancer, when metastases are formed in the bone tissue and cause damage to the internal vessels. Neuropathic – pain caused by disturbances in the nervous system. For example, the pressure of a tumor on the nerve endings or their damage. This type of sensation is also caused by radiation therapy or surgery. Psychogenic – pains without physical lesions associated with fear, depression, self-hypnosis of the patient. They appear as a result of strong emotional experiences and cannot be treated with painkillers.
Note In medicine there is the term “phantom pain” – it is pain in that part of the body that was removed as a result of the operation. For example, pain in the chest after a mastectomy or pain in an amputated arm or leg. There is still no exact explanation for this phenomenon. Some scientists see the reason for the inconsistency of that part of the brain, which is responsible for sensitivity, with the one that is responsible for thinking. Others believe phantom pain is the result of poorly performed anesthesia. Pain is the protector of the body and the main alarm. It was invented by nature to indicate a person to a problem, make him think and induce action.
However, chronic pain in oncology is devoid of these functions. It plunges the patient into a feeling of despondency, hopelessness, depression – even mental disorders, interferes with the normal functioning of the body, makes it impossible to feel like a full-fledged member of society. The pain takes away the strength needed in the fight against cancer. Progressive medicine treats such pain as a pathological process that requires separate therapy. Cancer anesthesia is not a one-time procedure, but an entire treatment program designed to preserve the patient’s social activity, to prevent the deterioration of his condition and mental oppression.
Cancer pain management
the nuances of the choice of anesthesia scheme So, the selection of effective therapy against pain is a difficult task that requires a step-by-step approach. First of all, the doctor needs a history: the cause of the pain (if it is established), prescription, localization, intensity, connection with the time of day and exercise, the type of analgesics that have already been used, and their effectiveness. If the patient complains of severe pain, first of all, it is necessary to exclude conditions requiring emergency care. For example, infections or pathological damage of the meninges by metastases. To do this, appoint an MRI, ultrasound, computed tomography and other studies at the discretion of the doctor. If the emergency condition is excluded, the choice of method of anesthesia will depend on the severity of pain and previously used analgesics.
It is imperative that the physician treat the pain of the patient with about all seriousness, not downplaying significance. It is necessary to control their decrease or increase. It happens that an oncologist can prescribe a higher dose of medication or go directly to narcotic drugs in order to achieve a quick effect. But this technique gives only a short-term result. Often, the mistakes are made by the patients themselves, who suffer “to the last” and only then begin to complain.
Meanwhile, the reception of painkillers is necessary when the first appearance of pain. Accurate adherence to the correct regimen will significantly delay the need for potent drugs. It happens that patients take all analgesics in a row, selecting what will help them better and faster. This is also a mistake as it is important to find out the cause of the pain.
Spasms in the abdominal cavity are removed with medications that, with bone pain, will be ineffective. Not to mention the fact that pain in general can only be associated with oncology indirectly or not at all. Each doctor acts in accordance with knowledge and experience, but the whole scheme of pain therapy is based on a unified scheme recommended by the World Health Organization – the “WHO ladder”. A three-stage system of pain relief for cancer: “WHO’s ladder” In the recommendations of WHO experts, there are three stages of pharmacotherapy, which provide a rational treatment of pain in cancer patients. In accordance with the level of selected and drugs. With mild pain – non-opioid analgesics.
When amplified – “light” opioid drugs.
With severe pain – narcotic anesthesia and adjuvant therapy. Consider each stage in more detail. First stage. Begin treatment of pain syndrome with non-narcotic analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs). These include paracetamol, ibuprofen, aspirin, meloxicam, etc. With pain in the muscles and joints, diclofenac, etodolac, etc. All these substances affect peripheral pain receptors. In the first days of the drugs can cause general fatigue and drowsiness, which passes on their own or adjusted by changing the dosage. If the pill does not give the desired result, proceed to the injection.
The second stage
When first-stage drugs become ineffective, weak opioids are connected to them. This is usually tramadol and codeine. The analgesic effect is achieved by affecting the opiate receptors of the central nervous system and replacing endorphins, the “joy hormones,” the production of which decreases with intense pain. Tramadol is prescribed in the form of tablets or injections. It is taken together with analgin, paracetamol and other first-stage drugs (synergistic effect): tramadol affects the central nervous system, and NSAIDs – the peripheral nervous system. The third step. The final stage of treatment, which is transferred to, if the patient is experiencing excruciating, incessant pain. The third stage drugs are strong opiates, the key of which is morphine.
However, there are more benign substances that are less addictive. This is buprenorphine (“Bunpronal”) – 50% efficiency relative to morphine; pyritramide (“dipidolor”) – efficiency 60%; fentanyl (“Durogezik”) – 75–125%. The effect occurs a few minutes after admission, but the patient must clearly follow the prescribed scheme. Start taking drugs with a minimum dose, gradually increasing it. Effective technologies for pain relief in cancer patients. The fundamental factor in choosing the method of pain relief in oncology is not only the effectiveness of the action, but also the convenience for the patient, the effect on his quality of life. Before, invasive methods were almost always used – injections. Modern methods of anesthesia are diverse and as comfortable as possible for patients. Pain relievers. This is a method of transdermal administration of the drug. The patch contains four layers: a protective polyester film, a reservoir with the active substance (for example, with fentanyl), a membrane that corrects the release intensity and a sticky layer. The patch can be stuck anywhere.
Fentanyl is released gradually over 3 days
The action occurs after 12 hours, after removal, the concentration of the drug in the blood slowly decreases. The dosage may be different, it is selected individually. The patch is prescribed, as a rule, at the very beginning of the third stage of anesthesia for oncology. Spinal anesthesia. In spinal anesthesia, the drug is injected into the spinal canal. This leads to a temporary “off” tactile and pain sensitivity. The introduction takes place through a catheter, which requires a certain amount of experience from the doctor. Morphine, norfin, fentanyl, etc. are used as an analgesic. They enter the brain through the cerebrospinal fluid and the general circulatory system. Side effects in the form of nausea and drowsiness are not excluded. Epidural anesthesia. The drug is injected into the epidural space located between the dura mater and the walls of the cranial cavity or spinal canal. The drugs are similar to spinal anesthesia.
Epidural Estezia is used to relieve cancer pain when secondary changes in the bones appear, and oral and parenteral administration methods do not produce results. Neurolysis through the gastrointestinal tract using endosonography. Neurolysis (neurolysis) is the process of destruction of the nociceptive (painful) nervous pathway. An analgesic is administered transgastrally through the gastrointestinal tract, and endoscopic ultrasound testing ensures accuracy. Such methods of local anesthesia are used, for example, for pancreatic cancer with an efficiency up to 90%. The analgesic effect is able to persist for more than a month, while narcotic analgesics in the classical way would have to be administered continuously.
The introduction of drugs in myofascial trigger points. Myofascial pain syndrome is expressed in muscle spasm and painful thickening in the tense muscles. They are called trigger points and painful when pressed. Injection in the trigger zone relieves pain and improves mobility of the body region. Vegetative blockade. Nerve blocking involves the introduction of the drug in the place of the projection of the nerve, which is associated with the affected organ and causes pain.
For example, a blockade for pancreatic cancer eliminates pain for several months. Depending on the type of anesthetic, the procedure is carried out once a year, semi-annually or every week. Another plus is the minimum number of negative consequences. Neurosurgical interventions. During the procedure, a neurosurgeon cuts the roots of the spinal or cranial nerves through which nerve fibers pass. Thus, the brain is unable to receive pain signals. Cutting the roots does not lead to loss of motor ability, but it can make it difficult.
Patient-controlled analgesia (PCA). This type of anesthesia is based on a simple rule: the patient receives analgesics when he wants it. The scheme is based on an individual perception of pain and the need for taking analgesics. In European countries, PCA has been adopted as a standard for postoperative pain management. The method is simple and relatively safe. However, patients need to undergo a thorough briefing.
The choice of a specific method of pain relief for cancer depends on many factors, which is why an individual approach and a thorough examination of the patient are so important, allowing the doctor to evaluate the effectiveness, feasibility and possible risks. Medicine is firmly established in the idea that pain syndrome should be treated, regardless of projections for the underlying disease. This is required to prevent the destructive effect of pain on the patient’s physical, moral and mental state, to preserve its social significance.