Today, with the rapid development of science and technology, people still “fear cancer”, however, among the cancer patients surveyed, 80% of them are most afraid of pain rather than death. In the past, doctors often pay attention to the treatment of cancer causes but neglect the control of cancer pain, on the other hand, the misunderstanding of some doctors and patients about pain treatment also affects the timely treatment. According to the statistics of World Health Organization (WHO), 30% to 50% of new cancer patients around the world have different degrees of pain every year, while the survey of this data in China shows that 51% to 61.6%. If cancer pain is not relieved, patients will feel extremely uncomfortable, which may cause or aggravate anxiety, depression, fatigue, insomnia, loss of appetite and other symptoms, and seriously affect patients’ daily activities, self-care ability, interaction ability and overall quality of life. Therefore, eliminating the fear of cancer patients and their family members about cancer pain and providing effective and standardized treatment for cancer pain is the key to the treatment of cancer patients.
1. Principles of cancer pain assessment
Cancer pain assessment is a prerequisite for reasonable and effective pain relief treatment. Routine assessment of cancer pain means that medical and nursing staff take the initiative to ask cancer patients whether they have pain, routinely assess the pain condition, and make corresponding medical records.
①Based on the patient’s chief complaint: the patient’s chief complaint is the most important.
②The patient’s family members or other primary caregivers.
③ Behavioral manifestations such as facial expressions body movements, crying.
④Measure changes in vital signs such as whistling, blood pressure, etc.
2.Cancer pain assessment tools
①Numerical pain intensity assessment scale (NRS): the pain level is expressed by 0-10 numbers in order, with 0 indicating no pain and 10 indicating the most severe pain. The patient chooses a number that best represents his or her pain level, or the health care provider asks the patient: How severe is your pain? The healthcare provider selects the corresponding number based on the patient’s description of the pain. The pain level is classified according to the number corresponding to the pain: mild pain (1-3), moderate pain (4-6), and severe pain (7-10).
②Pain-affected faces scale (Wong-baker faces scale): for patients with expression difficulties, such as children, the elderly, and patients with language or cultural differences or other communication barriers.
③Subjective pain level grading method (VRS): according to patients’ complaints about pain, the pain level is classified as mild, moderate and severe.
3.The treatment of cancer pain, with the development of sociology and medicine, has gradually changed from the original negative treatment to active treatment. According to the World Health Organization (WHO) guidelines for three-step pain relief treatment for cancer pain, the five basic principles of drug pain relief treatment for cancer pain are as follows.
1) Oral administration. Oral administration is the most common route of drug delivery. For patients who are not suitable for oral administration, other routes of drug delivery can be used, such as subcutaneous injection of morphine, patient-controlled analgesia, and more convenient methods such as transdermal patches.
2）Dosing according to the step. It means that the analgesic drugs of different strengths should be selected in a targeted manner according to the degree of pain of patients.
(1) Mild pain: non-steroidal anti-inflammatory drugs (NSAID) can be used. NSAIDs commonly used in cancer pain treatment include: ibuprofen, diclofenac, acetaminophen, indomethacin, celecoxib, etc.
②Moderate pain: weak opioids can be used, and NSAIDs can be used in combination. Commonly used are codeine, tramadol, etc.
③Severe pain: strong opioids can be used, and NSAIDs can be used in combination. At present, the short-acting opioids commonly used in cancer pain treatment are morphine immediate release tablets and long-acting opioids are morphine extended-release tablets, oxycodone extended-release tablets and fentanyl transdermal patches. For chronic cancer pain treatment, opioid agonist drugs are recommended.
(3) Timely administration of drugs. It refers to the regular administration of pain medication at prescribed time intervals. Timely administration helps to maintain stable and effective blood concentration.
(4) Individualized administration. It refers to the individualized dosing plan according to the patient’s condition and the dose of cancer pain relief drugs. When opioids are used, there is no ideal standard dose of opioids due to individual differences, and sufficient doses of drugs should be used according to the patient’s condition to provide pain relief.
5) Pay attention to specific details. Patients using pain medication should be monitored more closely, the degree of pain relief and the organism’s reaction should be observed closely, the interactions of drug combination should be noted, and necessary measures should be taken in a timely manner to minimize the adverse drug reactions with a view to improving the quality of life of patients. A series of side effects or complications such as peptic ulcers, nausea and vomiting, and constipation may occur. If these conditions occur, patients should visit the pain clinic in time and adjust the drug regimen or carry out symptomatic treatment under the guidance of doctors.
4.Common misconceptions of cancer pain patients
Although cancer pain is widespread among cancer patients, many cancer patients and their family members still have many concerns about cancer pain treatment, such as lack of confidence in cancer pain relief, fear of addiction to painkillers, fear of tolerance to painkillers, fear of intolerable side effects of painkillers, fear that reporting pain will affect doctors’ treatment of the primary disease, fear of using painkillers to cover up changes in disease, fear of not being able to get the medicine when pain is aggravated, etc. etc.
Common misconception 1: Injections for pain relief are fast and effective: in fact, it is just the opposite, compared with injections, oral drugs have the advantages of non-invasive, safe to use, convenient, self-medication and reliable absorption.
Common misconception 2: There is no need to use painkillers when it does not hurt: In fact, pain, like other chronic diseases, requires conventional medication
Common misconception 3: It is safer not to use non-opioid drugs and not to use opioid painkillers as a last resort: In fact, for patients who need long-term painkillers for chronic cancer pain, it is safer and more effective to use opioid drugs (such as morphine). The side effects of non-opioids are easy to ignore, and the dose of first-order NSAIDs should not be increased indefinitely, and their effects have a “capping effect”. For patients with moderate to severe cancer pain, opioid analgesics have an irreplaceable position.
Common misconception 4: Opioid application is addictive: Experimental research and clinical practice have confirmed that addiction rarely occurs when morphine or transdermal patches are taken orally by cancer pain patients. Once opioids are used, opioids can be safely discontinued at any time if the cause of cancer pain is controlled and the pain disappears. Long-term use of opioid painkillers by cancer pain patients may require gradual dose increases, and can be successfully withdrawn when the pain is relieved, which should be distinguished from so-called “addiction”. However, the use of opioids for non-medical purposes is drug abuse, such as repeated intravenous injection of large doses of opioids may lead to “addiction”.
5, opioids common adverse reactions
(1) constipation
① incidence of 90%-100%, affecting eating, serious nausea, enemas bring pain. Constipation does not produce tolerance due to long-term use of drugs.
②Prevention and treatment of constipation is an important issue in opioid analgesic treatment.
③Doctors should prescribe laxatives to prevent constipation while prescribing opioids. Commonly used laxatives include laxative, marengoil pills/capsules, sifu-tang, which should be taken regularly while taking opioids, and suppositories can be used in the morning to help defecate.
2）Nausea and vomiting
①The incidence of 30%, generally in the initial period of medication, most of the relief within 4-7 days, and then gradually reduce, and completely disappear.
②Exclude other causes: constipation, brain metastasis, chemotherapy, radiotherapy, hypercalcemia.
③Prevention: For the first time, it is best to use antiemetic drugs for the first week. Gastrofluan is commonly used, three times a day, half an hour before meals.
6.Tips for using pain medication
①The first time you use opioid drugs, you should take them orally together with Gastrofluan to prevent nausea.
②When opioids are used for the first time or in significantly higher doses, pay attention to the degree of sedation.
(3) Evaluate the 24-hour average pain intensity and the intensity and number of painful outbreaks every day during the drug administration.
④Evaluate the effect of pain relief and the degree of adverse reactions at any time.
⑤ If the patient is depressed or has sleep disorders, additional adjuvant medication is recommended.