I. Current situation.
According to the World Health Organization (WHO), there are more than 10 million new cancer patients and more than 6 million deaths worldwide each year, among which at least 5 million cancer patients are suffering from pain. 70% of advanced cancer patients consider cancer pain as the main symptom, and 30% have intolerable severe pain.
There are 2.6 million cancer patients in China, with more than 1.8 million new patients each year. The incidence of cancer pain is 62%, of which 30% are severe pain and 30% are moderate pain.
II. Causes of pain in cancer patients.
Regarding the mechanism of cancer pain generation, it is currently believed that there are three pathways, namely.
(1) Pain due to cancer development.
(2) Pain caused by diagnosis and treatment of cancer.
(3) pain occurring in cancer patients with co-infections, chronic painful diseases and cancer pain syndrome. Among these three pathways, 75% to 80% are caused by tumor invasion into soft tissues, bone marrow and the nervous system, 15% to 20% are generated during the diagnosis and treatment of cancer, and 5% to 10% are due to the combination of painful diseases.
III. Characteristics of cancer pain.
Cancer pain has many features, one of the prominent features is that it is more intense, often a persistent pain that keeps getting worse, with paroxysmal aggravation and heavy at night, often accompanied by anxiety and/or depression.
IV. Commonly used methods of treating cancer pain.
At present, the common method for treating cancer pain is the “WHO Three-step Cancer Pain Treatment Program” developed by the World Health Organization in 1982 at the meeting in Milan, Italy.
V. What is three-step therapy?
The “three-step” treatment plan is divided into three stages. Different treatment plans are adopted according to the mild, moderate and severe pain. The first step of treatment for patients with mild pain is the use of non-steroidal anti-inflammatory analgesic drugs for these patients with mild pain. The old representative of these drugs is aspirin, and currently the more commonly used drugs such as Isidin and Fenbendazole can make mild pain patients free from pain. For patients with moderate cancer pain, they are treated with second-stage drugs, whose drugs are mainly weak opioid drugs + non-steroidal anti-inflammatory analgesic drugs. Weak opioid analgesics are commonly used, such as Chimantin (Tramadol Hydrochloride Extended Release Tablets), Lugac (Aminophenol Dihydrocodeine Tablets), and Tongan (Aminophen Tramadol Tablets). They have better effect on patients with moderate cancer pain. For patients with severe cancer pain, the third-order drug treatment is used, which mainly consists of giving strong opioid drugs + non-steroidal anti-inflammatory analgesic drugs for treatment. The strong opioid analgesics commonly used are: mescaline (morphine sulfate controlled-release tablets), oxycontin (oxycodone hydrochloride controlled-release tablets), and dorigib (fentanyl transdermal patch).
VI. What are the principles of three-step therapy?
The general principles of three-step therapy are: non-invasive drug delivery, timely drug delivery, drug delivery by step, individualized drug delivery and attention to specific details.
1.Non-invasive administration: It means that all pain medications are basically administered through the mouth, skin or rectum instead of intramuscular, intravenous injection and nerve destruction, surgery and other traumatic and painful methods, which are not only simple, economical and convenient, but also easier for patients to accept, and the drugs are absorbed regularly, doctors can easily control the dosage, with precise efficacy and high safety.
2.Dosing on time: It means that painkillers should be taken at the point of arrival, not only when it hurts, only in this way can we ensure that the concentration of painkillers in the blood is maintained at a stable level, thus ensuring that pain can be relieved continuously.
3.Dosing by steps: It means that when applying painkillers, different steps of drugs should be selected according to the patient’s pain level, instead of starting with the first step of drugs, for example, for a cancer patient suffering from moderate or even severe pain, the second or even the third step of drugs can be used at the beginning.
4. Individualization of drug dosage: The cause and degree of pain as well as the way of relief and drug resistance are different for each patient, so special attention should be paid in the treatment to develop an individualized treatment plan for each patient according to the specific situation of each patient.
5. Pay attention to specific details: patients with pain medication should be monitored and their reactions should be closely observed. Our aim: patients get the best efficacy with the least side effects occurring and improve their quality of life.
Seven, what is the effect of three-step therapy?
According to WHO statistics, the regular implementation of three-step therapy can effectively control the pain of more than 90% of cancer patients.
Common misconceptions of cancer pain treatment
Myth 1: It is safer to use non-opioid drugs
Correct: Patients who take NSAIDs (e.g. Estradine, Fenbendazole, Fotarine) for a long time have an increased risk of gastrointestinal, hepatic, renal and platelet toxicity reactions with the prolongation of drug use, while opioids have no toxic effects on liver, kidney and other organs when taken for a long time, therefore, for patients who need long-term analgesic drugs for chronic cancer pain and those whose pain is still not satisfactorily controlled when the dose of NSAIDs reaches the limit, it is better to use non-opioid drugs. Therefore, it is safer to use opioids for patients who need long-term analgesics for chronic cancer pain and those whose pain cannot be satisfactorily controlled when the dose of NSAIDs reaches the limit.
Misconception 2: Use painkillers only when the pain is severe
Correct: If cancer pain patients do not receive effective pain relief treatment for a long time, they are prone to sympathetic nerve dysfunction related to neuropathic pain caused by pain and develop into intractable pain, therefore, timely and timely use of painkillers is not only safer and more effective, but also requires the lowest strength and dose of painkillers.
Myth 3: Analgesic treatment is sufficient to bring partial relief of pain
Correct: The purpose of pain relief treatment is to relieve pain and improve the patient’s quality of life. Therefore, the minimum requirement of pain relief treatment is pain-free sleep, and the higher requirement is for patients to achieve pain-free rest and pain-free activities in order to truly achieve the purpose of improving patients’ quality of life.
Myth 4: When adverse reactions such as vomiting and sedation occur with opioids, opioids should be stopped immediately
Correct: Except for constipation as a side effect, most adverse reactions to opioids are temporary or tolerable. Adverse reactions to opioids, such as vomiting and sedation, generally occur in the first few days of use, and the symptoms mostly disappear on their own after a few days. Adverse reactions to opioids, active preventive treatment, can be reduced or avoided.
Myth 5: The use of dulcolax is the safest and most effective painkiller
Correct: WHO has listed dulcolax (pethidine hydrochloride) as a drug not recommended for cancer pain treatment for the following reasons: the analgesic effect of pethidine hydrochloride is only 1/10 of morphine; its metabolite, desmethyl pethidine, has a long clearance half-life and has potential neurotoxicity and nephrotoxicity; pethidine hydrochloride has a low oral absorption rate and is mostly administered by injection, so it is not suitable for chronic treatment of cancer pain.
Myth 6: Only patients with end-stage cancer can use the maximum tolerated dose of opioid painkillers
Correct: Since the dosage of opioid analgesics varies greatly among individuals and there is no capping effect of opioids, the maximum tolerated dose of opioids can be used for any patient with severe pain, regardless of the clinical stage of the tumor and the expected survival time, as long as the analgesic treatment is needed to achieve ideal pain relief.
Myth 7: Long-term use of opioid painkillers will inevitably lead to addiction
Correct: A lot of domestic and foreign clinical practice shows that long-term treatment with opioid analgesics for cancer pain patients, especially oral and other long-acting preparations given on time, has minimal risk of addiction (psychiatric dependence).
Myth 8: Opioids, if widely used, are bound to cause abuse
Correct: Active implementation of WHO’s three-step cancer pain management principles and rational use of opioid painkillers will not only enable the majority of cancer pain patients to receive ideal pain relief treatment, but also avoid or reduce the risk of opioid abuse. In fact: Since WHO released the three-step cancer guideline in 1982, the global consumption of morphine for medical use has increased from about 2.2 tons to nearly 30 tons, without increasing the risk of opioid abuse.
Myth 9: Once you use opioids, you may need medication for life
Correct: After the cause of cancer pain is controlled and the pain disappears, opioid painkillers can be safely discontinued at any time, especially when the daily dosage of morphine is 30-60mg, and sudden discontinuation of the drug will generally not cause accidents. For long-term high-dose patients, the dosage of opioids should be gradually reduced after the pain disappears until the drug is stopped, for example, the dosage should be reduced by 25% to 50% in the first two days, and then by 25% in the next two days, until the daily dosage is reduced to 30-60 mg. In the process of reducing the dosage, if patients have pain or other abnormal reactions, they should go to the hospital for consultation.
Myth 10: Treatment with opioids for pain relief means giving euthanasia
Correct: Using opioid painkillers according to the condition of cancer pain can not only effectively control pain, but also reduce the risk of death due to severe pain, improve the quality of life and effectively prolong the survival of patients.
Myth 11: Lung cancer patients cannot use opioids
Correct: The side effects of opioid analgesics on central respiratory depression generally only occur in the case of overdose, especially when the peak blood concentration rises rapidly (intravenous administration of large doses) or when the drug accumulates and becomes toxic (such as renal insufficiency). The reason why patients with cancer pain rarely experience respiratory depression with rational use of opioid drugs is that pain is a natural antagonist of respiratory depression, and respiratory depression will not occur as long as pain cannot be stopped; patients with cancer pain who use opioid drugs for a long time will soon develop tolerance to the respiratory depression side effects of drugs. Therefore, patients with lung cancer pain can safely and effectively use opioid painkillers.