Pain is the most common and main symptom of tumor patients. According to the World Health Organization, more than half of tumor patients have pain. 80% of advanced stage patients have pain as the main symptom. Most of the cancer pains can be relieved significantly if they are treated regularly. So, how should we face the pain brought by tumor? How can we let tumor patients live a pain-free life? In the following, I will share with you my knowledge and understanding of cancer pain from two aspects: assessment and treatment of cancer pain.
I. Assessment of cancer pain
In the 2002 International Congress on Pain, experts elevated pain to the fifth vital sign after respiration, heart rate, pulse and blood pressure. This elevation is in the hope that clinicians will pay enough attention to pain, pay attention to this uncomfortable feeling of patients, and give appropriate treatment.
As clinicians, they need to make a thorough assessment of pain in oncology patients. First, patients should be encouraged to talk about their pain so that the physician can make a thorough and accurate assessment. Then go to the specific assessment of the time, location, nature and degree of pain. It is very important to correctly assess the degree of cancer pain. By assessing the degree of pain, it is possible to choose which treatment modality to use and to judge the dosage of medication and the quality of life of the patient. Commonly used grading methods are as follows.
1.Simple pain intensity grading method (VRS)
0 degree: no pain.
I degree: mild pain, tolerable pain, normal life, undisturbed sleep.
II degree: moderate pain, pain is obvious, tolerable, request for painkillers, sleep is disturbed.
III degree: severe pain, pain is severe, not tolerable, sleep is seriously disturbed, may be accompanied by autonomic disorder or passive position.
2.Numerical grading method (NRS)
The numerical grading method uses 0-10 to represent different degrees of pain, with 0 being no pain and 10 being severe pain. Choose a number that best represents the pain level. 0: no pain; 1-3: mild pain; 4-6: moderate pain; 7-10: severe pain.
3. Face scoring method. Applicable to children or adults with intellectual and mental disabilities.
II. Treatment of cancer pain
Drug treatment is the main method of cancer pain treatment. However, many tumor patients think that having tumor, pain is normal and it will pass after getting through. They think morphine is a kind of poison and will be addictive, so it is better not to use it if they can. These thoughts are understandable, but they do not mean it is correct.
At present, there are still some problems in the treatment of cancer pain in China. Let’s take a set of data to illustrate. The national per capita consumption of medical morphine is an important indicator of a country’s cancer pain control status. 2010, China’s medical morphine usage only accounted for 2% of the global medical morphine volume, and China’s per capita usage is less than one percent of the global average, and even more than two percent of the developed countries. From this set of data, we can see that there is still a long way to go to standardize the treatment of pain in China.
As to whether morphine is addictive, domestic and international data clearly show that the incidence of psychiatric dependence due to pain treatment is <1%< span="">, so it is not necessary to worry too much about the emergence of “addiction”.
In the following, I will focus on the basic principles and methods of drug pain relief.
1. Oral: If you can take drugs orally, try to take them orally. Oral administration is simple, economical and easy for patients to accept, and it can form stable blood concentration, which is equally effective as intravenous injection, but it is easier to adjust the dose and has more autonomy, and is not easy to addiction and drug resistance. However, for patients who cannot take it orally, for example, patients with pyloric obstruction of gastric cancer who vomit repeatedly, they can choose to give the drug by anal plug, to give the patch and so on.
2. Regularity: that is, the drug is given at prescribed intervals, such as once every 12 hours, regardless of whether the patient has an attack of pain at the time of administration, rather than on demand. This helps to ensure that the pain is continuous session. Many patients do not give the medication on time and regularly, and only take the medication when the pain breaks out, resulting in unsatisfactory pain control.
3.Dosing by step: follow WHO’s three-step drug administration principle.
First-step drugs: non-opioid drugs, usually non-steroidal anti-inflammatory analgesics, such as aspirin, ibuprofen, indomethacin, etc. It is effective for mild cancer pain. Second-order drugs: weak opioids, codeine, prednisolone, tramadol, etc. For moderate pain, second-order pain medications should be added on top of first-order medications. Third-order drugs: morphine tablets, OxyContin, Meclizine, etc. Used in severe pain.
It should be emphasized that the three-step treatment is artificially divided to facilitate the use of appropriate drugs according to the degree of pain, but attention is paid to the flexible application of drugs, so that if the pain is moderate to severe at the beginning, the second or third-step drugs can be used directly. And the use of moderate pain drugs is the current trend.
4, individualized administration: sensitivity to narcotic drugs varies greatly between individuals, so there is no standard dosage of opioid drugs. Where the pain can be relieved and the lowest side effects of the dose is the best dose. To judge the pain to control and relief, we commonly use: pain intensity <3 points, number of pain crises <3 times in 24 hours, and number of times in 24 hours requiring antidotes <3 times. However, because everyone's situation is different, it is still recommended to go to the hospital and adjust the dose of pain medication according to the doctor's medical advice.
5, pay attention to the prevention of drug side effects: because most of the pain medications have side effects such as stimulation of gastrointestinal mucosa, inhibition of gastrointestinal motility and constipation, it is also beneficial to add some gastric mucosa protectors, gastrointestinal motility drugs and laxatives in the process of application. The prevention of constipation needs to be emphasized here. Patients basically experience varying degrees of constipation during the use of opioids, so it is recommended to start the prophylactic use of laxative medications before the medication is administered to keep the stools open throughout the medication process to ensure that patients can successfully complete the medication.
Conclusion: On the shores of Lake Saranac in northeastern New York is engraved the epitaph of a physician: Sometimes to heal, often to help, always to comfort. I would like to say that a little more care and a little more love when facing our oncology patients may sometimes be more effective than the treatment itself. Although science is limited and medicine is limited, what we doctors can do is sometimes what science cannot do, and this is the power of humanistic care.