Pain and dyspnea are the most common symptoms that affect the quality of life of lung cancer patients.
(I) Pain
1. Assessment: Patient’s complaints are the gold standard for pain assessment, and the intensity of pain must be assessed before analgesic treatment. The numerical pain grading method is preferred, and the face-marking method can be used for children or elderly people with cognitive impairment. Pain intensity is divided into 3 categories, i.e. mild, moderate and severe pain; it is important to record not only the pain intensity at the time of the patient’s assessment, but also the heaviest, lightest and average pain intensity over the past 24h, and to understand the changes in pain intensity at rest and during activity.
A comprehensive assessment of pain should be performed. The assessment should include the etiology, characteristics and nature of the pain, aggravating or relieving factors, the impact of the pain on the patient’s daily life, and the efficacy and side effects of analgesic treatment. A brief pain scale is recommended for the assessment.
The assessment should also clarify whether the patient has pain due to oncologic emergencies so that relevant treatment can be given immediately. Common oncologic emergencies include pathologic fractures or precursor fractures of weight-bearing bones; metastatic cancer of the brain parenchyma, dura or soft meninges; pain associated with infection; visceral obstruction or perforation, etc.
2. Treatment: The goal is to achieve the best balance between analgesic effects and side effects. Analgesic drugs can relieve cancer pain in more than 80% of patients. A small number of patients may need non-pharmacological analgesic means, including surgery, radiotherapy for pain relief or nerve block, so the analgesic effect should be dynamically evaluated and interdisciplinary collaboration should be actively carried out.
(1) Basic principles: WHO three-step analgesic principles are still the most basic principles of cancer pain treatment.
Its main contents include the following five aspects.
(1) Preferred oral administration: Non-invasive, simple and safe routes of administration should be chosen as far as possible; oral administration is the preferred route of administration, and transdermal absorption, subcutaneous injection or intravenous infusion can be considered as appropriate.
②Dosing according to the ladder: choose pain medication according to the degree of pain according to the ladder. Choose acetaminophen or non-steroidal anti-inflammatory analgesics for mild pain, weak opioids for moderate pain, such as codeine and tramadol; strong opioids for severe pain, such as morphine, oxycodone, fentanyl, etc. Low-dose strong opioids can also be used to treat moderate pain.
(3) Timely administration of drugs: if chronic persistent cancer pain occurs, patients should be given analgesic treatment in time after timely administration of drugs, and it is recommended to choose fast-acting immediate release drugs.
④Individualized treatment: Before formulating the pain relief plan, the patient’s general condition, such as underlying diseases, heart, liver and kidney functions, concomitant symptoms and combined medications, should be comprehensively evaluated, and appropriate drugs and doses should be selected.
⑤ Attention to details: details during analgesic treatment refer to all factors that may affect the analgesic effect. It is important to pay attention to the information obtained from pain assessment and to pay attention to factors such as psychological, spiritual, economic status, family and social support of patients.
(2) Opioids are the core drugs for cancer pain treatment: whether opioid tolerance exists in patients should be judged before opioid treatment. The judgment of opioid tolerance is based on the standard of the U.S. Food and Drug Administration, namely: patients are currently taking at least 60 mg of morphine, 8 mg of hydromorphone, 30 mg of oxycodone, 25 mg of hydromorphone, 25 μg/h of fentanyl transdermal patch or other equivalent opioids per day for at least 1 week; patients who do not meet this standard are regarded as opioid intolerant.
In the selection of opioids, attention should be paid to: not using pethidine to control cancer pain; choosing pure receptor agonists as much as possible; avoiding morphine analgesia in patients with renal insufficiency. Opioid analgesic treatment is divided into short-acting titration phase and long-acting maintenance phase. Short-acting titration is the initial phase of opioid therapy, the purpose of which is to determine the opioid dose required for satisfactory analgesia as soon as possible. It is recommended that short-acting opioids be given on time, with the initial dose depending on whether the patient tolerates it or not. This phase should also be administered on an as-needed basis to relieve painful outbreaks, with a single dose calculated at 10% to 20% of the total daily opioid dose, or the starting dose for those who are opioid intolerant.
After pain relief is achieved by opioid titration, short-acting opioids can be converted to controlled extended-release dosage forms to extend the dosing interval and simplify treatment. It is important to actively prevent and treat opioid adverse effects. All opioid users need to prevent and control constipation, and laxative ingredients should include at least ingredients that stimulate gastrointestinal motility, such as senna and bisacodyl; side effects such as nausea and vomiting, vertigo, paranoia and respiratory depression should be dynamically observed throughout the analgesic treatment, and active intervention should be made once they occur.
(3) Treatment of neuropathic pain: analgesic drugs can only relieve part of the neuropathic pain. A combination of strong opioids and adjuvant medications is recommended.
Potentially effective adjuvant medications include.
(1) Gabapentin: 100-300 mg orally, 1 time/d, gradually increasing to 300-600 mg, 3 times/d, with a maximum dose of 3600 mg/d;
(ii) Pregabalin: 75 mg orally, 2 times /d, may be increased to 150 mg, 2 times /d, the maximum dose is 600 mg /d;
(iii) Tricyclic antidepressants: such as amitriptyline, 10-25 mg orally once a night, the usual dose is 25 mg twice a day, which can be gradually increased to the optimal therapeutic dose, the maximum dose is 150 mg/d;
Methadone and ketamine are effective for some neuropathic pain.
3. Education for patients and their relatives: Patients and relatives should be told that analgesic treatment is an important part of overall tumor treatment, and pain tolerance is not beneficial to patients. Morphine and its similar drugs are commonly used in cancer pain treatment, and addiction is rare; analgesic treatment should be carried out under the guidance of medical personnel, and patients should not adjust the treatment plan and drug dose by themselves; the efficacy and side effects of drugs should be closely observed, and patients should communicate with medical personnel at any time and follow up regularly.