Cancer Pain Relief With a Guide to Opioid Availability

70 Pages·2.4 MB·English

CANCER PAIN RELIEF
Second Edition
With a guide
to opioid
availability
World Health
Organization
Geneva
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Copyrightedmaterial
Cancer pain
relief
SECOND EDITION
With a guide to
opioid availability
World Health Organization
Geneva
1996
iiiii
CZX8-RU3-0R1P
WHOLibraryCataloguinginPublicationData
—Can2cnedrepdamrelief.withaguidetoopioidavailability.
1 Neoplasms drugtherapy 2 Pain-drugtherapy
3 Palliativetreatment 4 Narcotherapy
ISBN9241544821 (NLMClassification QZ200)
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Contents
Preface v
Acknowledgements vi
Part1.Cancerpain relief 1
Introduction 3
Causesof pain 5
Evaluation of pain 8
Treatment strategy 12
Useofanalgesics 14
"Bymouth" 14
"By the clock" 14
"By the ladder"
"Fortheindividual" 16
"Attentiontodetail- 16
Choiceofanalgesic 17
Non-opioid analgesics 17
Opioid analgesics 19
Drugsforneuropathic pain 29
Adjuvantdrugs 32
Summary 36
Part2 Ooioid availabilitv 39
Introduction 41
Background 41
New knowledge, newhope 41
Impediments to cancer pain relief 42
TheWHO strategy 42
Difficulties in obtaining opioids 43
Theparticipants in the drug distributionchain 45
TheSingle Convention on Narcotic Drugs 46
Description and purpose 4f
iii
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CANCER PAIN RELIEF
Fxrpntion^ 47
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reoulators 49
Obtainina a suoolvofooioids 50
ne reporting system DO
i
Isthe international svstem workina? 54
Regulationofhealth careworkers 56
Drug abuseversus patient need 56
Suggested guidelinesfor regulationofhealth
professionals 57
References 59
Selected further reading 60
Annex 1. Useofterms 61
Annex 2. Model importcertificate 62
iv
Preface
In most partsofthe world, the majorityofcancer patients present
with advanced disease. Forthem, theonlyrealistic treatment
option is pain reliefand palliativecare. In 1986, thefirst edition of
this publication proposed a methodfor reliefofcancerpain, based
on a small numberof relatively inexpensive drugs, including
morphine. Field-testing in several countries demonstrated the
efficacy ofthe method in mostcancer patients. Thefirst edition has
been translated into 22 languages and atotal ofoverhalf amillion
copies have been sold, reflecting thegrowing awarenessofthe
problemofcancer pain.
Thissecond edition takes intoaccount manyoftheadvances in
understanding and practicethat haveoccurred sincethemid-
1980s. The groundworkforthis revision was started in 1989, in the
contextofthe meeting ofaWHO Expert Committeeon Cancer Pain
ReliefandActive SupportiveCare.' Sincethen, each partofthe
book has been thoroughly revised and updated, and a section has
been added on opioid availability.
It is importantto notethat cancer pain management should be
undertaken as partofcomprehensive palliativecare.2 Reliefof
othersymptoms, and of psychological, social and spiritual
problems, is paramount. Attempting to relieve pain without
addressing the patient's non-physical concerns is likely to lead to
frustration and failure.
1 Cancerpamreliefandpalliativecare reportofaWHOExpertCommittee.Geneva.World
HealthOrganization,1990(WHOTechnicalReportSeries.No 804).
1See.forexample DoyleDetal.eds Oxfordtextbookofpalliativemedicine.Oxford,Oxford
UniversityPress. 1993.
v
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Acknowledgements
TheWorld Health Organization acknowledges the valuable contri-
butions madetothis book bythe late Mr N. R. Donaldson, formerly
Senior Consultant (Pharmacy). Drugs Directorate, Health Protection
Branch, Departmentof Health and Welfare. Ottawa, Canada;
Mr D. E. Joranson, Associate Directorfor Policy Studies, Pain
Research Group. UniversityofWisconsin Medical School. Madison,
Wl, USA, DrA Sbanotto. Consultant Physician, PalliativeCare Unit,
European Institute ofOncology. Milan, Italy; Ms Noreen Teoh,
formerlyTechnical Officer, Cancer and Palliative Care, WHO,
Geneva, Switzerland; Dr R. Twycross. Director, WHOCollaborating
Centre for PalliativeCancer Care, Oxford. England; and Professor
V. Ventafridda. Director, WHO Collaborating CentreforCancer Pain
Relief, Milan, Italy.
vi
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PART
I
Cancer pain relief
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Introduction
The numberofcancer patients in theworld is increasing. Ofthe
estimated nine million newcancercasesevery year, morethan half
are in developing countries. The majorityofthese patientsare
incurable bythe time their disease is diagnosed. Cancer mortality
isexpected tocontinue torise in most regions ofthe world, mainly
becauseofaging populationsand increases in tobacco
consumption.
Cancer patients need pain reliefatall stagesoftheirdisease. Pain
occurs inaboutone-third of patients receiving anticancer treat-
ment. In these, pain reliefmeasuresand anticancertreatment go
hand in hand. In patientswith advanced disease, morethan two-
thirdsexperience pain, and the managementof pain andother
symptoms becomesthe main aimoftreatment.
The physiological basis ofcancer pain includesa varietyof
mechanisms. The psychological aspects include anxiety, fear,
depression and a sense of hopelessness. The aim oftreatment is
to relievethe pain tothe patient's satisfaction, sothat heorshe
can functioneffectively and eventuallydie free of pain.
Pain reliefmay be achieved bya varietyofmeans(Table 1).
Treatment must betailoredtotheindividual, with drug treatment
and anaesthetic, neurosurgical, psychological and behavioural
approaches geared tothe patient's needs. This guide concentrates
on drug treatment becausethere issufficient knowledge and
clinical experiencetoadvocate itsgeneral implementationforall
cancer patientswhoexperience pain.
Drugtreatmentis the mainstayofcancerpain management.
Field testsofthese guidelines have shownthat dru—gsareeffective
inahigh percentageof patients, ifused correctly the right drug
3
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