Application of a who Protocol on Medical Therapy for Oncologic Pain in an Internal Medicine Hospital

Abstract

Pain symptomatology is present in 60% - 80% of patients affected by advanced cancer, but in most cases it is not adequately treated. Our series, composed of 45 patients affected by cancer in an advanced stage, demonstrates how the application of common concepts of pharmacotherapy, standardized according to a sequential scheme proposed by the WHO, makes it possible to reach total control (in 24.4% of our cases) or only slight residual persistence (in 68.8% of our cases) of pain from cancer, with scarce side effects that are easily controlled with symptomatic therapy. According to the type of pain, its behavior in relation to the therapy effected and any previous pharmacologic treatment, the proposed pharmacologic scheme foresees, as the first step, the use of non-narcotic drugs, eventually associated or substituted with weak narcotics or finally with strong narcotics. Attention is given to modulation of the administration, to guarantee an analgesic effect throughout the day, thus preventing the pain. Irrespective of the analgesic scheme employed, it is more effective if patients affected by chronic oncologic pain (who present an important emotional component) are treated contemporaneously with anxiolytic and antidepressive drugs and those in which nerve structures are involved are treated with steroids. In conclusion, pain of an oncologic patient in an advanced stage can almost always be alleviated or often eliminated by the rigorous application of therapeutic concepts well known by physicians but for various reasons often neglected in clinical practice.

The WHO analgesic ladder for cancer pain control, twenty years of use. How much pain relief does one get from using it?

“…These symptoms generally subsided when the dose of morphine was stabilized. The constipation, nausea, and vomiting were the most common side effects related with the use of codeine [13]. Periods free of side effects were higher with non-opioid drugs and with weak opioids than with strong opioids [29,48].…”

“…The reasons for termination of the survey were death [16,17,26,27,29,38,42,48,54,59], freedom from pain [15,29,42,59], low compliance [15,27,29,42], treatment continued by practitioner or in another hospital [15,16,29,42,59], loss of follow-up or contact (drop out) [13,15,16,27,29,38,42,54,59], no need of further therapy [16], change of therapy to other methods (e.g., neurolytic blocks, epidural or parenteral opioids, etc.) [38] and/or discharge from the program [54].…”

“…Vertigo, sedation, and other neuropsychiatric symptoms, constipation [13,48], nausea and vomiting [13,48,52], drowsiness [52], dyspnea and dry mouth [48,52] were more frequent during the treatment, according to step 3 of the WHO ladder, and sweating and urinary symptoms with drugs of the WHO step 1 [29]. These symptoms generally subsided when the dose of morphine was stabilized.…”

The second step of the analgesic ladder and oral tramadol in the treatment of mild to moderate cancer pain: A systematic review

“…At present, the three-step ladder represents the standard treatment of cancer pain and the touchstone to validate any innovative approach. [1][2][3][4][5][7][8][9][10][11][12] On the basis of our systematic review of the literature, none of the selected papers seems to add anything to the well-defined role of the three-step ladder, nor are they likely to have the power to modify the standard approach against cancer pain. The four trials [14][15][16]18 do not demonstrate that an earlier shift to step-three opioids is superior to the classic analgesic ladder.…”

“…[1][2][3][4][5][6][7][8][9][10][11][12] The use of the three-step WHO analgesic ladder and adjuvants in combination with the analgesic strategy, an aetiology based approach to the management of side effects of opioids, and the use 'opioid-rotation' concurred to obtain pain control in more than 90% of cancer patients, dramatically reducing invasive procedures against resistant cancer pain. 4,5,13 In recent years, some authors suggested a novel approach against cancer pain to by-pass the second step of the WHO analgesic ladder.…”