Slavica Lahajnar

Institute of Oncology Ljubljana

Choice of Analgesic Choice of Analgesic Appropriate to Pain Intensity Appropriate to Pain Intensity

PMI in Patients at the Institute of Oncology

Chronic Pain in CancerChronic Pain in Cancer

• Around 60-80 % of patients with advanced cancer suffer pain.

• Up to 40 % suffer from uncontrolled pain (VAS≥4).

• Inappropriate use of opioids may often be the cause of uncontrolled pain.

Evendingen MH, Rijke JM, Kessels AG et all. Ann Oncol 2007; 18: 1437-49 Cohen MZ, Easley MK, Ellis C et all. J Pain Symptom Manage 2003; 25: 519-527 Maltoni M. Ann Oncol 2008; 19: 5-7

• Negative PMI: considering pain intensity, the prescribed analgesic is not strong enough.

• Metaanalysis of 26 trials (Ann. Oncol. 2008): 43% (8-82%) has negative PMI.

• Estimate of the pain management interventions on the basis of good clinical practice (using WHO three-grade pain scale).

• Rough estimate of the pain management in general population.

Pain Management Index (PMI)Pain Management Index (PMI)

Cleeland CS, Gonin R, Hatfield AK et all. N Engl J Med 1994; 330: 592-6 Wit R, Dam F, Loonstra S et all. Pain 2001; 91: 339-349 Deandrea S, Montanari M, Moja L. Ann Oncol 2008; 19: 1985-91

• 248 patients’ charts

• Negative PMI in patients with uncontrolled pain.

• Comparison with a similar study performed in 2005.

• Other causes of uncontrolled pain.

Raziskava na Onkološkem inštitutuRaziskava na Onkološkem inštitutu

- prescribed analgesic - patient’s estimate of pain intensity (the 5th vital sign)

A Study Carried Out at the Institute of A Study Carried Out at the Institute of OncologyOncology

A Study Carried Out at the Institute of A Study Carried Out at the Institute of OncologyOncology

18%

0 50 100 150 200 250

NO. OF PATIENTS

2005

2009

YE

AR

PAIN INTENSITY

TOTAL

VAS 0-3

VAS≥4

45%

18%

A Study Carried Out at the Institute of A Study Carried Out at the Institute of OncologyOncology

0

20

40

60

80

100

NO

. O

F P

AT

IEN

TS

2009 2005 YEAR

Analgesics in Patients with Uncontrolled Pain

nonopioids

weak opioids

strong opioids

total74% 22%

A Study Carried Out at the Institute of A Study Carried Out at the Institute of OncologyOncology

0 20 40 60 80 100

NO. OF PATIENTS

2005

2009

YE

AR

PMI in Patients with Uncontrolled Pain

total

PMI 0,1,2

neg. PMI

11%

56%

11 33 - 2- 2

prescribed analgesic – pain intensity = PMI

- =

A Study Carried Out at the Institute of A Study Carried Out at the Institute of Oncology Oncology

Conclusions (1): In 2009 (in comparison to 2005):

- Less patients with VAS ≥ 4 (none with VAS ≥ 7).

- The patients with VAS ≥4 are receiving analgesics (the majority are treated with a strong opioid, noone with nonopioid alone).

- Less patients are treated with analgesics that are not strong enough considering the pain intensity (neg. PMI).

○○

Instructions provided to Instructions provided to therapists, nurses and therapists, nurses and patientspatients

PMI Positive Patients with Uncontrolled PMI Positive Patients with Uncontrolled PainPain

33

prescribed analgesic – pain intensity = PMI

33- = 00

• immediate-release opioid for break-through pain• adjuvant agents to relieve side effects of opioids• adjuvant agents and interventions to relieve neuropathic pain

• cancer treatment (bone metastases)

A Study Carried Out at the Institute of A Study Carried Out at the Institute of OncologyOncology

Patients under Opioid Treatment pain intensity

pain management VAS ≥ 4N=46

VAS ≤ 3N=91

strong opioid 74% 34%

immediate-release opiod 85 % 78 %

laxative 59 % 27.5 %

antiemetic 9 % 13 %

agents and interventions to relieve neuropathic pain

19.5 % 12 %

agents and interventions to releive pain caused by bone metastases

13 % 15 %

corticosteroid 6.5 % 9 %

locally advanced disease and bone metastases

65 % 52 %

A Study Carried out at the Institute of A Study Carried out at the Institute of OncologyOncology

Conclusions (2):

• Patients with z VAS ≥ 4 are treated with inadequate dose of controlled-release opioid.

• They do not take “rescue” dose of immediate-release opioid as prescribed

• Patients with advanced cancer (bone metastases) often suffer uncontrolled pain.

titration of opioid

rotation of strong opioid

treatment efficiency follow-up

individulized pain management

Thank you for your attention!