Cancer is a progressive disease characterized by multiple attacks and leading in one out of two cases to a painful death. Pain that can be parietal, visceral or bone is related to the evolution of the cancer by its local, regional or metastatic progression. Bone metastases are the most common cause of chronic pain in cancer patients. The most common sites of these bone metastases are the vertebrae (70% dorsal, 20% lumbo-sacral, 10% cervical), the pelvis, the femur, the skull. Multiple myeloma, breast, prostate and lung cancers are the most common causes of bone metastases.
The physiopathology and the defenses of the body are the same as in non-cancer pain.
EVALUATION OF PAIN:
The evaluation of pain is identical to that of non-cancer pain.
– Scale of mimicry for children under 3 years old which has a series of faces expressing increasing degrees of pain.
– Ladders cubes for children over 3 years : board with 6 cubes of weight and increasing size. The child is asked to choose the cube that best represents his painful situation, knowing that the largest cube represents the intensity of the strongest pain.
– The Saint Antoine Pain Questionnaire (QDSA). It has 61 qualifiers divided into 17 subclasses:
• 9 sensory;
• 7 affective;
• 1 evaluator.
In addition to assessing the intensity of the pain, this questionnaire allows to appreciate the experience of the pain (anxious and depressive experience).
TRAINING THE PAIN:
The treatment is identical to that of non-cancer pain.
WHO recommendations:
LEVEL 1:
Non-opioids for mild to moderate pain:
• Salicylates
• NSAIDs
• Paracetamol
If failure
LEVEL 2:
Opioids for moderate to severe pain and / or failure of level 1 analgesics.
– Codeine dextropropoxyphene paracetamol or aspirin
– Tramadol
If failure
LEVEL 3;
Strong opioids for severe pain and / or failure of level 2 analgesics
• Partial agonist (buprenorphine)
• Antagonist agonist (nalbuphine)
• Pure agonists (morphine hydrochloride, morphine sulfate, fentanyl, dextromoramide)
Use of strong opioids:
Morphine LP:
– Moscontin unscored tablets dosed at 10-30-60-100 and 200 mg to be given morning and evening at a fixed time.
– Skenan: capsules that can be opened for patients with gastric tube, dosed at 10-30-60-100 and 200 mg
The passage of a level 2 analgesic to strong opioids starts at a dosage of 30 mg morning and evening.
– Morphine tablets dosed at 10 and 20 mg (Actiskénan; Sévrédol) serving as “Joker” doses. If the patient has severe pain during the day or at night, he may take a dose of 1 cp. Depending on the doses used, it will increase doses of morphine LP morning and evening.
– Subcutaneous morphine (ampoules: 1 mL / 10 mg, 1 mL / 20 mg, 5 mL / 50 mg, 10 mL / 100 mg, 10 mL / 200 mg) based on weight; doses in children and adults are equivalent to 0.5 mg / kg / day. It will be used every 4 to 6 hours.
In patients who already have oral morphine, the equivalent initial daily dose will be half of the oral dose administered.
– Morphine IV (ampoules same as subcutaneous): dosage: 0.3 mg / kg / day in continuous infusion The daily dosage will be 1/3 of the administered oral dose.
For patients with severe pain, continuous infusion will be associated with boluses at the request of the patient corresponding to one hour of infusion. Each bolus will be spaced at least 10 to 15 minutes apart. If the pain is not controlled, the daily dosage of morphine should be increased from 30% to 50%.
There is no upper limit as long as the side effects can be controlled. Any morphine treatment leads to the systematic prescription of an antiemetic and a laxative to prevent nausea and constipation.
– Transdermal Fentanyl : Durogésic patch at 25, 50, 75, 100 μg / hour to be used in case of stable pain and / or if morphine has poorly managed side effects. It does not begin to take effect until the 11th hour and its duration of effectiveness is 72 hours.
Equivalencies between morphine and Durogésic:
Oral morphine mg / d Durogesic micrograms / hour
45-134 25
135-224 50
225-314 75
315-404 100
405-494 125
495-584 150
585-674 175
675-764 200
765-854 225
855-944 250
945-1034 275
1035-1124 300
– Sophidone LP capsules at 4-8-16 and 24 mg knowing that 1 mg of sophidone equals 7.5 mg of morphine. The concentration is obtained in 4 to 5 hours and the release is in 12 hours.
The product is given morning and evening and can be given in children> 7 years old.
Legal conditions for prescribing strong opioids:
The prescription must be made on a secure prescription, it must be written in any letter limited to a maximum of 28 days except for injectable morphine which is limited to 7 days.
Coanalgesics:
– Antidepressants: Laroxyl type 0.3 to 2 mg / kg / day given in the evening.
– Anticonvulsant type Rivotril 0.03 to 1 mg / kg / day.
– NSAID, type Voltarene or Profenid.
– Corticosteroids: Solupred per os or Solumedrol IV.
– Anxiolytics.
