Pain Management in

Palliative Care

dr. Idajani Marjadi, M.Med.Pall.Care (ECU)

Surabaya, 29 September 2018

 Palliative Care
An approach that improves quality of
life of patients and their families facing
with life-threatening illness through
prevention and relief suffering by
means of early identification and
impeccable assessment and treatment of
pain and other physical,psychosocial
and spritual problems.
 Cancer Pain

●More than 70% in advanced disease → poor

physical and well-being.

●One-third of these patients do not receive

appropriate analgesics proportional to their pain
intensity
 Cancer Pain

Caused by:
● Direct tumour infiltration
●Diagnostic and/or theurapetic
interventions
● Unrelated to cancer
Type of Cancer Pain

● Nociceptive
● Neuropathic
● Breakthrough Pain (BTP)
 Nociceptive Pain

Caused by ongoing tissue damage →

stimulate nociceptor
1. Somatic (bone pain, non-bone pain)
2. Visceral
 Neuropathic Pain

Caused by damage/dysfuntion in the

nervous system
1. Central
2. Perifer
 Breakthrough Pain (BTP)

●Transitory flare of pain that occurs on a

background of relatively well-controlled
baseline pain
●Moderate to severe intensity, rapid in
onset, relatively short duration
 BTP

●A breakthrough dose is usually

equivalent to 10-15% of total daily dose

●If > 4 rescue doses are needed, the

baseline opioid treatment with slow-
release formulation must be adapted
 BTP
●A breakthrough dose is usually
equivalent to 10-15% of total daily dose

●If > 4 rescue doses are needed, the

baseline opioid treatment with slow-
release formulation must be adapted
Pain Management

● By the ladder
● By the clock
● By the mouth
● By the patient
 Attention to

● Patient's general status

● Drug's therapeutic effects
● Drug's side effects

● → continued monitoring
● → pain re-assessment
 WHO' Three Step Analgesic
Ladder
Mild pain (NRS 1-3)
●

→ non opioid +/- adjuvant

●

Moderate pain (NRS 4-6)

●

→ weak opioid +/- non opioid +/- adjuvant

●

Severe pain (NRS 7-10)

●

→ strong opioid +/- non opioid +/- adjuvant

●
 Paracetamol

Efek analgesik+, antipiretik+, anti inflamasi-

●

Dosis dewasa: 500-1000mg tiap 4-6jam

●

Dosis anak : 10-15mg/kg BB tiap 4-6jam

●

ESO : gangguan faal hati

●
 NSAID
Diclofenac : 75-150mg/hr dalam dosis terbagi
●

Ibuprofen : 1,2-1,8gr/hr dalam dosis terbagi

●

Ketoprofen : 100-200mg/hr dalam dosis terbagi

●

Meloxicam : 7,5-15mg/hr
●

Asam mefenamat : 500mg tiap 8jam

●

●ESO : GI bleeding, menghambat agregasi platelet,

gangguan fungsi hati & ginjal
 Adjuvant Analgesic

●Adalah obat-obat yang secara

farmakologis bukan analgesik murni
tetapi dapat memperkuat efek anti nyeri
analgesik utamanya
●Kortikosteroid, anti depresan, anti
convulsan, benzodiazepine,
biphosphonate, hyocin n-butylbromide
 Codein

● Termasuk weak opioid

● Lama kerja 4-6jam
● Dosis maksimal : 240mg/hr
ESO : konstipasi, sedasi,
●

mual/muntah, depresi nafas.

 Tramadol

● Suatu sintetik Codein

Dosis dewasa : 50-100mg tiap 4-6jam,
●

maksimal 400mg/hr
●ESO : seperti Codein tapi kurang
menyebabkan konstipasi & depresi
nafas
 Morfin

● Termasuk strong opioid

●Sediaan : injeksi, controlled release
tablet
●Dosis oral lepas lambat : 15-30mg tiap
12 jam
●Dosis iv : 15mg bolus, diikuti infus
kontinyu 0,8-80mg/jam
 Fentanyl
●Merupakan semi sintetik opioid yang
lebih larut lemak daripada morfin
● Dimetabolisme di liver
● Dosis dan sediaan :
● Injeksi iv : 25-50mcg/jam
●Transdermal patch : 12-100mcg/jam,
selama 72jam
 Oxycodone

● Merupakan strong opioid

●Sediaan : injeksi, cotrolled-release
tablet
●Dosis oral lepas lambat : 10-20mg tiap
12jam
 Opioid Switching

Process of substituting one opioid for

another to improve pain relief or reduce
adverse effects
 Laxatives must be routinely
prescribed for both the
prophylaxis and management
of opioid-induced constipation
THANK YOU