Update: October 2018
Both acute and chronic types of pain require
medical assistance. Chronic pain syndrome
cancer has its own characteristics:
- May develop in a short time (due to compression of the nervous
trunks growing tumor or rapid massive destruction
- May exist almost constantly due to re-nudging
- May persist even after removing its source (due to
breakdowns in the braking system of nerve impulses).
Therefore, even at the stage of the absence of any sensations, but
a proven diagnosis of malignancy
developed tactics of phased anesthesia – from weak to severe
By the time the pain appears or becomes worse, the doctor and
the patient must be armed with a ready-made strategy that can
be used in this particular cancer patient with
meeting the required time limits for increasing the dosage of drugs or
enhance the analgesic effect.
Evaluation of cancer pain
The level of pain can be adequately assessed only by those who
is experiencing. In addition, patients experience different feelings:
drilling, sting, tingling, ripple, burning, etc. In order
so that these experiences are better understood by the doctor, use a visual scale
pain levels (see figure).
Scale of pain levels from 0 to 10
By origin of pain in oncology are:
- Visceral pain. When tumors in the abdominal cavity.
Feelings of squeezing, fullness, aching or dull, not having
- Somatic pain. Develop in vessels, joints, bones,
nerves Long, dull pain.
- Neuropathic pain. Occur with damage to the nervous
Systems: central and peripheral.
- Psychogenic pain. Appear against the background of depression, fear,
self-hypnosis without any organic damage like
painkillers generally do not help here.
What to do?
In case the oncology is confirmed histologically, there is
The diagnosis and the patient is observed by the oncologist:
- at the stationary stage, the department is responsible for anesthesia;
where a person is operated on or treated,
- if the patient in the clinic is observed by the therapist, and in
Oncologist oncologic dispensary or referred to the doctor for observation
antitumor clinic clinic, it should be together with
with all extracts and medical records contact an analgist (more often
just in oncologic dispensary). This should be done, even if there is no pain.
An analgist paints a phased pain relief scheme, which
the doctor will be observing the patient.
If cancer is not confirmed yet – no histology confirmed.
diagnosis, but there is pain – it is also worth contacting an analgist and
receive written recommendations in the medical records
(record in the out-patient card, an extract).
- If the analgologist has not yet been contacted, but there is pain –
contact your local GP. In his power to appoint
non-narcotic analgesics and related drugs that remove
or relieving pain.
- If previously used non-narcotic analgesics, but their
effect is not enough, you should immediately get recommendations
an analgist who is referred to a therapist at the place of residence,
less often – to the doctor of the polyclinic antitumor cabinet.
Without a prescription today in the pharmacy you can get unless
nonsteroidal anti-inflammatory (below there is an instruction how
get the necessary painkillers for the patient in a timely manner
Standardized pain relief regimens
At each examination of a cancer patient, the attending physician
assesses his subjective sensation of pain and in the appointment
painkillers moving up the three-step stairs from the bottom up. Not
be sure to move the stairs in succession. Presence strong
unbearable pain immediately involves the transition to stage 3.
Stage 1 – mild pain Stage 2 – severe pain Stage 3 –
First stage – mild pain
At the first stage of anesthesia for oncology are located
nonsteroidal anti-inflammatory drugs with pain medication
effect (ibuprofen, ketoprofen, diclofenac, celecoxib,
Lornoxicam, Nimesulide, Etoricoxib, Meloxicam) or
Oncology pain pills
- Start with the lowest doses (see table) with gradual
increase if necessary.
- Since the effect of painkillers is cumulative,
instant, a few days should not exceed the original
- You need to start with the tablet form, then move on to
injections. With contraindications to oral administration or the effect of
pills low, you need to enter pain medication
- Take pills after meals, under the guise of omeprazole and its
analogues, you can drink milk, in order to avoid damage to the mucous
First Stage Injections
For all types of cancer pain, except bone pain:
- Кетанов (или более эффективный
Кеторол), в separate syringe.
- Папаверин для усиления эффективности. If a
the patient smokes, then papaverine will be ineffective.
For bone pains:
- Neither papaverine nor Ketanov will be compared in effectiveness with
костных болях с Пироксикамом, Мелоксикамом,
Ксефокамом. Choose one of the drugs and enter in
- With primary bone tumors or metastases in them
It is advisable to discuss the use of bisphosphonates with your doctor.
radiopharmaceuticals, Denosumab. In addition to the painkiller, they
have a therapeutic effect.
If a больной не страдает пониженным давлением и температура тела
нормальная, то показаны Реланиум, Сибазол.
Reinforce the above means can
- anticonvulsants – Carbamazepine, Pregabalin (Lyrica),
- central muscle relaxants – Gabapentin (Tebantin),
- tranquilizers – Clonazepam, Diazepam, Imipramine.
Improve sleep, have a sedative effect, strengthens the effect
- кортикостероиды — Преднизолон, Дексаметазон. Increase
appetite, in combination with painkillers give effect for pain in
spine, bone, pain of internal organs.
- Neuroleptics – Galaperidol, Droperidol, increase analgesics and
- anticonvulsants – Clonazepam, effective for shooting
pain, increases narcotic analgesics.
Second stage – moderate to severe pain
Because first-stage drugs become poorly effective
Paracetamol (or nonsteroidal anti-inflammatory) is required in
combination with weak opioids (codeine or
With such pains, pills are often prescribed for oncology:
- Tramadol – it is prescribed in the first place, precisely when
non-narcotic pain medications already help. It applies either to
tablets (often causes nausea) or injections. Together with
NSAIDs (Paracetamol, Ketorol). Tramadol should not be taken along with
narcotic analgesics and with MAO inhibitors (Fenelzin,
Iproniazid, Oklobemid, Selegilin).
- Zaldiar is a complex preparation of Tramadol and Paracetamol.
- Tramadol + Relanium (in different syringes)
- Tramadol and diphenhydramine (in one syringe)
- Codeine + Paracetamol (max. Daily intake 4-5 thousand
To achieve the effect and at the same time reduce pain as much as possible.
fewer drugs need to be combined
Codeine or Tramadol with other NSAIDs (Paracetamol, Ketorol and
Further, Paracetamol may be prescribed with small doses.
Fentanyl, Oxycodone, Buprenorphine, Related to Strong
opioid analgesics. The combination is reinforced and auxiliary
therapy from the first stage.
Third Stage – Severe Pain
With severe pain or persistent pain, for example, at stage 4,
high doses of Tramadol or Codeine no longer help. Oncological
the patient needs strong opioids in combination with Paracetamol and
auxiliary миорелаксантами или транквилизаторами.
Morphine – a drug that is prescribed in oncology
intolerable pains. In addition to the analgesic effect, it has everything
strong drug side effects (addiction, addiction),
after applying it, there will be nothing to help, there will be no
choice of means. Therefore, to move from the weak (Tramadol) to more
strong should be very balanced.
List of analgesics that are desirable to apply before
|A drug||Effectiveness relative to morphine||Act|
|Trimeperidine (Promedol)||50-60%||4-8 hours|
|Buprenorphine (Bupronal)||40-50%||4-6 hours|
|Pyritramide (Dipidolor)||60%||6-10 hours|
|Fentonil (Duragesic)||75-125 times more efficient||6 or more|
The list of narcotic painkillers from weaker to more
- Tramadol – по некоторым источникам считается синтетическим
analogue of drugs, for other non-narcotic analgesics.
- Trimeperidine – in tablets, the effect is 2 times lower than
инъекционных, меньше побочных действий в сравнении с Morphineом.
- Buprenorphine – addiction and dependence develop more slowly,
- Pyritramide – action is very fast (1 minute), compatible with
- Fentonil is more convenient, painless and effective to use in
patch, not in / muscular or in / venno.
- Morphine – эффект наступает через 5-10 мин.
The doctor should offer these drugs to the patient, but as a rule,
need to take the initiative to relatives of the patient and discuss with him
the ability to use less non-narcotic drugs
сильные опиаты, чем Morphine.
The choice of method of administration
- Tablets oncology and capsules are convenient almost
always, except in cases of difficulty swallowing (for example, in case of cancer
stomach, esophagus, tongue).
- Cutaneous forms (patches) allow for progressive absorption
drug without irritation of the mucous membranes of the gastrointestinal tract and sticking plaster one
once every few days.
- Injections are more often performed intracutaneously or (when there is a need for
rapid elimination of pain) intravenously (for example, cancer
For any route of administration, dosage selection and feed rate
medication is administered individually with regular quality control.
pain relief and the presence of undesirable effects of substances (for this
examination of the patient is shown at least once every ten days).
- Pain relief injections представлены: Tramadolом, Тримеперидином,
Фентанилом, Бупренорфином, Буторфанолом, Налбуфинлм, Morphineом.
- Комбинированным средством: Codeine + Morphine + Носкапин +
Papaverina hydrochloride + Tebaine.
Tablets, capsules, drops, patches
Notинъекционные варианты опиоидных обезболивающих:
- Tramadol в капсулах по 50 mg, таблетках по 150, 100, 200
milligrams, rectal suppositories, 100 milligrams each, drops to take
- Парацетамол + Tramadol капсулы 325 мг + 37,5 milligram,
325 mg coated tablets + 37.5 MIDs,
- Dihydrocodeine tablets of the prolonged action 60, 90, 120
- Propionylphenylethoxyethylpiperidine in cheek tablets of 20
- Buprenorphine skin patch 35 µg / hour, 52.5 µg / hour, 70
mcg / hour
- Бупренорфин + Налоксон подъязычные таблетки 0,2 мг/0,2 mg,
- Oxycodone + Naloxone and long-acting tablets with
sheath 5 mg / 2.5 mg; 10 mg / 5 mg; 20 mg / 10 mg; 40 mg / 20
- Tablets of tapentadol with prolonged film coating
высвобождения вещества по 250, 200, 150, 100 и 50 milligram,
- Trimeperidine tablets,
- Fentanyl skin patch 12.5; 25; 50, 75 и 100 mcg / hour
- Morphine капсулы длительного высвобождения 10, 30, 60, 100
milligram, таблетки пролонгированные с оболочкой по 100, 60, 30
How to get painkillers
Appointment of light opioids is signed by the medical officer once, then
re-discharge can be done by the doctor. Re-started
Looks at the argument of changing the dose or switching to another drug.
(for example, gain).
Today, if there is a normal recommendation
an alnalgologist (stepwise enhancement of therapy), then move on it and
no one waits for a long time:
- Kohl Ketorol, less often Diclofenac, then immediately go to
Tramadol (при усилении болей).
- Трехкратный прием Tramadolа в сочетании с парацетамолом и
Gabapentin with no effect – switch to Durgesic (Fentanyl).
- After increasing the dosage to the maximum or impossibility
use of patches – go to morphine.
Cutaneous options – Fentanyl anesthetic patches and
Buprenorphine is the preferred alternative.
preformed opioids. It is a strong painkiller with gradual
drug release. The question of their destination rests on
price tag and availability.
- If a у пациента имеется группа инвалидности, и он имеет право
on preferential drug provision
the issue of discharge of the same Fentanyl (Durgezik) is carried out by
place of residence by a district physician or surgeon
antitumor study (in the presence of recommendations from an analgist,
filling out the documentation – preferential recipe and its copy signed
medical institution at the primary discharge of the drug). AT
further, the district therapist may discharge the medication
independently, referring to the help of the head of the media only with the correction
- AT случае, когда человек с инвалидностью отказался от
drug provision and gets cash for it
he may start getting the required pills, capsules or
patches for free. I need to get a certificate from the local doctor.
free form about the need for expensive therapy
with indication of the drug, its dose and frequency of use for the seal
physician and medical institution, which must be provided in
Pension Fund. Preferential drug provision
recovers from the beginning of the following reference
of the month.
To obtain Fentanyl in a patch, the patient must:
- Contact the pharmacy in person or fill out a power of attorney addressed to
relative in a medical institution.
- As before another therapy, a person is asked to complete
informed consent to initiate therapy.
- The patient is given instructions on the use of the skin.
- Disability in cancer pathology should start
make out from the moment of verification of the diagnosis and getting results
histology. This will allow by the time chronic pain occurs.
syndrome and its progression to take advantage of all the possibilities
- AT отсутствии возможностей получить накожный пластырь
painkiller for free or buy for your own money, man
morphine is offered in one of the dosage forms. Injection
формы Morphineа назначаются и при невозможности обеспечить пациенту
taking non-parenteral opioids. Injections are performed by SP or
hospice workers in the patient’s residence.
- About all cases of undesirable effects of drugs
or incomplete pain suppression should inform your
the therapist. He will be able to correct treatment, to replace the regime.
treatment or dosage forms.
- When switching from one opioid to another (due to inefficiency,
side effects) the initial dosage of a new drug is chosen
slightly below that shown in order to avoid the summation of doses and effects
Thus, adequate pain therapy for
cancer patients in the Russian Federation is not only possible, but also available.
Notобходимо лишь знать порядок действий и не терять драгоценное
time showing forethought.