Page 150 Guide to Pain Management in Low-Resource Settings

138 Andreas Kopf

a solid fecal mass in the rectum, which had to be manu- of morphine to 30 mg q.i.d. To improve sleep, the bed-
ally removed for three consecutive days. After that en- time dose was doubled, too. Seemingly, things changed
emas, bisacodyl, and senna were able to regulate the for the better. Although his abdomen remained consid-
consistency of Mr. Kassete’s stool. He was advised to take erably distended, Mr. Kassete found some rest, was re-
senna daily and add a tablespoon of vegetable oil or liq- lieved from the pain and from vomiting twice daily, and
uid margarine to his daily diet. Since it was assumed was almost free of nausea. Th e family was advised not
that the constipation was at least in part codeine-in- to force him to take any food or drink, and Mr. Kassete
duced, the doctor advised him to take senna on a regular did not ask for it. After becoming sleepy on the fourth
base with lots of fl uids. Also, since the daily codeine dose day, he died in the night of the sixth day after the begin-
was already 100 mg q.i.d., the doctor changed the opioid ning of his deterioration.
from codeine to morphine for better eff ectiveness. Accord-
ing to the opioid equivalence dose list, he calculated the Why a chapter on abdominal
daily morphine demand to be 10 mg q.i.d., which actual-
ly was also cheaper than codeine for Mr. Kassete. But his cancer with constipation
family was shocked to learn that the oldest son was now and anorexia?

“on drugs” and joined him on his next visit to the doctor
Pain starts early in the course of abdominal cancer. For
to complain. It took the doctor a lot of courage to explain
example, in pancreatic cancer, symptom management
why opioids were now inevitable and would have to be
and surgery are the only realistic treatment options,
used by the patient for a long time to come. He also re-
even in developed countries, since radiochemotherapy
vealed to the patient and the family for the fi rst time that
hardly infl uences the course of the illness. Constipa-
the diagnosis was pancreatic cancer without surgical op-
tion, although appearing to be a simple health prob-
tions. A Cuban doctor currently present at the depart-
lem, often complicates therapy and further decreases
ment suggested a celiac plexus block, but Mr. Kassete did
the quality of life of patients. Anorexia, cachexia, mal-
not trust his words and refused.
absorption, and pain may additionally complicate the
Th e family immediately decided not to let Mr.
course of abdominal cancer. Although awareness about
Kassete travel back to Nazret, and he moved in with
the need to control cancer-related symptoms has in-
his family, which allowed him to use a small room for
creased in the last few decades, pain management of-
himself. Th e hospital dispensary had no slow-release
ten remains suboptimal.
morphine available but handed him morphine syrup in
a 0.1% solution (1 mg/mL) to be taken 10 cc q.i.d. Th is
dose proved to be fi ne for Mr. Kassete. He was in bed What special issues apply to patients
most of the time now, and washing and sitting up for a with gastrointestinal cancer?
little snack increased his pain unbearably. But he found
that a regular smoke of some “bhanghi” helped reduce Th e average incidence of pain in cancer is 33% in the
the nausea, allowing him, at least, a little food intake. early stage and around 70% in the late stage of disease.
His brother was clever enough to propose an extra and In gastrointestinal cancer, these numbers are consider-
higher dose of morphine. In the next few weeks, his gen- able higher, e.g., in pancreatic cancer almost all patients
eral condition deteriorated, but with 15 mg morphine develop pain in the advanced stages of disease. With re-
4 times daily, and sometimes 6 times daily, Mr. Kassete gard to pain intensity, about half of patients report mod-
was fi ne until he again developed a massive abdominal erate or major pain, with the incidence of major pain
swelling, with nausea and abdominal pain. Since he was tending to be highest in cancer of the pancreas, esopha-
now too weak to go to the hospital, a neighbor working gus, and stomach.
as a nurse was called to see him. When she noticed the Typical causes of pain in gastrointestinal cancer
foul smell of the vomit, it was clear to her that intestinal include stenosis in the small intestines and colon, cap-
obstruction was present, and no further eff orts could be sula distension in metastatic liver disease, and obstruc-
indicated to restore his bowel function. Th rough her in- tions of the bile duct and ureter due to infi ltration by
tervention, a nurse from the Addis Hospice came to see cancer tissue. Such visceral pain is diffi cult to localize
Mr. Kassete and talked to the family. It took some time to by the patient due to the specifi c innervation of the ab-
convince the family and Mr. Kassete to increase his dose dominal organs, and it may appear as referred pain, e.g.,