Page 168 Guide to Pain Management in Low-Resource Settings

156 Rainer Sabatowski and Hans J. Gerbershagen

a minimum time interval of 1 hour. Additionally, dexa- in a dose of 16–24 mg/d should be added. After stabiliz-
methasone, 16 mg/d, was started to improve pain as well ing the pain, the dose might be reduced slowly down to
as to stimulate appetite. (Mr. Perez had reported that he 4–8 mg/d. In treatment-refractory situations, morphine
could no longer eat Elotes con Rajashe, which his wife might be switched to methadone (details are described in
used to prepare as his favorite dish.) Th e dose of metha- the section above).
done had do be increased on day 2 up to 7.5 mg every
4 hours. On day 4, application times could be prolonged
What is the scope of the problem?
to 8-hour intervals (t.i.d.), the breakthrough medica-
tion interval was prolonged to 3 hours, and dexameth- Lung cancer is the most common malignancy world-
asone was tapered down to 2 mg/day. It became a ma- wide. Despite progress in diagnosis and treatment, 80–
jor problem to convince his family and his local doctor 90% of patients die within 1 year after having been di-
that methadone, even though it is often used in patients agnosed. Lung cancer is associated with a major burden
with narcotic drug dependency, was the best drug in his for the patients and their relatives. Among the symp-
situation. Constipation was satisfactorily controlled by toms associated with lung cancer, pain is one of the
drinking more water and eating some dried fruits. Th e most feared, as well as very common. Approximately
prescription of laxatives was not necessary. A developing 40–90% of patients who suff er from a malignant disease
paresis of the left arm was treated with elastic bandages experience cancer-related pain. Palliation of symptoms
to hold his arm in a comfortable position. and especially of pain due to lung cancer is crucial to
For the doctors caring for Mr. Perez, there were improve the patient’s situation and the quality of life for
two options for pain management. In option 1, they both patients and their relatives.
could start with carbamazepine in a dose of 3 × 100 mg.
If pain relief is not suffi cient, the dose should be titrated Are there factors associated
up slowly to a maximum of 1000–1200 mg/d. Morphine
with pain in lung cancer?
should be added, if carbamazepine monotherapy is in-
suffi cient or if a dose limit is reached due to intolerable
Th ere is no clear evidence for a relationship between
side eff ects. Morphine should be titrated in 5-mg steps the histological subtype of lung cancer and pain preva-
with immediate-release tablets or a solution. Dosing in-
lence. Th e most important factor associated with pain is
tervals should be every 4–6 hours. In case of stable dose the stage of the disease, which is often advanced—even
requirements, immediate-release morphine should be
at the time of the fi rst diagnosis—because patients with
switched to a sustained-release formulation, if avail- lung cancer often present late, and pain is often the fi rst
able. For management of breakthrough pain episodes,
symptom that prompts patients to visit their physician.
a single dose of about 1/6 of the daily morphine dose
should be administered.
Option 2 would be to start with an anticonvul- What types of pain have to be
sant such as gabapentin or carbamazepine. Slow up- expected in lung cancer?
titration is required to prevent severe side eff ects (e.g.,
Pain in lung cancer is usually of mixed pathophysiology.
sedation, drowsiness). Th e maximum dose of gabapen-
Th e majority of patients experience nociceptive pain,
tin should not exceed 2100 mg (or for carbamazepine,
but approximately one-third of patients present with
1200 mg). In cases of severe pain, an opioid should be
neuropathic pain.
added immediately. Th e opioid can be either tramadol
(maximum dose 400 mg/d) or morphine. Be aware that
patients should have access to the use of immediate for- What is neuropathic pain, and what
mulations, not only in the titration period but for the are possible reasons it may occur
management of breakthrough pain as well. If the pain is in lung cancer?
described as a burning sensation, treatment with an an-
tidepressant such as amitriptyline should be added. Start Th e IASP defi nes neuropathic pain as pain initiated or
with 25 mg in the evening; the maximum dose should be caused by a primary lesion or dysfunction in the ner-
75 mg. When this combination is unsatisfactory (and in vous system (e.g., compression or infi ltration of the tu-
case of tumor infi ltration of the plexus), dexamethasone mor into the brachial plexus, or compression of a nerve