Over 7 million people in India suffer avoidable pain simply because of lack of access to morphine, says a Human Rights Watch report on the society’s obligation to ensure palliative care. People in agony are often unseen and unheard because they drop off the social radar unless they happen to have family or close friends. They are people battling life-threatening conditions including cancer, HIV/AIDS, tuberculosis and renal disease. Many paraplegics too suffer extreme pain.
Ten lakh new cancer patients are diagnosed every year in India more than half of whom are diagnosed in advanced stage. They require only pain management and palliative care. As these patients are not relieved by drug treatment alone, they require interventional pain management. When the studies say 90% of cancer pain can be adequately controlled, statistics point out that 60-80% complain of inadequate pain relief. Cancer pain being inevitable at some stage of the disease, it is not know that 90% of the same was curable by some means or the other.
Pain remains one of the most common and feared symptoms of cancer. It may be a side effect of cancer treatment or caused by cancer itself. If not adequately managed, pain can have a tremendous—and sometimes devastating—effect on the quality of life. Despite its prevalence, pain is often under-treated and inadequately managed.
Despite recommendations and the demonstration of patients’ needs, these needs are not being met. The trend over the past two decades towards excluding pain specialists from mainstream cancer pain management meant that they tend to be called in at a very late stage as a ‘last resort’. This causes patients to miss out on the benefits of combined multidisciplinary care combining palliative care and pain medicine. There appears to be a lack of engagement with organizational structures such as cancer networks and a lack of lead intervention as recommended. There is a need to focus on a multidisciplinary approach to cancer pain management which should be reflected through training.
The WHO analgesic ladder, which has the clear principle of regular “by the clock” oral medication, has helped cancer sufferers all round the world in a cost-effective manner. However, the increasing complexity of cancer and its treatment in the developed world has led to a dawning realization of the limitations of the stepped analgesia approach. There is a need for different working models that recognize the limitations of the WHO ladder. Morphine is arguably not the “gold standard”, but rather a standard; non-oral routes may be better and preferable at times. Opioids remain the mainstay of cancer pain management, but the long-term potential complications of tolerance, dependency, hyperalgesia and the suppression of the hypothalamic/pituitary axis should be acknowledged and managed in both non-cancer and cancer pain. It is time to move towards a new model of cancer pain management which is mechanism-based, multimodal, uses combination therapies and is interventional and advocates personalized medicine with the aim of optimizing pain relief while considerably reducing the adverse effects.
Pain management should not only be considered after all oncological treatments have been exhausted, but should begin much earlier at pre-diagnosis when pain is often a patient’s presenting symptom. During a patient’s journey, there will be a need for pain management as a result of cancer treatments and the development of metastatic disease, in addition to the management of pain at the end of life.
Increasingly, cancer patients are going into remission with an increasing length of survival, but they do suffer from persistent pain. The importance of holistic care and support throughout this journey should be acknowledged. The main principles of pain management, including the biopsychosocial approach, should be applied rather than simply following the WHO ladder.
There is a need for clear information on what pain services can provide and how they may be accessed. Better links between palliative care and specialist pain services are also important. Care of a patient suffering from cancer pain requires a holistic approach combining psychological support, social support, rehabilitation and pain management in order to provide the best possible quality of life or quality of death.
Persistent pain can have profound and widespread effects upon a patient’s quality of life. Mobility, physical functioning, sleep, and concentration are typically affected by pain. Unrelieved pain can engender anxiety, a sense of helplessness and hopelessness, and is a major risk factor for depression.
Patient selection for an interventional procedure requires knowledge of the disease process, the prognosis, the expectations of the patient and family and a careful assessment and discussion with the referring physicians. There is good evidence for the effectiveness of a coeliac plexus block and intrathecal drug delivery. Safety, aftercare and the management of possible complications have to be considered in the decision-making process. Where applied appropriately and carefully at the right time, these procedures can contribute enhanced pain relief, reduction of medication and a markedly improved quality of life.
Interventional procedures are considered to be the most effective. They deal with the pharmacological blockade of neural tissue by targeted injection or infusion; their destruction by chemical, physical or surgical methods; and the fixation of vertebral compression fractures. It has been traditional to consider exhausting oral or topical analgesia before considering invasive methods. In case of unacceptable side-effects from opioids such as drowsiness, invasive methods could be preferred. A pump implanted early in advanced cancer can allow for the maximum benefit.
Now with the growing population and development in healthcare sector, many new private hospitals are coming up to provide healthcare with latest technology available. But pain management and palliative care remained the missing link in the development of medicine and there existed a large gap between the cancer patient suffering with severe pain and a proper pain relief.
I have been working on this for the last 4 years in the Pain Clinic at the IMS and SUM Hospital, Bhubaneswar. This is the first and only hospital to provide such a facility at affordable cost. This clinic is providing all kinds of latest interventions as well as proper palliative care to cancer patients. Nerve blocks are being done for the particular affected organ and it provides a long term pain relief. They include Celiac and Splanchnic plexus block for cancer affecting gall bladder, liver, pancreas, stomach, upper intestine etc., superior hypogastric plexus block for lower abdominal malignancies and pain due to chocolate cyst and chronic pelvic pain, ganglionimpar block for rectal and genitalia malignancies, sympathetic plexus block for sympathetic mediated pain both benign and malignant in nature and trigeminal and shenopalatine ganglion block for facial pain.
Now a days, radiofrequency ablation is being performed for more precise nerve ablation instead of neurolytic block used in earlier days. It also provides a longer effect. Facilities for spinal cord pump to provide a continuous supply of drug without affecting daily activities was also available in this only ‘state-of-the-art pain clinic’ providing service to all kinds of cancer and non-cancer patients. Pin-hole surgery as well as minimally invasive techniques were available for treatment of back pain, sciatica, slip disc, neck pain, headache, migraine, fibromyalgia and many more.
DR. SHOVAN KUMAR RATH
IN-CHARGE OF PAIN CLINIC
IMS & SUM HOSPITAL