CURE vs CARE There is no role of

CURE vs CARE There is no role of physician in terminal care ! ? ?

‘통증’은 무엇을 말하는가? ‘Pain is what the patient says hurts’ Pain is always subjective. Pain is what the patient says it is and not others think it ought to be.

1995 2000

Number of Patients Number of Pains From Twycross and Fairfield (1982)

Primary site and the incidence of pain Primary site Bone Cervix Oral Stomach Lung Female genitourinary Pancreas Male genitourinary Breast Colon-rectum Intestine Kidney Lymphoma Leukemia Incidence of pain (%) 85 85 80 70 -75 50 -70 70 70 60 -75 55 -68 50 -60 58 55 20 5

Factors affecting pain threshold Threshold lowered Threshold raised Discomfort Insomnia Fatigue Anxiety Sadness Depression Boredom Introversion Mental isolation Social abandonment Relief of symptoms Sleep Rest Communication Sympathy Understanding Reduction in anxiety Elevation of mood Analgesics Anxiolytics Antidepressants

통증은 어떻게 평가 하는가? Trust the patient’s assessment of pain. The extent of disease does not exactly tell the extent of pain.

통증의 평가 Tell me all about your pain !

통증의 평가 Visual Analogue Scale (VAS) NO PAIN WORST PAIN Ask the patient to indicate on the line where the pain is in relation to the two extremes. Measure from the lefthand side to the mark which the patient indicated in centimeter to obtain the rating

통증의 평가 Graphic Rating Scale Verbal Rating Scale 0 = No Pain 10 = Strongest Pain 0 = No Pain 100 = Strongest Pain Faces Scale

진통제의 분류 Non-narcotics Aspirin Acetaminophen Ibuprofen Narcotic agonists Narcotic agnist-antagonist Weak: Codeine Oxycodon Weak: Pentazocine profadol Strong: Diamorphine Morphine Pethidine Oxycodon Methadone Hydromorphone Strong: Nalbuphine Buprenorphine Butorphanol

Co-analgesics for pain in cancer Type of pain Bone pain IICP Nerve pressure pain Superficial dysasthetic pain Intermittent stabbing Gastric distension pain Rectal tenesmoid pain Lymphedema Infected marginal ulcer Co-analgesics NSAIDs (Aspirin, Ibuprofen), corticosteroid Dexamethasone, Mannitol, Cerol Dexamathasone, prednisone Amitriptyline Valporate, carbamazepine Asilone, Maalox, Mexolon Chlorpromazine Massage, elastic stocking, pump Antibiotics

WHO’s Three Step Ladder Severe Moderate Weak narcotics +/- Adjuvant Non-narcotics Mild +/- Adjuvant Strong narcotics +/- Adjuvant

데메롤 (Pethidine) 모르핀과 다른 점 1. 작용 기간이 짧다 2. 천장 효과 (Ceiling effect)가 있다 3. 진해효과가 없다 4. 변비가 덜 온다 5. smooth muscle 수축이 적다 (biliary tract, sphicter of Oddi) 6. 동공수축이 없다 7. Atropine 양 부작용이 있다 8. Norpethidine 이 tremor, twitching, convulsion등을 유발 9. phenoarbital, chlorpromazine, MAO inhibitors등과 Interaction * 만성 통증의 조절에 사용하지 않는다

모르핀 의존성 환자에게 발생하는 금단증상 1. Anxiety, nervousness and irritability, alternating chills and hot flushes 2. Wetness ( salivation, lacrimation, rhinorrhea, sneezing, sweating), gooseflesh 3. Nausea & vomiting, abdominal cramps, insomnia, multifocal myoclonus 4. Time course : 6 -12 hours이내에 발현, 24 -72시간에 peak (methadone-long acting, onset 36 -48 hours) 5. 매일 전일 용량의 25%씩 줄여 투여한다

증례 1 51세 여자 진단명 : recurrent breast cancer 주소 : pain on left upper chest wall below the nipple line 현 병력 2001년 2002년 7월 8월 4월 4월 5월 : left breast cancer 진단, MRM : 2001년 12월 CMF 6회 : multiple metastases on sternum and liver : radiation therapy on sternum - 9월 : chemotherapy 검사실 소견 CBC : Hb 10. 2 g/d. L , WBC 4, 200 (Seg. N 52%), PLT 247, 000 /u. L Blood Chemistry : WNL

진 단 1) neuropathic pain due to possible nerve compression by multiple bone metastasis (T 7, T 9 spines) 2) bone pain

치 료 1) Radiation therapy on T spines 2)Ibuprofen 600 mg PO, every 4 hrs 3) Amitriptyllin 5 -10 mg po, tid

증례 2 48세 여자 진단 : adenocarcinoma of lung 주소 : vague headache for 1 month 현 병력 : 2개월 전 Lung cancer with spine metastasis 진단 spine radiation therapy 받은 후 chemotherapy 위하여 입원 이학적 소견 : 신경학적 검사 – 정상 검사실 소견 : CBC : Hb 9. 0 g/dl, Hct 29%, WBC 3, 900, PLT 250, 000/ Blood chemistry : WNL

진 단 Lung cancer with brain metastasis

치 료 1) Radiation therapy 300 c. Gy/day, for 10 days 2) Dexamethasone 5 mg PO, every 6 hours to prevent radiation induced edema

증례 3 51세 여자 진단명 : Pancreas tail cancer 주소 : Pain on right upper abdomen, dull, continuous 현 병력 : 2002년 12월 상기 질환 진단, 복통으로 MS contin 20 mg PO, every 12 hours로 조절 중 통증이 심해져서 입원 검사실 검사 소견 : CBC : Hb 7. 9 g/d. L , WBC 3, 600 (Seg. N 52%), PLT 123, 000 /u. L Blood Chemistry : WNL

진 단 Abdominal pain due to liver capsule distension by metastatic cancer

증례 4 67세 여자 진단 : Left ureter cancer with hydronephrosis and left cervical lymph node metastasis 주소 : left abdominal pain 현 병력 : 2개월 전 lt. supraclavicular LAP 발생. abd. CT – 3 cm mass in left distal ureter and lymphadenopathy ureter biopsy - poorly differentiated carcinoma with focal mucin production (probably transitional cell carcinoma) 검사실 소견 : CBC : Hb 9. 1 g/dl, Hct 27%, WBC 4, 300, PLT 130, 000/u. L Urinalysis : a few bacteria, 10 -15 WBC Blood chemistry : WNL

진 단 Nociceptive pain from ureter and lymph node

치 료 1) MS contin 30 mg PO bid, every 12 hours 2) Haloperidol 1. 5 mg#3 PO for nausea control 3) Mg. OH 3 T #3 PO for prevention of constipation 4) Amitriptylline 30 mg#3 PO

증례 5 31세 여자 진단명 : Non-Hodgkin’s lymphoma 주소 : pain on calf muscle and back pain 현 병력 : 2001년 9월 Non-Hodgkin’s lymphoma 진단 2001년 9월 – 2002년 2월 : CHOP 8회 2002년 2월 – 4월 : IVAM 3회 신경학적 소견 Reversed SLR : ++/++ Motor & sensory : normal 검사실 소견 CBC : Hb 10. 3 g/d. L , WBC 7, 600 (Seg. N 47%), PLT 145, 000 /u. L Blood Chemistry : WNL CSF : negative

진 단 refractory lymphoma leptomeningeal carcinomatosis

치 료 1) Intrathecal chemotherapy by using Ara-C, methotrexate 2) Gabapentin 900 mg#3, PO 3) Salvage chemotherapy

증례 6 14세 여자 진단명 : Osteogenic sarcoma with multiple lung metastases 주소 : 1) pain on right leg 2) back pain 3) voiding difficulty 4) severe coughing 현 병력 : 2002년 8월 Osteogenic sarcoma on right distal tibia 진단 chemotherapy 없이 지내다가 상기 증상 발생, 심해져서 내원 검사실 검사 소견 CBC : Hb 8. 7 g/d. L, WBC 3, 600 (Seg N 55%), PLT 223, 000 /u. L Blood Chemistry : WNL

진 단 Osteogenic sarcoma Metastasis on the pedicle of L 4 spine with mild spinal cord compression

치 료 1) MS contin 60 mg Po bid, every 12 hours 2) external beam radiation therapy on lumbar spines 3) dexamethasone injection