Every February 4, World Cancer Day is celebrated, a date that aims to raise awareness and mobilize society to advance in the prevention and control of this disease. It is a pathology that occurs with different levels of pain intensity throughout the disease. For this reason, Relieve Your Pain, a program that facilitates access to information about each type of pain, allows patients to connect and create a community where they can share their story and stay updated on the latest advances and existing treatments.
According to the latest estimates made by the International Agency for Research on Cancer (IARC), Argentina has an incidence rate of 218 cases per 100,000 inhabitants, which positions the country with a “medium-high” incidence in the world. It is positioned in the fifth place among the countries of the American continent. Breast cancer is the largest in terms of occurrence, with a volume of more than 21,000 cases per year, representing 17% of all malignant tumors and almost a third of female cancers. In addition, cancer continues to be the second leading cause of death, after cardiovascular conditions. It is not possible to modify the risk factors such as poor diet, tobacco and little physical activity. In men, the most common types of cancer are colorectal, prostate, lung, kidney, and bladder. In women, after breast cancer (which has a rate of 73 cases per 100,000 women), the highest incidences correspond to colorectal, lung, cervical and thyroid cancer.
People who develop cancer have abnormal cells in their body, which remain in one place or can migrate to other tissues (metastases). These cells divide uncontrollably and manage to generate a mass of tissue known as a tumor. The latter, in its process of expansion can affect adjacent organs, nerves and other parts of the body, causing mild, moderate or intense pain. However, not only the tumor can cause pain but also this can be derived from causes such as:
Cancer treatments such as surgery, radiation or chemotherapy.
Scar tissue resulting from surgery or cancer treatment.
Patients with oncological disease can suffer pain at any stage of their disease: at the beginning, during treatment, post-treatment, in the palliative phase or even with the disease cured. 80% of cancer patients will have pain at some point in its evolution and 50 to 60% of them will have it at a moderate to severe intensity. One-third of patients will have more than four types of pain. When suffering from pain from cancer, it is essential to have resources to cope with it as best as possible. One such is the drug infusion pump, also called the “intrathecal drug delivery system.” This pump is implanted so that you can send pain medication directly to the fluid surrounding the spinal cord. This targeted supply is designed to reduce pain and minimize side effects, in order to improve the patient’s quality of life. Since pain medications go directly to the area surrounding the spine, a drug infusion pump can offer a considerable degree of pain control, with a lower dose than required with oral medications.” Within the medical community, as well as patients and their families, it is essential to know and differentiate therapeutic alternatives to treat chronic cancer pain. Timely implantation of the morphine infusion pump can treat pain and improve the patient’s quality of life at different stages of the disease: during treatment, within the framework of a palliative care program and in survival,” said Dr. Pierina Bachetti, intensivist physician, head of the pain diagnosis and treatment service at the Alexander Fleming Institute. Director of the Comprehensive Center for Diagnosis, Containment and Treatment of Pain -CENDO-. Pain levels
Pain not only includes the organic, but also the subjective, previously lived and learned by each patient in relation to their illness and pain. In addition, not all patients feel the pain with the same intensity. Therefore, the most common -at the beginning of a consultation- is that the professional and the patient give an objective value to that pain. The most practical way is with the numerical visual scale that allows to graduate the “pain threshold”. This establishes a scale ranging from 0 (zero) to 10 (ten). The zero represents that there is no pain while the ten repressesIn the worst pain imaginable. From one to three represent nuisance. From four to six there is a moderate pain with which the patient can live with medication, and from seven to nine, patients manifest a pain that commands and limits their life, referring that they can only do “what the pain allows them”. This graduation of pain will help, in the course of treatment, to evaluate the response to drugs based on the decrease in the number in it. Another aspect that a doctor must take into account when questioning a patient with pain, in addition to the intensity, is what type of pain he has and the determination of sensations when he presents it. For example: if it punctures, burns, burns, oppresses, contracts or has the feeling of having something nailed. According to the answers, pain can be framed in different types:
Nociceptive pain: occurs when bones, muscles or tendons hurt. Patients for example may report a feeling of tightness or weight in the affected area.
Neuropathic pain: This is when a peripheral nerve or nerve plexus hurts. Patients manifest a burning sensation, burning, electric current in the affected area or feeling that it is wet, hot, swollen, even if it is not. This usually occurs because there is a nerve affected by the disease or treatment. It, instead of emitting the right sensations, sends anomalous sensations to the brain.
Nociplastic pain: in which there is no organic repercussion. The lesion is not seen, but the patient has pain. It is a perception disorder at the level of the central nervous system. It would be like having the volume increased to perceive the pain.
Inflammatory pain: it is generated by inflammatory mediators in areas of the body such as an arm, leg, finger, back, etc. It usually manifests with a heartbeat sensation in the affected area.
Once the type of pain has been defined, it is time to choose the treatment, for which it is necessary to understand how the drugs are handled before implanting the Morphine intrathecal infusion pump. The WHO, since 1986, recommends using the Analgesic Ladder, to treat cancer patients and / or with any pathology that generates acute and chronic pain. This ladder stratifies analgesics according to their potency and the magnitude of pain, through 4 steps, namely:
In the first step are non-steroidal anti-inflammatory analgesics, for patients with mild pain. However, these analgesics cannot be extended over time because of their adverse effects.
In the second step, there are minor opioids that are indicated for patients with moderate pain. If the pain persists after reaching a maximum dose, or if it is necessary to use more than one minor opioid, it is passed to the third step.
For patients with severe pain, treatment with major opioids that are located in the third step, such as Morphine, Oxycodone, Methadone and / or Fentanyl, is indicated. In addition, other drugs can be used – at all levels – as adjuvants that collaborate in the modulation of pain.
When adequate analgesia is not obtained with systemic opioids, the fourth step should be considered that includes invasive procedures to treat pain such as intrathecal infusion pumps, neurostimulators, root blocks and radiofrequency.
In general, patients who have the Morphine intrathecal infusion pump implanted lead a normal life with very little adverse effect, thus improving their quality of life. Morphine intrathecal infusion pump: when should it be implanted and how is it done?
“There is a basic condition to request the implantation of the intrathecal infusion pump of Morphine: the patient must have a survival greater than 3 months and must have previously completed a staggered and optimized treatment with oral medications, thus demonstrating that -despite having been treated with them- there was no adequate pain control. Fulfilling these conditions, a patient can be instructed to implant the pump when the pain does not respond correctly to pharmacological treatment, “says Dr. Fabián Piedimonte, Neurosurgeon, president of the CENIT Foundation for neuroscience research. ” However, the intervention to implant the pump can be considered a minimally invasive procedure, of an outpatient nature with a temporary hospitalization of a few hours, aimed at the recovery of post-implantation sedation, and with an excellent tolerance of the pump by the patient, “adds the specialist in neurosurgery. An intervertebral puncture is placed in the spine at the lumbar level, the end of which is adjacent to the specific area of the spinal cord where Morphine must act. This catheter is connected to the bomba proper, which is implanted in the abdominal wall through a small incision in the skin. In this way, with very small amounts of the drug, a high analgesia is obtained with very low frequency of undesirable or adverse effects. The system is absolutely implanted, that is, there is no external element that is outside the skin. In this way, the patient can continue with their previous activities without additional limitations. The operation of the pump is automatic, that is, the attending physician performs the programming of this in his office, through a computer, and in this way the supply of the drug is regularized. In most cases, a continuous infusion mode is pre-established, in which the patient receives the daily dose of the drug, distributed homogeneously 24 hours a day. According to the patient’s symptoms, the practitioner adjusts the daily dose of the drug, as well as modifies the mode of infusion. In the latter scenario, in patients with greater daytime than nocturnal pain, the system can be programmed so that the infusion is higher during the period where it refers to greater discomfort and discomfort due to pain. Intrathecal infusion therapy has several decades of application, and has proven its efficacy and safety. In Argentina there are hundreds of patients implanted with pumps and there are also centers highly specialized in treatments with this type of devices.
