1
UTILIZATION OF PAIN MANAGEMENT INDEX (PMI) IN
EVALUATING CANCER PAIN AT RSUP SANGLAH
I Putu Ardinata1, I B Tjakra Wibawa Manuaba2
1Faculty of Medicine, Udayana University
2Department of Surgery – Oncology Division, RSUP Sanglah
ABSTRACT
Access to pain treatment is a human right. Therefore, cancer pain is one of the main focus of the treatment, especially in advanced cancer case. Although there is no accurate method to assess adequacy of drugs prescription according to patient’s need, we can use Pain Management Index (PMI) as a simple parameter to calculate the level of adequacy between pain and drugs. The data taken were Pain Scale (0-10 scale) and Analgesics. Pain scale scored as: 0 if no pain (pain scale 0); 1 if mild pain (pain scale 1-4); 2 if moderate pain (pain scale 5-6); 3 if severe pain (pain scale 7-10). The same went with analgesic. Analgesic scored as: 0 if no analgesic; 1 if using non-opioid analgesic; 2 if using weak non-opioid; 3 if using strong non-opioid. Then, PMI calculated by subtracting pain score from analgesic score.
From total of 30 samples, twelve samples scored negative PMI, which means inadequate treatment. And eighteen samples already received adequate pain management. The percentage of under treatment is still high in RSUP Sanglah, but this may vary among patients, because cancer pain is usually patient self-reported and it depends on the patients’ condition and how the patients managing their pain. Monitoring patients’ condition is needed to achieve pain-free condition.
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PENGGUNAAN PAIN MANAGEMENT INDEX (PMI) DALAM
EVALUASI NYERI KANKER DI RSUP SANGLAH
I Putu Ardinata1, I B Tjakra Wibawa Manuaba2
1Fakultas Kedokteran, Universitas Udayana 2SMF Bedah – Divisi Onkologi, RSUP Sanglah
ABSTRAK
Akses ke pengobatan nyeri adalah hak setiap manusia. Karenanya, nyeri pada kanker merupakan salah satu dari tujuan pengobatan pada kanker, terutama pada stadium lanjut. Meskipun saat ini belum ada metode yang tepat dalam mengukur kecukupan pemberian obat berdasarkan kebutuhan pasien, Pain Management Index (PMI) masih dapat digunakan sebagai parameter sederhana dalam mengukur angka kecukupan pemberian obat anti nyeri. Data yang diambil adalah Skala Nyeri dan Analgesik yang diberikan. Skor nyeri: 0 jika tidak ada nyeri (skala 0); 1 jika nyeri ringan (skala 1-4); 2 jika nyeri sedang (skala 5-6); 3 jika nyeri berat (skala 7-10). Begitu pula dengan analgesik. Skor analgesik: 0 jika tidak diberikan analgesik; 1 menggunakan obat non-opioid; 2 jika menggunakan opioid lemah; 3 jika opioid kuat. Kemudian, PMI akan diukur dengan cara mengurangkan skor nyeri dan skor analgesik.
Dari total 30 sample, 12 diantaranya mendapat skor PMI yang negatif, yang berarti pengobatan masih belum cukup. Sementara 17 sample lainnya telah mendapat pengobatan yang cukup. Persentase kurangnya pengobatan nyeri masih tinggi di RSUP Sanglah, akan tetapi angka ini dapat sangat bervariasi berdasarkan pasien, dikarenakan nyeri kanker dirasakan oleh pasien itu sendiri dan tergantung dari kondisi pasien tersebut dan bagaimana pasien tersebut menangani dan menghadapi nyeri yang dirasakan. Memperhatikan kondisi pasien diperlukan untuk mencapai kondisi bebas nyeri.
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Introduction
Cancer is a broad group of various diseases which involves uncontrolled cell growth forming tumors, which is usually malignant, and invades other parts of the body. The cancer spread to more distant parts of the body through the lymphatic system or bloodstream.1
Cancer can be detected in various ways, including the presence of certain signs and symptoms, screening tests, or oncologic imaging. After the cancer is detected, the examination is continued to establish the diagnosis and stage of cancer. The chances of surviving the cancer differ by the type and location of the cancer and the extent of disease at the start point of treatment. 1
Majority of cancer patients complaint about their pain. Access to pain treatment is a human right because every person has their right to be in pain-free condition. Therefore, this make cancer pain is one of the main focus of treatment. 2
Pain could be occurred due to tumor presses neural structure and neural damage caused by surgery, chemotherapy and radiation therapy. The effective pain management requires a multidisciplinary approach. Previous studies have stated that most of cancer patients will require
interventional techniques from an anesthetist with special interest in pain management to maximize pain reliever. Treatment guidelines for the use of drugs in the management of cancer pain have been published by the World Health Organization (WHO), known as the stepladder. Healthcare professionals have to make sure that the patient and/or patient's guardian is well-informed about the risks and benefits associated with their pain management options. In early stage, simple analgesic (e.g: aspirin, paracetamol, or ibuprofen) can be used to control the pain. But in later stage, combination with opioid might be needed, as the pain may become worse with the progression of the cancer.3, 4,5,6
Although there is no accurate method to assess adequacy of drugs prescription according to patient’s need, we can use Pain Management Index (PMI) as a simple parameter to calculate the level of adequacy between pain and drugs.7,8
Methods
4 patient with pain at Angsoka Room, RSUP
Sanglah Denpasar.
The study was done by interviewing cancer patient based on prepared questionnaire. The data taken were Pain Scale (0-10 scale) and type of analgesics. Pain scale is scored as: 0 if no pain (pain scale 0); 1 if mild pain (pain scale 1-4); 2 if moderate pain (pain scale 5-6); 3 if severe pain (pain scale 7-10). The same goes with analgesic. Analgesic scored as: 0 if no analgesic; 1 if using non-opioid analgesic; 2 if using weak opioid; 3 if using strong opioid. Then, PMI calculated by
substraction of pain score from analgesic score. The lower value (negative result) represent undertreatment.
Results
In three weeks observation, total sample gathered was 30. Amongst those 30 samples, 6 samples had no pain.
As for basic information, we can find patient characteristic from the data (see table 1). Most patient during the study are female (70%). Age range is 27 years old until 72 years old (Mean 52,13, Standard Error of
Mean 3,8).
Table 1. Sample Characteristics
Characteristic No. %
Mean Age ± SE of Mean, years 52,13 ± 2,1
Sex
Male 9 30
Female 21 70
Occupation
Employee 3 10
Farmer 4 13,3
Housewife 7 46,7
Labor 3 10
None 8 26,7
Seller 5 16,7
Marital Status
5 From total 30 patients observed in
Angsoka Room 3rd Floor, thirteen samples scored negative results (see tables below).
Negative PMI was calculated 40%, although the patients had treated they still suffer from
certain degree of pain
Table 2. Pain Scale
No Pain Frequency
1 No Pain 7 (23,3%)
2 Mild Pain 12 (40%)
3 Moderate Pain 7 (23,3%)
4 Severe Pain 4 (13,4%)
Table 3. Analgesic
No Analgesic Frequency
1 No Drug 10 (33,3%)
2 NSAID 17 (56,7%)
3 Weak Opioid 3 (10%)
Table 4. Pain Management Index
No Score Frequency
1 -2 2 (6,7%)
2 -1 10 (33,3%)
3 0 16 (53,3%)
4 1 1 (3,3%)
6 The drug (analgesic) administered to
the patient were also vary. Type of analgesic is important in any way of treating the patient pain. Table 2 shows the frequency of certain drugs used as pain management. Simple analgesic (e.g. Paracetamol and
Mefenamic Acid) is the most used in this study (66,6%)
Table 5. Type of analgesic used in treating pain
No Drug Administration Frequency
1 Paracetamol 500 mg 12 (40%) managing cancer patient. Pain is reported in every cancer case; 25%-50% reported from newly diagnosed patient, 30% from patients who underwent treatment, and the highest of 75% reported in advanced/severe cancer case.9 Pain had been shown to have impact on personal life of the cancer patient including relationships, job performance, mood, and the overall quality of life.
The purpose of this study was to study the level of adequacy in managing pain in cancer patient. We use PMI to fulfill the purpose of this study. The score of zero is considered as acceptable treatment
because it is a balance between the pain score and the analgesic score. But the lower PMI (which means negative score) is directly considered as under treatment, because it has higher pain score but lower analgesic score.
The calculated negative PMI of 40% means there are still high occurrence in pain under treatment. From those samples observed, 18 out 0f 30 samples already got considerable pain management. This may vary among patients, because the pain is usually patient self-reported and it depends on the patients’ condition and how the patients managing their pain.
7 actually questionable. If the patient feel the
pain is too strong for them to handle, they should be asking the doctor to adjust the dose of the medicine or even may ask the doctor to change the drug. As a doctor, fast response is needed. Because cancer patients are suffering from many things, including pressing bone, soft tissue, neural structures, obstruction of ductal system, or ulceration of mucous membrane.9
Compared to previous study, this study was likely to yield same result. Recent study showed 43% (weighted mean value) of patient scored negative in PMI.6 This mean, overall, doctors still need to work on pain management. This can be done by exploring patient’s daily situation. Many patients still hesitate to ask doctor about medication given to them. Once the doctors gave prescription, most patients will stick with it until the pain disappears, or they may change doctor if the medication failed to give any response. This will require doctor’s ability to communicate to the patient, to make sure they understand the medication
that given to them and that they can ask doctor anything related to their condition.
Conclusion
There are still high occurrences in pain under treatment in RSUP Sanglah. From total 30 patients observed in Angsoka Room 3rd Floor, twelve patients scored negative results. This condition can be related to many things. In this case monitoring patients’ condition and doctor-patient communication is strongly needed to achieve appropriate pain management
References
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8 4. World Health Organization. Palliative
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6. Oya H, Matoba M, Murakami S, Ohsiro T, Kishino T, Satoh Y, Tsukahara T, Hori S, Maeda M, Makino T, Maeda T. Mandatory Palliative Care Education for Surgical Residents: Initial Focus on Teaching Pain Management. Japan Journal of Clinical Oncology 2012 7. Deandrea S, Montanari M, Moja L,
Apolone G. Prevalence of undertreatment in cancer pain. A review
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9. Henry, JL. Pathophysiology of Chronic Pain in Chronic Pain: a Health Policy Perspective. Germany, Wiley-Blackwell, 2008
