Appendix - Preparation of Solutions

PREPARATION OF NEUROLYTIC SOLUTIONS - PHENOL (HYDROXYBENZENE)

At 20 0 e one part phenol dissolves in 12 parts of water. Accordingly, phenol may be prepared in aqueous solution only in lower con• centrations. If a stronger preparation is required a water-glycerin mixture is used as the solvent. Product: phenol injection 5% in glycerin Formula: phenol crystals 5 g glycerin (previously dried at 120 0 e and cooled) to 100 g Method o/preparation: Dissolve the phenol in glycerin with the aid of gentle heat. Whilst still warm pass through a No.3 sintered glass filter. Packaging: Pack in 2 ml or 5 ml ampoules. Protect from light. Store in a cool place.

Sterilization: Dry heat at 1500 e for 1 h. Stability: 1 year from date of manufacture.

185 186 Appendix

Product: aqueous phenol 5% phenol injection 7% Formula: phenol crystals 5 g phenol crystals 7 g water for injections glycerin 50% v/v in water for injec• to 100ml tions to 100 ml Method of preparation: Pass through sintered glass filter, pack in ampoules and sterilize by autoclaving at U5°e for 30 min. Packaging: 2 ml or 5 ml ampoules. Protect from light. Store in a cool place. Precautions: Avoid prolonged contact with rubber or plastics. Stability: 1 year from date of sterilization.

INJECTION ABSOLUTE ALCOHOL Method ofpreparation: In order to avoid absorption of moisture, the infiltration procedure is best carried out under positive pressure, using solvent inert membrane filters. The preparation is then packed in 2 ml or 5 ml ampoules. Sterilization: Autoclave at 155°e for 30 min. Special precautions: Absolute alcohol absorbs moisture from the atmosphere: once the ampoule is opened the content should be used at once. Stability: 2 years from date of sterilization.

PREPARATION OF ORAL MORPHINE SOLUTION

Product: oral morphine 5% (1 ml = 5 g) Formula: Morphine hydrochloride or sulphate powder 5 g + disodium edetate 50 mg sodium metabisulphite 1 g benzoic acid 1 g or + distilled water to 1 L Amber glass bottles Shelf life: 6 months Preparation of Solutions 187

Method of preparation: Dissolve powder in fresh distilled water. Add preservative (chloroform water or benzoic 'acid or alcohol) to 1000 ml. Packaging: 100 ml bottle. (1 ml will contain 5 mg). Protect from light. Store in a cool place. Stability: Up to 6 weeks.

PREPARATION OF EPIDURAL MORPHINE Product: Epidural morphine Formula: 1 cgjl ml vial of morphine sulphate Preparation: Dissolve in 9 ml distilled water in a sterile 10 ml syringe

SALIVA REPLACEMENT SOLUTION Syrup 40ml Glycerin to 200 ml Shelf life: 1 month Glossary

Afferent A fibre carrying stimuli from the periphery to the central nervous system Algesic Pain causing Algogenic Pain producing Allocheiria Reference of pain to the opposite side of the body Allodynia Pain (such as referred pain) which occurs on non-noxious stimulation of normal skin Analgesia Absence of pain on noxious stimulation Antidromic Impulse transmitted opposite to the normal direction Causalgia A syndrome which follows a traumatic nerve lesion, com- prising burning pain, vasomotor and sudomotor dysfunction and eventually trophic changes Central pain Pain caused by a lesion in the CNS Commissure A band of nerve fibres which run across the midline of the cord connecting corresponding parts on each side Deafferentation Nerve cells disconnected from normal afferent input Decubitus From the posture or position when lying in bed Denervated Deprived of innervation Dysaesthesia Unpleasant, abnormal sensation Efferent A nerve fibre carrying stimuli from the CNS to the periphery Endorphinergic Nerve fibres which release endorphin

189 190 Glossary

Enkephalinergic Nerve fibres which release enkephalin Hyperaesthesia Great sensitivity to any somatic stimulation Hyperalgesia Increased sensitivity to noxious stimulation Hyperpathia A painful response to a stimulus involving delayed reaction, over-reaction and after-sensation Hypoaesthesia Diminished sensitivity to any somatic stimulation Hypoalgesia Diminished sensitivity to noxious stimulation Hypotonia Reduced muscle tone Inhibition A restraining effect Lancinating Intermittent, sharp shooting or stabbing (pain) Nociceptor Nerve receptor which responds to painful stimuli Noxious Pain causing Opioids Narcotic analgesics Paraesthesia A 'pins and needles' type of disturbance of sensation Somatotopical Orderly representation of part of the body in a part of the eNS Synapse Junction between two nerve cells Index

A-delta fibres II antibiotics 90, 132 abdomen 95 anticholinergics 153. 164 coeliac plexus block 122 anticoagulants and coeliac plexus block 117 surgery 99 anticonvulsants 61, 84, 85 acceptance and adjustment 170 antidepressants 27,30,61,86, 169-70 acetominophen 61,71-2 antiemetic drugs 155 activity-precipitated pain 83 anti-fungal agents 152 acupuncture 33 antihistamines 155 acute pain 9, 38, 39 antimetabolites 90 addiction 5-6 antineoplastic drugs 90 adenocarcinoma 96 antioestrogens 90 adjuvant drugs 83-8 antispasmodic drugs 158 adrenalectomy 95, 132 antitumour chemotherapy, effectiveness 92 adriamycin 90 anxiety 10, 23-5, 85 aetiology of 131 anxiolytics 30, 61, 88 afferent fibres 10-11 ascites 100 agitation 87 surgery 99 alcohol 108 aspirin 61,70-1 solution 186 administration 70 alcohol neurolytic block dosage 69 position III hypersensitivity 70 for upper thoracic levels 116 side effects 70-1, 156 alcoholic rhizotomy 140 assessment 37-54 algogenic effect 12 ataxia 86 alkylating agents 90 atropine ISS aminocaproic acid 165 autonomic 121-2 amitryptyline 61, 84, 86 axial nervous system involvement 102-3 and glaucoma 86 analgesic ladder 62 basic drug list 61 analgesics 60-3 bedsores 179 basic list 61 biochemistry 9-21 anger 24 biofeedback 31,33 anorexia 152 bladder carcinoma 92

191 192 Index bleomycin 90 collars 179 blood transfusion 169 colorectal carcinoma 96 bone, aseptic necrosis 52 colostomy 97 bone pain 85 colovesical fistula 175 corticosteroids 87 communication 175 bone tumour 45 confusion 78, 168-9 brachial plexus 48 in terminal care 181-3 chemotherapy 96 constipation postradiation pain 52 drug-induced 78, 86 chemical neurolysis 120 treatment 159-60 bradykinin 11, 12 continuing care 64--5 brain stimulation 17 cord compression, corticosteroids 87 brain tumours 96 cordotomy 144--9 breast cancer 171 corticosteroids 61,84,86-7,95 intercostal block 118 and aspirin 87 rhizotomy 137 cough 163-4 stellate ganglion block 124 counselling 31-2 surgery 99 counter-irritation 179 breathing exercises 179 cyclophosphamide 90 bronchus, carcinoma intercostal block 118 deafferentiation 14, 83 opiates 164 stellate ganglion block 126 bupivacaine 121, 128 death buprenorphine 61,80-1 approach of 183-4 Burkitt's lymphoma 92 fear of 173-4 burning pain 12, 48 home ix epidural neurolysis 116 death-rattle 162 buttock, unilateral block III decubitus 83 butyrophenones 155 dehydration 152 depression 27,85 C-fibres 11 dermatome chart 108 Cancer Pain Relief Program 7 descending inhibitory control 15-17 candidosis 153 dexamethasone 61,84,87, 153 carbamazepine 61,84,85-6 dextropropoxyphene 61 castration, chemical 97 dosage 74 catheter, urinary 164--5 diagnosis 26 caudal block 116 diagnostic block 104 causalgia 128, 132-3 peripheral nerve 117 central nervous system 10 sympathetic 128, 133 cerebral cortex 19 diagnostic procedures 42 cerebrospinal fluid evaluation 43 diazepam 61,84,88, 162 cervical cancer 92 diclofenac 70 cervical percutaneous rhizotomy 142 dietary measures 153 cervical vertebrae 47 distraction, in terminal care 179 chemical factors 12 doctor/patient relationship 29-30 chemo-hormono-radio-therapy 94-6 dorsal column stimulation 15 chemotherapy 81-3 dorsal hom 14--15 emotional distress 24 dorsal root 13-14 postchemotherapy pain 51-2 drug-induced vomiting 155 chlorpromazine 61,84 drug interactions 61 and pethidine 80,87,153,158,169 drug list, basic 61 chondrosarcoma 92 drugs, correct use 60-3 choriocarcinoma 92 dysaesthesia 83 chronic pain 9-10,38,39 superficial pain 85 clivus metastases 46 dying patient 173-84 codeine 61 assessment 40 dosage 73 communication 175 for cough 164 prognosis 175-6 coeliac plexus block technique 120-4 teamwork 174--5 cold and heat 179 treatment 177-8 Index 193 dyspeptic symptoms 87 hospital, referral xii dysphagia 153-4 hydromorphine 61 dyspnoea 16<}-2 hydroxyzine 61,84,88 hyoscine 155, 162 electrical stimulation 147 hypercalcaemia 156-7 emotional disorders 23-33 hypnotics, for insomnia 167 management 29-33 hypnotherapy 31,32,179 and surgery 130 hypomania 87 endocrine glands, ablation 100 hypophysectomy 95,149 enemas 159 ephedrine 124 ibuprofen 70 epidural catheter II9 image intensifier epidural neurolysis II7-19 percutaneous cordotomy 146 epidural space identification 118 spinal rhizotomy 142 examination of patient 42 stellate ganglion block 126 exercise in terminal care 178-9 trigeminal rhizotomy 139 expectorants 163 immobilization 179 extremities, surgery of tumours of the 101 impotence 29 incontinence face, alcohol block 121 after subarachnoid block 114 faecal softeners 160 treatment 164-5 family, care of 180-1 indomethacin 70, 168 family in terminal care 180 inhalations for cough 163 fistulae 165-75 inhibitory control 15-17 Floriani Foundation ix insomnia 167-8 5-fiuorouracil 90 intercostal nerve block 118 fracture, pathological 104 intestinal obstruction 158 surgery 101 intestinal occlusion 95 fungating tumours 166-7 surgery 99 intracranial pressure, raised 85,87, 157-9 gall bladder, coeliac plexus block 122 intra-orbital 135 gastric distension pain 85 intrathecal injection 107 gastrointestinal bleeding 87 gastrointestinal cancer 92 jaundice and pruritis 164 gastrointestinal symptoms 152-60 jugular foramen syndrome 46 gastrostomy 154 Gate Control theory 15 laminectomy 102-3 glaucoma and amitryptyline 86 laxatives 159-60 glossary 189-90 leukaemia glossopharyngeal rhizotomy 141-2 acute adult 92 glucocorticosteroids 153, 154, 169 chronic 92 lymphoblastic 92 haematuria 165 radiotherapy 95 hallucinations, in terminal care 182 levorphanol 61,81 haloperidol 61,84,87, 155, 169 libido, loss of 29 head, alcohol block 119 life expectancy 131 headache 95,96 lignocaine II6, II7, 124, 128 corticosteroids 87 limbs, tumours of 101 head and neck cancer 92, 95 liver dysfunction and opioid therapy 75 heat and cold 179 local anaesthetic block 105, 117 herpes zoster 54 lumbar plexus 49 hiccup 158 radiation fibrosis 52 history taking 41 lumbar puncture, position 109 Hodgkin's disease 52,92 lumbar rhizotomy 143 home care 65-6 lumbar sympathetic block 127 hormonal therapy 95-7 lumbar vertebrae 47-8 hormones 90 lung cancer 92, 96 Homer's syndrome 46 rhizotomy 137 after stellate ganglion block 126 lymphoedema, stellate ganglion block 126 hospice 65-6 lymphomas 92 194 Index magnesium sulphate 160 neuroleptics 61, 87 malnutrition and drug therapy 75, 85 neurolesion 64 massage 179,180 neurolytic agent, duration 109 mastectomy 50-1, 97 neurolytic block 105 depression 27 technique 109 stellate ganglion block 125 neurolytic solutions, preparation 185-7 mechlorethamine 90 neurophysiology 9-21 medical investigation 26 neurosurgical techniques 129-50 meditation 179 night sweats 168 melanoma 92 nitrazepam 167 meningeal carcinomatosis 49 nitroso-ureas 95 meperidine 80 nociceptors 9, 11-13 metastases 95 non-cancer pain syndromes 54 evaluation 43 non-opioid analgesics 61 surgery 131 recommendations for use 186 methadone 61,63,79-80 non-steroidal anti-inflammatory drugs 70 methotrexate 90 noradrenaline 12 methyl cellulose 160 noxious input 10 methylprednisone 117 noxious stimuli 14 for rib pain 119 nurses, community 65 metoclopramide 155, 158 and counselling 27 mid-thoracic region, phenol block 112 teamwork 174-5 mobilization 179 nutritional status and opioid therapy 75 morphine 16,61,63,72-7 nystatin 152 bronchial carcinoma 164 epidural and intrathecal 82 oedema 87 intolerance 87 oesophageal carcinoma 154 oral dosage 76-9 oophorectomy 132 rectal administration 81 open cordotomy 145, 148-9 side effects 78 operant conditioning 31 solutions 186-9 opiate bindings 15 subcutaneous 82 opiates mucolytics 157 for cough 164 multiple myeloma 92 for dyspnoea 162 muscle spasm 81,85 opioids 5, 61,63,73-8'2 in terminal care 179 opium, standardized 61,81 muscle training programme 17 Opsite, for bedsores 179 mutilation, emotional distress 24, 29 oral candidosis 152 myelinated fibres 9 oral hygiene 152, 153 myelography 43 orchidectomy 97, 132 myelopathy, radiation 53 organic brain syndrome 27 myofascial pain 120-1 organic confusion state 27 orthostatic hypotension, after coeliac plexus naloxone 16 block 124 naproxen 70 osteosarcoma 92 nasogastric tube 154 outpatient care 65 nausea and vomiting 78,86, 154-6 ovarian cancer 92 neck, neurolytic block 119 ovariectomy 95 neck, radical dissection 51 oxygen, in dyspnoea 162 nerve blocks, general principles 105 nerve compression 83 pain assessment, general principles 40 corticosteroids 86-7 pain extension 131 nerve destruction pain 85 pain pathways, ascending 17-19 nerve fibres, regeneration 109 palliative surgery 97-103 nerve pressure pain 85 clinical conditions 99 , tumour infiltration 48 general principles 97-8 neural stimulation 149 methods 98-103 neurectomy 133-5 Pancoast's tumour, 94 neuroblastoma 92 blocks for 120 neurodestructive therapies 63-4 pancreas, coeliac plexus block 122, 130 Index 195 para-aqueductal grey matter 15-16 promethazine 155 paracentesis 100 prostaglandins 11, 12 paracetamol 61, 71-2 prostatic cancer 96 paraffin, liquid 160, 167 proximal myopathy 87 paraplegia 46 pruritis 79 pathological fracture 102 treatment 164 patient instruction 76-7 psychiatric illness 24-5 patients psychological dependence 74 classification 37--40 psychological history 37,41 communication 29-30 psychological preparation 132 incapacity 130 psychosocial status 41 pelvic carcinoma 96, 100 psychotherapy 31-2 lumbar sympathetic block 127 psychotic symptoms 79 surgery 101 psychotropic drugs 30,84,85, 167, 169 percutaneous anterior cordotomy 145 purgatives 160 percutaneous lateral cordotomy 145, 146-8 peripheral nerve tumours 53 quality of life 173 perineal pain sacral rhizotomy 139 radiation unilateral block III emotional distress 24 peripheral nerve block 117 fibrosis 52 peripheral nerves 48 myelopathy 53 peripheral neurectomy 133-5 postradiation pain 52 peripheral neuropathy 51 therapy 92-8 pethidine 61, 80 radiofrequency generator 140, 155 phantom-limb 51 radiofrequency glossopharyngeal pharyngodynia 95 rhizotomy 141-2 phenobarbitone and pethidine 810 radiosensitive tumours 93 phenol radiotherapy 92--4 blocks 108, 109 radiotherapy dosage 94 epidural neurolysis 116 radiotherapy failure 94 neurolytic block 110 receptors 10 peripheral nerves 118 recent trends 6-7 solution 185 rectal area neurolytic block 111 phenolic rhizotomy 140 rectal/bladder tenesmus 111 phenolphthalein 160 rectovaginal fistula surgery 99 phenothiazines 155 rectovesical fistula surgery 99 phenytoin 61,84,86 rectum, epidural neurolysis 116 physical mutilation 24, 28-9 relatives, communications 29-30 physical therapies 60 relaxation in terminal care 179-80 in terminal care 178-9 renal cancer 92 physician-directed service 66 renal dysfunction physiotherapy 170 and opioid therapy 75 in terminal care 178 and pethidine 80 platelet aggregation, inhibition 71 respiratory symptoms 160--4 cis-platinum 90 rhizotomy 134-44 posterior rhizotomy 135-44 rib metastasis, intercostal block 119 postherpetic neuralgia 54, 83 rifampicin 80 postradiation therapy pain 52-3 postsurgery pain 50-I sacral metastases 47-8 post-treatment outcome 28 sacral plexus 49 prayer 179 sacral rhizotomy 139, 143 prednisolone 61,84,87, 153 sacroiliac joint, local anaesthetic premedical contact 25 injection 121 pressure sores 179 saliva replacement solution 187 prevalence 4 sarcomas 92 procarbazine 90 senna 78, 160 prochlorperazine 61,84,87, 155, 158 separation anxiety 181 progestogens 90 sexual disorders 27, 29 prognosis, adjusting to 17~ skin problems 166-7 196 Index skull metastases 46 thoracic cordotomy 145 sleep 57 thoracic rhizotomy 138, 142 social history 37 thoracotomy 50 soft tissue sarcomas 92 thorax, blocks for 120 solutions, preparation 185-7 thyroid cancer 92 sphenoid-sinus metastases 46 tinnitus 71 spinal cord compression 48,50, 102 tissue inflammation 9 corticosteroids 87 tomography 47 surgery 99 traction 179 spinal cord lesions 143-9 traditional medicine xii spinal neurolysis 107 tranquillizers, in dyspnoea 162 spinal rhizotomy 142 treatment 26-7 spinothalamic tract 17-19 treatment team 30 splintage 179 trigeminal neuralgia 86, 119 stabbing pain 83, 85 trigeminal rhizotomy 137, 139-40 stellate ganglion block 124--{i trigger points 120-1 stereotactic cordotomy 155 tumour chemotherapy 92 steroid pseudo-rheumatism 52 tumour involvement 45--50 steroid therapy 52 tumour radiosensitivity 93 stomach, coeliac plexus block 122 tumour response 91 stomas 180 types of pain 38 strong opioid analgesics 61,74-9 subarachnoid neurolysis 107-15 unmyelinated fibres 9 complications and failure 114 uraemia 156 postinjection management 113-14 urinary retention 86 substance P II, 15 after subarachnoid block 116 substantia gelatinosa 14-15 treatment 165 suicide risk 27 urinary symptoms 164--{i suppositories 160 urinary tract occlusion 101 supra-orbital neurectomy 134 surgery 99 supra-trochlear neurectomy 134 surgery, analgesic 130 vertebral bodies, metastases 46-8 sympathectomy 132-3 vesicovaginal fistula 177 symptom control 151-70 vinblastine 90 team 65 vinca alkaloid drugs 51 vincristine 90 teamwork 174-5 visceral pain 20, 83 temazepam 167 coeliac plexus block 124 tension headaches 83,96 volunteers, in care 66-7 terminal care 171-84 vomiting 78, 86 communication 175 treatment 154--{i5 prognosis 176 vulval lesions 167 teamwork 174-5 treatment 177-8 walking aids 179 test block 118 weakness 169-70 testis, tumour 92, 97 weak opioid analgesics 61,73-4 therapeutic deficiencies 4--{i Wilm's tumour 92 therapeutic strategy 57--67 withdrawal symptoms 74 initial approach 58--60 thigh, unilateral block III X-rays 42-3, 53 From the World Health Organization CANCER PAIN RELIEF A book that promises to make pain relief a routine component of cancer care

In a concise, didactic, and logical way, Cancer Pain Relief sets forth information and arguments designed to correct the many false assumptions and faulty practices that hinder the relief of pain in cancer patients. Coverage ranges from statistics on the number of cancer patients who suffer unrelieved pain each day, through reasons for the inadequate use of established and highly effective treatments, to details on a method of treatment capable of relieving pain in 80-90% of patients. Throughout the book, emphasis is placed on the central importance of analgesic drugs and the need for guidance in their use. The book has two main parts. The first provides background infor• mation on the prevalence and nature of cancer pain, the reasons for its inadequate control, and the steps necessary for improvement on a global scale. Basic principles of management are outlined and the need for professional and public education is discussed. The second part of the book presents a detailed yet simple method of pain relief based on the sequential use of aspirin, codeine, and mor• phine administered 'by the clock'. This 'three-step ladder' method, which was worked out and agreed upon by more than 40 experts, shows how the correct use of a small number of safe, effective, and inexpensive drugs can provide complete and continuous pain relief in the vast majority of patients. For doctors and nurses who lack formal training in pain management, Cancer Pain Relief will be welcomed as a source of sound, practical advice certain to improve their competence when working with cancer patients. The book should also be read by all public health authorities and hospital managers seeking to implement comprehensive pro• grammes for the relief of cancer pain.

Cancer Pain Relief Available from: World Health Organization, 1986 World Health Organization 74 pages; available in English or Distribution and Sales French 1211 Geneva 27 ISBN: 92--4-156100-9 Switzerland SW.fr. 13.-/US$7.80