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Management of Cancer Pai n
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71
Management of Cancer Pai n
Appendix 8
GUIDE FOR TRANSDERMAL FENTANYL USE
Important notes when using transdermal fentanyl:
When indicated, transdermal (TD) fentanyl should only be used in
patients already on stable doses of morphine or other opioids.
TD fentanyl is contraindicated in patients with severe uncontrolled
pain where rapid dose titration is required.
When converting to TD fentanyl from 4-hourly morphine, overlap
regular 4-hourly morphine for the rst 12 hours after applying the
patch.
When converting to TD fentanyl from 12-hourly SR morphine or CR
oxycodone, apply the patch and serve the nal dose of SR morphine
or CR oxycodone at the same time.
When converting to TD fentanyl from continuous SC/IV infusion of
morphine or fentanyl, continue the infusion for 12 hours after applying
the patch.
When applying the patch:
The date and time of application and/or renewal should be written on
the patch.
The underlying skin should be dry, non-inamed, non-irradiated and
with minimal body hair.
Body hair should be clipped with scissors if necessary and NOT
shaved.
If skin is washed, use only water and DO NOT apply soap, cream or
ointment on the area.
Press the patch rmly for at least 30 seconds to ensure adherence.
Film dressings and plaster may be applied to provide additional
adherence.
After 72 hours, remove the patch and change the site of application
of new patch in order to allow the skin at the previous site to rest for
three days.
Used patches should be folded with the adhesive side inwards and
discarded in clinical waste bins (in hospital) or in a dustbin at home.
Source: Twycross R, Wilcock A. Palliative Care Formulary. Third Edition. Nottingham: Paliativedrugs.
com; 2007
72
Management of Cancer Pai n
Appendix 9
GUIDE FOR NALOXONE USE
Naloxone for iatrogenic opioid overdose:-
Seldom necessary in palliative care setting
Used only if life threatening overdose occurs
NOT USED for treating drowsiness or delirium associated with
opioids which is not life threatening
IV route is preferable but SC or intramuscular can also be used
Onset of action: 1 - 2 minutes via IV and 2 - 5 minutes via SC
Half-life: about one hour
If opioid overdose is conrmed:-
Respiratory rate >8/minute and arousable Wait and see after
withholding opioids
Respiratory rate <8/minute and comatose or cyanosed Treat with
naloxone
o Dilute 400 mcg (1 ampoule) in 10 ml water
o Administer small boluses of 0.5 ml (20 mcg) every two minutes
until respiratory rate is satisfactory
o Titrate dose against respiratory rate and NOT conscious level as
this may result in return of severe pain or physical withdrawal
May need further boluses after one hour and sometimes infusion in
cases where overdose is associated with long acting opioids (SR
tablets, transdermal fentanyl or methadone)
Caution:-
Opioid overdose must be managed with frequent close monitoring to
assess effects of withdrawal and pain, and to continue or discontinue
naloxone therapy as needed
Do not use large bolus such as 1 ampoule stat in patients who
receive opioids for chronic pain relief
Source: Twycross R, Wilcock A. Palliative Care Formulary. Third Edition. Nottingham: Paliativedrugs.
com; 2007
73
Management of Cancer Pai n
Appendix 10
PAIN MANAGEMENT AND PALLIATIVE CARE SERVICE
PROVIDERS
PAIN CLINICS
Hospital Tel No. URL
Hospital Selayang, Selangor 603-61203233 http://www.hselayang.moh.gov.my
Hospital Melaka, Melaka 606-2822344 http://www.hmelaka.moh.gov.my
Hospital Sultan Ismail, Johor 607-3565000 http://www.hsi.moh.gov.my
Hospital Raja Permaisuri Bainun, Perak 605-2533333 http://www.hipoh.moh.gov.my
Hospital Raja Perempuan Zainab II, Kelantan 609-7452000 http://www.hrpz2.moh.gov.my
Hospital Tengku Ampuan Rahimah, Selangor 603-33757000 http://www.htar.moh.gov.my
Pusat Perubatan Universiti Malaya, Kuala Lumpur 603-79494422 http://www.ummc.edu.my
Pusat Perubatan Universiti Kebangsaan Malaysia, 603-91455555 http://www.ppukm.ukm.my
Kuala Lumpur
Hospital Universiti Sains Malaysia, Kelantan 609-7663000 http://www.medic.usm.my
PALLIATIVE CARE UNITS
Hospital Tel No. URL
Hospital Selayang, Selangor 603-61203233 http://www.hselayang.moh.gov.my
Hospital Bukit Mertajam, Kedah 60-45383333 http://www.hospbm.moh.gov.my
Hospital Duchess of Kent, Sabah 6089-212111 http://www.hdok.moh.gov.my
Hospital Melaka, Melaka 606-2707653 http://www.hmelaka.moh.gov.my
Hospital Pulau Pinang, Pulau Pinang 604-2293333 http://www.hpp.moh.gov.my
Hospital Queen Elizabeth, Sabah 6088-206258 http://www.qeh.moh.gov.my
Hospital Raja Permaisuri Bainun, Perak 605-5222245 http://www.hipoh.moh.gov.my
Hospital Raja Perempuan Zainab II, Kelantan 609-7485533 http://www.hrpz2.moh.gov.my
Hospital Sultanah Aminah, Johor 607-2231666 http://www.hsajb.moh.gov.my
Hospital Sultanah Bahiyah, Kedah 60-47303333 http://www.hsbas.moh.gov.my
Hospital Sultanah Nur Zahirah, Terengganu 609-6233333 http://www.hsnzkt.moh.gov.my
Hospital Tawau, Sabah 6089-773533 http://www.htwu.moh.gov.my/
Hospital Tengku Ampuan Afzan, Pahang 609-5133333 http://www.htaa.moh.gov.my
Hospital Tuanku Jaafar, Negeri Sembilan 606-7623333 http://www.htjs.moh.gov.my
Hospital Umum Sarawak, Sarawak 6082-208069 http://www.hus.moh.gov.my
Pusat Perubatan Universiti Malaya, Kuala Lumpur 603-79494422 http://www.ummc.edu.my
Pusat Perubatan Universiti Kebangsaan Malaysia, 603-91455555 http://www.ppukm.ukm.my
Kuala Lumpur
74
Management of Cancer Pai n
HOSPICES/PALLIATIVE CARE SOCIETIES
Source:
i. Malaysian Association For the Study of Pain, 2010 (internet communication, 6 February 2010 at
http://masp.org.my)
ii. Hospis Malaysia, 2010 (internet communication, 6 February 2010 at http://www.hospismalaysia.
org/index.php?mid=385)
iii. Asia Pacic Hospice Palliative Care Network, 2010 (internet communication, 6 February 2010
at http://www.aphn.org)
Hospis Malaysia 603-91333936 http://www.hospismalaysia.org
info@hospismalaysia.org
Malaysian Hospice Council 604-2284140 http://www.malaysianhospicecouncil.org
ncsmpg@gmail.com
Charis Hospice 604-8266757 http://www.charishospice.com
charisp@streamyx.com
Home Care Hospice Programme Sabah 6088-222315 http://www.sabah.org.my/scss/cancer
cancer_sabah@yahoo.com
Hospice Klang 603-33242125 http://www.hospiceklang.org
hpsklang@gmail.com
Hospice Malacca 606-2925849 drrajagopal@hotmail.com
Hospice Pahang 609 5670743 -
Kasih Hospice 603-79607424 http://www.kasih-hospice.org
admin@kasih-hospice.org
Kuching Hospice Cancer Care 6082-337689 cancercare@pd.jaring.my
Palliative Care Association Johor Bahru 607-2228858 pcajb.admin@gmail.com
Palliative Care Association of Kota 6088-231505 http://www.sabah.org.my/pcakks
Kinabalu Sabah paliatif@streamyx.com
Penang Hospice Society 604-2284140 http://www.penanghospice.org.my
chanke@islandhospital.com
Perak Palliative Care Society 605-5464732 ppcs95@tm.net.my
Persatuan Hospis Kedah 604-7332775 sriwahyu2006@yahoo.com.my
Persatuan Hospis Kelantan 609-7475418 drimisairi@kit.moh.gov.my
Persatuan Hospis Tawau 6089-774666 vicraja@gmail.com
Persatuan Hospis Terengganu 609-8593333 drahmah@trg.moh.gov.my
Pertubuhan Hospice Seremban 606-7621216 hospiceseremban_2008@yahoo.com
Pure Lotus Hospice of Compassion 604-2295481 plotus@streamyx.com
Rumah Hospis Pulau Pinang 604-2284140 http://www.penanghospice.org.my
ncsmpg@gmail.com
Sarawak Hospice Society 6082-276575 tangtiengswee@gmail.com
Taiping Palliative Society 605-8072457 veraliew@hotmail.com
The Hospice Association of Sandakan 6089-632219 http://www.hospicesdk.com
hcs98@hospicesdk.com
SOCIETY Tel No. URL/E-mail
75
Management of Cancer Pai n
LIST OF ABBREVIATIONS
76
Management of Cancer Pai n
PROPOSED CLINICAL AUDIT INDICATORS FOR QUALITY
MANAGEMENT
Percentage of
patients
with satisfactory
cancer
pain control =
Annual
consumption of
strong opioid in
Malaysia =
ACKNOWLEDGEMENT
The members of the development group of these guidelines would
like to express their gratitude and appreciation to the following for their
contributions:
Panel of external reviewers who reviewed the draft
Dr. Sheamini Sivasampu, Public Health Physician
Ms. Loong Ah Moi, Nursing Sister
Technical Advisory Committee for CPG for their valuable input and
feedback
All those who have contributed directly or indirectly to the development
of the CPG
DISCLOSURE STATEMENT
The panel members had completed disclosure forms. None held shares
in pharmaceutical rms or acted as consultants to such rms. (Details
are available upon request from the CPG Secretariat)
SOURCES OF FUNDING
The development of the CPG on Management of Cancer Pain was
supported nancially in its entirety by the Ministry of Health Malaysia
while the printing was partly funded by Malaysian Association for the
Study of Pain (MASP).
Number of patients whose pain is
satisfactorily controlled within 72 hours
x 100%
Total number of patients presenting
with cancer pain
Dened daily dose (DDD)
x 100%
100,000 population