Transcript Cancer Pain Management 101 - VCU Internal Medicine

Cancer Pain Management 101
Sarah Beth Harrington, MD
Internal Medicine Noon Conference
November 30, 2007
Objectives
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Review primary causes of cancer-related
pain.
Recognize effects of pain on cancer
patients.
Understand basic concepts of
pharmacologic management techniques
with opioids and non-opioids.
Discuss non-pharmacologic techniques in
cancer pain management.
Causes of Cancer-Related Pain
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Tumor / Mass effect
Post-chemotherapy
Post-radiation
Post-surgical
Somatic Pain
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Tumor / Mass effect
Musculoskeletal
Dull, sharp, localized
Visceral Pain
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infiltration, compression, extension, or
stretching of the thoracic, abdominal, or
pelvic viscera
pressure, deep, squeezing
not well-localized
referred
Neuropathic Pain
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CA compressing or infiltrating nerves/nerve
roots/blood supply to nerve
Nerve damage from treatments
Shooting, sharp, burning, “pins & needles”
Cranial neuropathies
Post-herpetic neuropathies
Brachial plexus neuropathies
Post-radiation
Neuropathic Pain
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Chemotherapy-induced neuropathies
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Cisplatin, Oxaliplatin
Paclitaxil, Thalidomide
Vincristine, Vinblastine
Surgical Neuropathies
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Phantom limb pain
Post-mastectomy syndrome
Post-thoracotomy syndrome
Summary
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Causes
Descriptors
Tumor size may not correlate with pain
intensity
Physiological effects of Pain
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Increased catabolic demands: poor wound
healing, weakness, muscle breakdown
Decreased limb movement: increased risk of
DVT/PE
Respiratory effects: shallow breathing,
tachypnea, cough suppression increasing risk
of pneumonia and atelectasis
Increased sodium and water retention (renal)
Decreased gastrointestinal mobility
Tachycardia and elevated blood pressure
Psychological effects of Pain
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Negative emotions: anxiety, depression
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Sleep deprivation
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Existential suffering
Immunological effects of Pain
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Decrease natural killer cell counts
Effects on other lymphocytes not yet
defined
What Does Pain Mean to Patients?
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Poor prognosis or impending death
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Decreased autonomy
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Particularly when pain worsens
Impaired physical and social function
Decreased enjoyment and quality of life
Challenges to dignity
Threat of increased physical suffering
Principles of Assessment
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Ask
Dispel myths/ misunderstandings
Believe the patient
Assess and REASSESS
Use methods appropriate to cognitive status
and context
Assess intensity, relief, mood, and side
effects
Include the family
Patient Pain History
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Site(s) of pain/radiation?
Quality?
Severity of pain?
Onset / duration
What aggravates or relieves pain?
Impact on sleep, mood, activity?
Effectiveness of medication?
Pharmacologic Management
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WHO Ladder
Non-opioid therapy / Co-analgesics
Opioids
WHO Ladder
Non-Opioids
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NSAIDS
Acetaminophen
Topicals
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Lidocaine, Capsaicin
Practice Points:
 Mild pain
 “ceiling” effect
 Start at lowest effective
dose
 Review pt’s underlying
medical illnesses
Adjuvants
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Antidepressants
 TCAs for neuropathic
pain
Anticonvulsants
Corticosteroids
Neuroleptics
Alpha2 – agonists
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Benzodiazepines
Antispasmodics
Muscle relaxants
NMDA-blockers
Systemic local
anesthetics
Adjuvants
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Bone pain
 Bisphosphonates
 Calcitonin
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Pain from malignant
bowel obstruction
 Steroids
 Octreotide
 Anticholinergics
Practice Points:
 Choose adjuvant
carefully (risk:benefit)
 Start low and titrate
gradually
 Avoid initiating several
adjuvants concurrently
Opioids
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Step 2 opioids
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Step 3 opioids
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Codeine, Oxycodone, tramadol, hydrocodone
Oxycodone, morphine, dilaudid, fentanyl,
methadone
AVOID: meperidine, agonists/antagonists,
combo agents, propoxyphene
Opioids
Practice Points:
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If pain constant/chronic – use long-acting
opioids with short-acting for breakthrough
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Breakthrough dose - 10-20% of total daily dose
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Assess pt’s clinical and financial situation before
prescribing
Mr. Smith
58 yo AAM with chronic bone pain from met.
prostate CA. Prescribed Percocet (5/325)
in the ER 2 weeks ago and is now in your
clinic for f/u. Pain is well controlled, but
tends to recur ~1 hr before the next dose.
He takes 2 Percocets q4hrs around the
clock, even at night.
Mr. Smith
10mg oxycodone 6 times/day = 60mg oxycodone in 24 hrs
Equivalent SR oxycodone= Oxycontin 30mg q12h
Rescue dose – 10% (60mg) = 6 mg
20% (60mg) = 12mg
ANSWER:
Oxycontin 30mg q12h with Oxycodone 5-10mg q4h prn
Changing opioids
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Intolerable side effects, method of
delivery, cost
Practice points
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Incomplete cross-tolerance with different
opioids
Start new opioid at ½-⅔ of equianalgesic
dose
Ms. B
50 yo breast CA survivor with chronic
neuropathic pain from her mastectomy.
She currently is well-controlled on a 75
mcg/hr fentanyl patch. She lost her job
and can no longer afford the patch. You
want to switch her to MS Contin with MS
IR for breakthrough. What dose?
Ms. B
75 mcg/hr
fentanyl patch
75 mg po morphine/day
25 mcg/hr fentanyl patch
⅔ (225 mg) ≈ 150 mg morphine/day
75 mg MS Contin q12h
Breakthrough - 10% 150 = 15 mg
20% 150 = 30 mg
MS Contin 75 mg q12h with 15-30mg MS IR prn
225 mg po
morphine/day
Parenteral Opioids
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1mg IV morphine = 3 mg po morphine
1mg IV dilaudid = 4-5 po dilaudid
Rapid escalation, assess pt’s pain needs
(PCA), fast-acting
PCA tips
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How to order – IV PCA dose q6 min, basal,
bolus q1hr prn
If pt on a long-acting opioid – can continue po or
convert all to IV basal (DO NOT STOP)
REASSESS, REASSESS, REASSESS
Double PCA and bolus dose if pain score worse
or >50% original
SQ option – morphine & dilaudid – higher
concentration; PCA dose q15 min
Opioid adverse effects
Common
Uncommon
Constipation
Dry mouth
Nausea / vomiting
Sedation
Sweats
Bad dreams / hallucinations
Dysphoria / delirium
Myoclonus / seizures
Pruritus / urticaria
Respiratory depression
Urinary retention
Radiation / Nuclear Medicine
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Radiation – curative treatment, adjuvant,
palliative
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Bone metastases – pain response rate 3560%, duration 12-24 wks
Strontium-89
Non-Pharmacologic
Management
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Acupuncture
Yoga
Guided imagery
Cold/heat
Massage
Vibration
TENS units
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Exercise programs
Hypnosis
Counseling
Music
Pet therapy
Cancer Pain Emergencies
(a.k.a. things you can’t miss)
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Cord Compression
Withdrawal
Bone Mets/Impending Fractures
WHO Ladder
What about the 20%!?
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Have the opioids been titrated aggressively?
Is the pain neuropathic?
Has a true pain assessment been
accomplished?
Have you examined the patient?
Is the patient receiving their medication?
Is the medication schedule and route
appropriate?
Modified WHO Analgesic
Ladder Quality of Life
Invasive treatments
Proposed 4th Step
Opioid Delivery
Pain persisting or increasing
Step 3
Opioid for moderate to severe pain
±Nonopioid ±Adjuvant
Pain persisting or increasing
The WHO
Ladder
Step 2
Opioid for mild to moderate pain
±Nonopioid ±Adjuvant
Pain persisting or increasing
Step 1
±Nonopioid
±Adjuvant
Pain
Deer, et al., 1999
Cancer pain management 201
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Interventions
Blocks
Epidural
Intrathecal pain pumps
Lidocaine infusion
Ketamine
Sedation
Interventions
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Palliative surgery
Nerve Blocks
Kyphoplasty/Vertebroplasty
Epidural
Intrathecal pain pumps
Celiac Plexus Block
Celiac Plexus Block
Kyphoplasty/Vertebroplasty
Kyphoplasty/Vertebroplasty
Intrathecal Pain Pumps
Intrathecal Pain Pumps
Conclusion
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Cancer pain can be from the cancer itself,
or from cancer-related treatments
Can be somatic, visceral, or neuropathic
Negative effects of cancer-related pain
can effect QOL, mortality
Ask the patient about pain and
REASSESS!
Conclusion
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Choose non-opioid / adjuvants carefully
paying close attention to side effect profile
Use WHO ladder guidelines when titrating
pain medications
Use long-acting opioids for chronic cancer
pain
Recognize “4th step” in WHO ladder and
utilize your multidisciplinary resources
Palliative Care Service
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N4N – 6-1295
Fellows: Dr. Paresh Patel, Dr. Keith Swetz
NPs – Pat Coyne and Bart Bobb
Questions?