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Cancer Pain Management 101 Sarah Beth Harrington, MD Internal Medicine Noon Conference November 30, 2007 Sarah Beth Harrington, MD Internal Medicine Noon.

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Presentation on theme: "Cancer Pain Management 101 Sarah Beth Harrington, MD Internal Medicine Noon Conference November 30, 2007 Sarah Beth Harrington, MD Internal Medicine Noon."— Presentation transcript:

1 Cancer Pain Management 101 Sarah Beth Harrington, MD Internal Medicine Noon Conference November 30, 2007 Sarah Beth Harrington, MD Internal Medicine Noon Conference November 30, 2007

2 Objectives 1. Review primary causes of cancer-related pain. 2. Recognize effects of pain on cancer patients. 3. Understand basic concepts of pharmacologic management techniques with opioids and non-opioids. 4. Discuss non-pharmacologic techniques in cancer pain management. 1. Review primary causes of cancer-related pain. 2. Recognize effects of pain on cancer patients. 3. Understand basic concepts of pharmacologic management techniques with opioids and non-opioids. 4. Discuss non-pharmacologic techniques in cancer pain management.

3 Causes of Cancer-Related Pain Tumor / Mass effect Post-chemotherapy Post-radiation Post-surgical Tumor / Mass effect Post-chemotherapy Post-radiation Post-surgical

4 Somatic Pain Tumor / Mass effect Musculoskeletal Dull, sharp, localized Tumor / Mass effect Musculoskeletal Dull, sharp, localized

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7 Visceral Pain infiltration, compression, extension, or stretching of the thoracic, abdominal, or pelvic viscera pressure, deep, squeezing not well-localized referred infiltration, compression, extension, or stretching of the thoracic, abdominal, or pelvic viscera pressure, deep, squeezing not well-localized referred

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11 Neuropathic Pain 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 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

12 Neuropathic Pain Chemotherapy-induced neuropathies Cisplatin, Oxaliplatin Paclitaxil, Thalidomide Vincristine, Vinblastine Surgical Neuropathies Phantom limb pain Post-mastectomy syndrome Post-thoracotomy syndrome Chemotherapy-induced neuropathies Cisplatin, Oxaliplatin Paclitaxil, Thalidomide Vincristine, Vinblastine Surgical Neuropathies Phantom limb pain Post-mastectomy syndrome Post-thoracotomy syndrome

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14 Summary Causes Descriptors Tumor size may not correlate with pain intensity Causes Descriptors Tumor size may not correlate with pain intensity

15 Physiological effects of Pain 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 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

16 Psychological effects of Pain Negative emotions: anxiety, depression Sleep deprivation Existential suffering Negative emotions: anxiety, depression Sleep deprivation Existential suffering

17 Immunological effects of Pain Decrease natural killer cell counts Effects on other lymphocytes not yet defined Decrease natural killer cell counts Effects on other lymphocytes not yet defined

18 What Does Pain Mean to Patients? Poor prognosis or impending death Particularly when pain worsens Decreased autonomy Impaired physical and social function Decreased enjoyment and quality of life Challenges to dignity Threat of increased physical suffering Poor prognosis or impending death Particularly when pain worsens Decreased autonomy Impaired physical and social function Decreased enjoyment and quality of life Challenges to dignity Threat of increased physical suffering

19 Principles of Assessment 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 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

20 Patient Pain History Site(s) of pain/radiation? Quality? Severity of pain? Onset / duration What aggravates or relieves pain? Impact on sleep, mood, activity? Effectiveness of medication? Site(s) of pain/radiation? Quality? Severity of pain? Onset / duration What aggravates or relieves pain? Impact on sleep, mood, activity? Effectiveness of medication?

21 Pharmacologic Management WHO Ladder Non-opioid therapy / Co-analgesics Opioids

22 WHO Ladder

23 Non-Opioids NSAIDS Acetaminophen Topicals Lidocaine, Capsaicin NSAIDS Acetaminophen Topicals Lidocaine, Capsaicin Practice Points: Mild pain “ceiling” effect Start at lowest effective dose Review pt’s underlying medical illnesses

24 Adjuvants Antidepressants TCAs for neuropathic pain Anticonvulsants Corticosteroids Neuroleptics Alpha 2 – agonists Antidepressants TCAs for neuropathic pain Anticonvulsants Corticosteroids Neuroleptics Alpha 2 – agonists Benzodiazepines Antispasmodics Muscle relaxants NMDA-blockers Systemic local anesthetics

25 Adjuvants Bone pain Bisphosphonates Calcitonin Pain from malignant bowel obstruction Steroids Octreotide Anticholinergics Bone pain Bisphosphonates Calcitonin 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

26 Opioids Step 2 opioids Codeine, Oxycodone, tramadol, hydrocodone Step 3 opioids Oxycodone, morphine, dilaudid, fentanyl, methadone AVOID: meperidine, agonists/antagonists, combo agents, propoxyphene Step 2 opioids Codeine, Oxycodone, tramadol, hydrocodone Step 3 opioids Oxycodone, morphine, dilaudid, fentanyl, methadone AVOID: meperidine, agonists/antagonists, combo agents, propoxyphene

27 Opioids Practice Points: If pain constant/chronic – use long-acting opioids with short-acting for breakthrough Breakthrough dose % of total daily dose Assess pt’s clinical and financial situation before prescribing Practice Points: If pain constant/chronic – use long-acting opioids with short-acting for breakthrough Breakthrough dose % of total daily dose Assess pt’s clinical and financial situation before prescribing

28 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.

29 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 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

30 Changing opioids Intolerable side effects, method of delivery, cost Practice points Incomplete cross-tolerance with different opioids Start new opioid at ½-⅔ of equianalgesic dose Intolerable side effects, method of delivery, cost Practice points Incomplete cross-tolerance with different opioids Start new opioid at ½-⅔ of equianalgesic dose

31 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?

32 Ms. B 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 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 75 mcg/hr fentanyl patch 75 mg po morphine/day 25 mcg/hr fentanyl patch 225 mg po morphine/day

33 Parenteral Opioids 1mg IV morphine = 3 mg po morphine 1mg IV dilaudid = 4-5 po dilaudid Rapid escalation, assess pt’s pain needs (PCA), fast-acting 1mg IV morphine = 3 mg po morphine 1mg IV dilaudid = 4-5 po dilaudid Rapid escalation, assess pt’s pain needs (PCA), fast-acting

34 PCA tips 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 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

35 Opioid adverse effects CommonUncommon ConstipationBad dreams / hallucinations Dry mouthDysphoria / delirium Nausea / vomitingMyoclonus / seizures SedationPruritus / urticaria SweatsRespiratory depression Urinary retention CommonUncommon ConstipationBad dreams / hallucinations Dry mouthDysphoria / delirium Nausea / vomitingMyoclonus / seizures SedationPruritus / urticaria SweatsRespiratory depression Urinary retention

36 Radiation / Nuclear Medicine Radiation – curative treatment, adjuvant, palliative Bone metastases – pain response rate %, duration wks Strontium-89 Radiation – curative treatment, adjuvant, palliative Bone metastases – pain response rate %, duration wks Strontium-89

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38 Non-Pharmacologic Management Acupuncture Yoga Guided imagery Cold/heat Massage Vibration TENS units Acupuncture Yoga Guided imagery Cold/heat Massage Vibration TENS units Exercise programs Hypnosis Counseling Music Pet therapy

39 Cancer Pain Emergencies (a.k.a. things you can’t miss) Cord Compression Withdrawal Bone Mets/Impending Fractures Cord Compression Withdrawal Bone Mets/Impending Fractures

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42 WHO Ladder

43 What about the 20%!? 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? 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?

44 Pain Step 1  Nonopioid  Adjuvant Pain persisting or increasing Step 2 Opioid for mild to moderate pain  Nonopioid  Adjuvant Pain persisting or increasing Step 3 Opioid for moderate to severe pain  Nonopioid  Adjuvant Invasive treatments Opioid Delivery Quality of Life Modified WHO Analgesic Ladder Proposed 4 th Step The WHO Ladder Deer, et al., 1999

45 Cancer pain management 201 Interventions Blocks Epidural Intrathecal pain pumps Lidocaine infusion Ketamine Sedation Interventions Blocks Epidural Intrathecal pain pumps Lidocaine infusion Ketamine Sedation

46 Interventions Palliative surgery Nerve Blocks Kyphoplasty/Vertebroplasty Epidural Intrathecal pain pumps

47 Celiac Plexus Block

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49 Kyphoplasty/Vertebroplasty

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51 Intrathecal Pain Pumps

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54 Conclusion 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! 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!

55 Conclusion 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 “4 th step” in WHO ladder and utilize your multidisciplinary resources 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 “4 th step” in WHO ladder and utilize your multidisciplinary resources

56 Palliative Care Service N4N – Fellows: Dr. Paresh Patel, Dr. Keith Swetz NPs – Pat Coyne and Bart Bobb N4N – Fellows: Dr. Paresh Patel, Dr. Keith Swetz NPs – Pat Coyne and Bart Bobb

57 Questions?


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