1. CANCER PAIN MANAGEMENT SCOTT MAGNUSON, MD PAIN MANAGEMENT OF NORTH IDAHO, PLLC

2. FACTS Cancer is a leading cause of death worldwide accounting for 8.2 million deaths in 2012 according to WHO Cancer is the second leading cause of death in the US Pain will affect more than 70% of those patients with cancer More than 50% of patients with cancer pain will rate it as moderate to severe WHO estimates that 95% of these patients should be able to achieve adequate pain control

3. COMMON CANCER PAIN TREATMENTS Opioids Co-analgesics Anti-neoplastic therapies Interventional techniques Cognitive behavioral therapies

4. BARRIERS TO EFFECTIVE PAIN MANAGEMENT Fear of addiction (patient and provider) Fear of disease progression Acceptance of inevitability of pain Communication barriers Side effects of medications including tolerance Lack of adequate assessment by provider Lack of training in pain management Regulatory fears

5. CANCER PAIN IS COMPLEX 90% of pain is tumor related 70% due to tumor 20% due to procedures for evaluation or treatment of the tumor 10% is other non related pain generators

6. PATHOPHYSIOLOG Y Cancer pain shares the same neurophysiologic pathway as non-cancer pain

7. CANCER PAIN ASSESSMENT

9. NON-OPIOID PAIN MEDICATIONS Acetaminophen NSAIDs COX2 inhibitors

10. OPIOIDS FOR MILD TO MODERATE PAIN MEDICATIONADULT DOSINGMAX DAILY DOSE TRAMADOL 50-100 MG Q 4-6 HRS 400MG BUTRANS5 MCG Q 7 DAYS20 MCG TAPENTADOL 50-100 MG Q 4-6 HRS 600 MG CODEINE 15-30 MG Q 4-6 HRS 360 MG HYDROCODONE 2.5-10 MG Q 4-6 HRS

11. OPIOIDS FOR MODERATE TO SEVERE PAIN EXTENDED RELEASE MEDICATION ADULT DOSING (STARTING DOSE IN OPIOID TOLERANT PATIENTS) NOTES MORPHINE 15-30 MG Q 8-12 HRS MAY INCREASE DOSE Q 1-2 DAYS OXYCODONE 10-20 MG Q 12 HRS MAY INCREASE DOSE Q 1-2 DAYS FENTANYL 12-25 MCG PATCH Q 72 HRS MAY INCREASE DOSE Q 3-6 DAYS OXYMORPHONE 5-10 MG Q 12 HRS MAY INCREASE DOSE Q 3-7 DAYS HYDROMORPHONE8 MG Q 24 HRS MAY INCREASE DOSE Q 3-4 DAYS METHADONE 2.5-5 MG Q 8-12 HRS INC NO MORE THAN Q 1-2 WKS

12. ANALGESIA VS PAIN

13. BREAKTHROUGH PAIN Use sustained release opioid for baseline pain control Dose short acting opioid prn for BTP Each dose for BTP should be roughly 10% of total daily dose of sustained release opioid If greater than 4 episodes of BTP per day, increase sustained release opioid by at least amount of BTP med used in 24 hours

14. OPIOID ROTATION Humans have at least 11 variants of morphine opiate receptor - 1 First opioid prescribed is only effective for 36% of patients Calculate equianalgesic dose using equianalgesic table or calculator and decrease that dose by 30-50% to start with because of incomplete cross tolerance Goal is to find the opioid with the greatest relief with the least amount and severity of side effects

16. ADJUVANT ANALGESICS: ANTIDEPRESSANTS Tricyclic antidepressants Tertiary amines (amitriptyline) Secondary amines (nortriptyline, desipramine SSRIs paroxetine citalopram SNRIs venlafaxine duloxetine Bupropion

17. ANTIDEPRESSANT DOSING MAY INCREASE DOSE Q 1-2 DAYS STARTING DOSE USUAL EFFECTIVE DOSE AMITRIPTYLINE10-25 MG Q HS50-150 MG NORTRIPTYLINE10-25 MG Q HS50-150 MG DESIPRAMINE10-25 MG Q HS50-150 MG PAROXETINE10-20 MG Q D20-40 MG CITALOPRAM10-20 MG Q D20-40 MG VENLAFAXINE37.5 MG Q D37.5-112.5 MG BUPROPION50-75 MG BID75-150 MG

18. CORTICOSTEROIDS Effective for bone pain, arthralgias, visceral pain, neuropathic pain Dexamethasone (2-4 mg/qd-bid) first choice due to low mineralcorticoid activity. Prednisone also used. Can also stimulate appetite and lessen nausea and fatigue Lowest effective dose should be used

19. ALPHA-2 ADRENERGIC AGONISTS Clonidine Tizanidine May be effective for neuropathic pain but studies are lacking Intraspinal clonidine has been shown to be effective for neuropathic pain in cancer patients

20. ANTICONVULSANTS GABAPENTIN FIRST LINE AGENT. EFFECTIVE FOR NEUROPATHIC PAIN. WIDE THERAPEUTIC RANGE. GOOD SAFETY PROFILE AND TOLERABILITY. PREGABALIN SAME EFFICACY AS GABAPENTIN. BID DOSING MAY IMPROVE COMPLIANCE. OTHERS LAMOTRIGENE, OXCARBAZEPINE, CARBEMAZEPINE, LEVETIRACETAM, TOPIRAMATE, TIAGAPINE, ZONISAMIDE

21. LOCAL ANESTHETICS Lidocaine Mexiletine

22. N-METHYL-D-ASPARTATE RECEPTOR BLOCKERS Dextromethorphan Ketamine Amantidine Memantadine

23. OTHER AGENTS Baclofen Cannibinoids Benzodiazepines Psychostimulants

24. TOPICAL ANALGESICS Lidoderm Capsaicin NSAID creams

25. ADJUVANT ANALGESICS FOR BONE PAIN Calcitonin Subcutaneous or intranasal Dose for intranasal is 200 IU via one nostril q day Nausea and hypersensitivity reactions are potential side effects, mostly with the subcutaneuous form Bisphosphonates Pamidronate and zoledronic acid Osteoclast inhibitors

26. NEUROABLATIVE PROCEDURES Provide better pain relief when used in early stages Includes the interruption of pain pathways surgically, chemically or thermally Neuromodulation involves the interruption of pain pathways by opioids or other medications, or by electrical stimulation.

27. SYMPATHETIC BLOCKS Blocks of the sympathetic chain can produce relief for varying cancer pain syndromes. Often, diagnostic block first with local anesthetic followed by neurolytic block is done.

28. CELIAC PLEXUS BLOCK Upper abdominal viscera Reduction or elimination of opioids Successful relief in 85% of pancreatic cancer pain and 73% of pain from other abdominal malignancies Underutilized

29. SUPERIOR HYPOGASTRIC PLEXUS BLOCK Retroperitoneal pain 69% of patients have satisfactory pain relief 72% of patients are able to decrease opioids (average reduction = 43%)

30. GANGLION IMPAR BLOCK Visceral pain in perineal malignancies

31. VERTEBRAL AUGMENTATION Pain due to vertebral compression fractures from metastatic solid malignancies Contraindicated when evidence of posterior cortical disruption, spinal cord compression and overt instability Can be effective in up to 90% of patients with MCFs

32. INTRATHECAL DRUG DELIVERY Opioids +/- nonopioids Prialt Decreased side effects Effective for widespread pain Early use is more cost effective Trend towards improved survival rates

33. SPINAL CORD STIMULATION Effective for neuropathic pain from tumor invasion or as a result of cancer treatment (i.e., postradiation neuropathic pain) Limited studies, but 4 studies in a Cochrane review. All 4 demonstrated improved VAS scores and decreased analgesic use

34. NEUROSURGICAL PROCEDURES Percutaneous cordotomy Commissural myelotomy Limited midline myelotomy Punctate midline myelotomy

35. –DR. ALBERT SCHWEITZER “Pain is a more terrible lord of mankind than even death itself.”