1. Management of Cancer Pain Prof. Dr. Başak Oyan-Uluç Yeditepe Üniversitesi Hastanesi Medikal Onkoloji Bölümü

2. Cancer pain At diagnosis% 20-50 During treatment% 30-40 Advanced stage %75-90

3. Physiological effects of Pain Decreased limb movement: increased risk of DVT/PE Respiratory effects: shallow breathing, tachypnea, cough suppression resulting increased risk of pneumonia and atelectasis Tachycardia and elevated blood pressure Increased catabolic demands: poor wound healing, weakness, muscle breakdown Increased sodium and water retention (renal) Decreased gastrointestinal mobility

4. Psychological effects of Pain Negative emotions: anxiety, depression Sleep deprivation Existential suffering Patient questions the very foundations of their life: whether their life has any meaning, purpose or value

5. Immunological effects of Pain Decrease natural killer cell counts Tolerance to chemotherapy decrease. infection

6. Cancer pain Physiological effects Psychological effects Immunological effects Decreased quality of life Shorter survival

7. 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

8. Causes of Cancer-Related Pain Tumor / Mass effect (70%) Bone metastases, soft tissue infiltration, nerve infiltration Treatment related (20%) Post-chemotherapy Post-radiation (mucositis, enteritis, etc) Post-surgical (mucositis, neuropathy, G-CSF related bone pain, etc) Other (10%) –Decubitis ulcers, constipation –Postherpetikc neuralgia

9. Types of pain Somatic pain Visceral pain Neuropathic pain

10. Somatic Pain Generally described as musculoskeletal pain Dull, sometimes sharp Intermittent or continuous Well-localized: Because many nerves supply the muscles, bones and other soft tissues, somatic pain is usually easier to locate than visceral pain. Related to tumor / mass effect Example: Soft tissue infiltration, bone metastases

11. Patient with head and neck cancer: Large right sided mass causing somatic pain

12. Visceral Pain Infiltration, compression, extension, or stretching of the thoracic, abdominal, or pelvic viscera Pressure, deep, squeezing, cramps Not well-localized or referred pain Intermittent or continuous Example: Intraabdominal metastases

13. Colorectal cancer with liver metastases: Visceral pain

14. Neuropathic Pain Causes: Cancer compressing or infiltrating nerves/nerve roots/blood supply to nerve Nerve damage from treatments Types: Dysestetic: Burning, “pins & needles” Ex: Postherpetic neuralgia Neuralgic: Sharp, shooting and paroxysmal pain along the course of a nerve Ex: Trigeminal neuralgia

15. Neuropathic Pain Chemotherapy-induced neuropathies: symmetrical polyneuropathy – localized in hands and feet Cisplatin, Oxaliplatin Paclitaxel, Thalidomide Vincristine, Vinblastine Surgical Neuropathies Phantom limb pain Post-mastectomy syndrome Post-thoracotomy syndrome

17. Most cancer pts have some sort of combination of somatic, visceral pain and neuropathic pain Patient with cervival cancer Visceral pain due to peritoneal carcinomatosis Somatic pain: Due to vertebral metastasis Neuropathic pain from nerve root involvement

18. Assessment of cancer pain

19. Assessment of Pain Pain history Onset / duration Severity of paiN Site(s) of pain/radiation Type of pain What aggravates or relieves pain? Impact on sleep, mood, activity Effectiveness of medication

20. Non-verbal signs of pain Autonomic changes –Hypertension, tachycardia, sweating Patients with organic brain syndrome: Agitation or confusion Patients with cognitive dysfunction: Apathy, inactivity, irritability –Refuse eating –Avoidance of painful site –Painful expression on face

21. Principles of Assessment A (Ask) Assess and REASSESS B (Believe) the patient and care-givers C (Choose) Use methods appropriate to cognitive status and context D (Deliver) E (Empower) Include the family

22. Pain scales –Numeric –categoric –Facial expression pictures Body maps Pain queries Assessment of severity of pain MUST BE FİLLED BY THE PATIENT

23. TREATMENT

24. MAXIMUM PAIN CONTROL MINIMUM SIDE EFFECT INCREASED QUALITY OF LIFE No pain at rest No pain with activity No interrruption of sleep due to pain Aims of Cancer Pain treatment

25. Modalities of treatment Pharmacological Management Radiation / Nuclear Medicine Non-Pharmacologic Management Interventions –Blocks –Epidural or intratecal pain pumps –Palliative surgery (ablative neurosurgery) –Nerve Blocks

26. Pharmacological Treatment

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

28. WHO Ladder (1-3) (4-6) (7-10) Oral By the clock Step by step 4. Basamak: Invasive modalities

29. Non-Opioids NSAIDS Acetaminophen (Paracetamol) Topicals Lidocaine, Capsaicin For mild pain Ceiling effect: increasing doses of a given medication to have progressively smaller incremental effect Can be combined with opioids-> Opioid dose lower No tolerance and no addiction risk NSAID: Gastointestinal, renal and hematological side effects

30. Adjuvants Primary indication other than pain, but have some analgesic properties in some painful conditions Usually coadministered with other analgesics Benzodiazepines Antispasmodics Muscle relaxants NMDA-blockers Systemic local anesthetics Antidepressants Anticonvulsants Corticosteroids Neuroleptics Alpha 2 – agonists

31. Adjuvants for special pain types Neuropathic pain: Antidepresants, Anticonvulsants, GABA agonists, etc Bone pain: Osteoclast inhibitors (bisfosfonates), radiopharmaceuticals, corticosteroids Musculoskeletal pain: Muscle relaxants

32. Opioids Step 2 opioids Codeine, Oxycodone, tramadol Step 3 opioids Oxycodone, morphine, fentanyl AVOID: Meperidine If pain constant/chronic – use long-acting opioids with short-acting for breakthrough pain

33. Principles of analgesic treatment Patient –specifc treatment: Dose, route By clock: Analgesics should be administered at regular intervals, not as needed Appropriate dose Consider renal and liver functions When changing to and other opioid or the route of adb- ministration, use “ equal analgesic conversions” guides Avoid placebo

34. Principles of analgesic treatment Be aware of drug side effects and prevent side effects Monitor development of tolerance DO NOT USE MEPERİDİNE (Dolantin) for cancer pain –Toxic metabolite is normeperidine –> highserum levels can cause seizures –Short-acting

35. Side effects of opioids Physiological side effects Sedation Constipation Nausea-vomiting Urinary retention Supression of cough Toxic side effects Lethagy Hallusination Myoclonik jerks Supression of respiration Tolerance to Nausea-vomitingand sedation: Early Tolerance to constipation : Late

36. Success rate of Cancer pain Treatment Oral /Transdermal Administer by clock Step by step Patient-specific Appropriate –Dose –Route –Dose interval Treatment of breakthrough pain Treatment od side effects Success rate>%80

37. Reasons for failure to relieve cancer pain Inadequate dose of opioids –No ceiling dose for agonist opioids like morphine –Only dose-limiting factor: Side effects In young patients, dose should be higher Seminars in Oncology, Vol 27. No.1 February 2000: pp 45-63

38. Torkey Mean: 0.0872 World: Rank number 44 EURO zone Rank number 33

39. Torkey Mean: 0.1763 World: Rank number 106 EURO zone Rank number 42

41. Reason for inadequate doing of opioids? Physicians’ lack of information about opioids Patients’/Relatives’ lack of information about opioids Exaggeration of risks Side effects Risk of addiction Legal factors

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

43. Intervensions Palliative surgery Nerve Blocks Kyphoplasty/Vertebroplasty Epidural Intrathecal pain pumps

44. Celiac Plexus Block

45. Kyphoplasty/Vertebroplasty

46. Intrathecal Pain Pumps

47. Conclusion Cancer pain can effect quality of life and mortality Ask the patient about pain and REASSESS! 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