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CANCER PAIN MANAGEMENT PAMELA M. SUTTON, M.D. FAAHPM DECEMBER 2013

CANCER PAIN MANAGEMENT PAMELA M. SUTTON, M.D. FAAHPM DECEMBER 2013. “ TOTAL PAIN ”. “ EVERYTHING HURTS” PHYSICAL PAIN EMOTIONAL PAIN SOCIAL PAIN SPIRITUAL PAIN. PAIN ASSESSMENT. PATIENT RATES INTENSITY/SEVERITY OF PAIN ON SCALE OF ZERO TO TEN LOCATION

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CANCER PAIN MANAGEMENT PAMELA M. SUTTON, M.D. FAAHPM DECEMBER 2013

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  1. CANCER PAIN MANAGEMENTPAMELA M. SUTTON, M.D. FAAHPMDECEMBER 2013

  2. “TOTAL PAIN” “EVERYTHINGHURTS” • PHYSICAL PAIN • EMOTIONAL PAIN • SOCIAL PAIN • SPIRITUAL PAIN

  3. PAIN ASSESSMENT PATIENT RATES INTENSITY/SEVERITY OF PAIN ON SCALE OF ZERO TO TEN • LOCATION • QUALITY (ACHING, BURNING, SHOOTING) • DURATION (INTERMITTENT OR CONTINUOUS) • WHAT MAKES PAIN BETTER/WORSE

  4. CAUSES OF PHYSICAL PAIN IN CANCER • Bone Metastases-50% • Nerve Injury(neuropathic)or compression-25% • Cancer treatments-19%

  5. NOCICEPTIVE vs. NEUROPATHIC PAIN

  6. TREATMENT OF PHYSICAL PAIN • TREAT UNDERLYING ILLNESS • ELEVATE PAIN THRESHOLD • INTERRUPT PAIN TRANSMISSION

  7. WORLD HEALTH ORGANIZATION 3 STEP METHOD FOR CANCER PAIN RELIEF(“Analgesic Ladder”) • STEP 1. “NON-OPIOID” +/- ADJUVANT If pain persists or worsens, go to: • STEP 2. MILD OPIOID +/- NON-OPIOID +/- ADJUVANT If pain persists or worsens, go to: • STEP 3. STRONG OPIOID +/- NON OPIOID+/-ADJUVANT

  8. ANALGESIC LADDER ORAL MEDICATION IS PREFERRED EASE OF ADMINISTRATION STEADY BLOOD LEVELS SAFETY

  9. ANALGESIC LADDER OPIOIDS DO NOT ALWAYS RELIEVE PAIN! NON-OPIOID ADJUVANTS AND/OR OTHER PAIN METHODS MAY BE NECESSARY.

  10. ANALGESIC LADDER PAIN TREATMENT SUCCESSFUL IN 90% OF PATIENTS WITH PROPER MEDICATION USE

  11. WORLD HEALTH ORGANIZATION 3 STEP METHOD FOR CANCER PAIN RELIEF(“Analgesic Ladder”) • STEP 1. “NON-OPIOID” +/- ADJUVANT If pain persists or worsens, go to: • STEP 2. MILD OPIOID +/- NON-OPIOID +/- ADJUVANT If pain persists or worsens, go to: • STEP 3. STRONG OPIOID +/- NON OPIOID+/-ADJUVANT

  12. NON-OPIOID ANALGESIC PARACETAMOL 500-1000 MG EVERY 4-6 HOURS • Advantages: Available, cheap, effective for mild pain. • Disadvantages: Potential liver toxicity. Not anti-inflammatory. Not best choice for bone pain.

  13. NON-OPIOID ANALGESICS NSAID’S • Advantages: Anti-inflammatory effects helpful for bone pain. Dosage may be less frequent than paracetamol. • Disadvantages: Potential GI/renal side effects and interference with platelet function.

  14. NSAIDS • SALICYLATES Aspirin • PROPRIONIC ACIDS Ibuprofen--every 6 hours; liquid Naproxen--every 12 hours • ACETIC ACIDS Diclofenac--every 8 hours Ketorolac (Toradol)--oral or parenteral; short term use only

  15. NSAIDS COX 2 INHIBITORS • Celecoxib • Less GI toxicity (not perfect); • Less anti-platelet activity • Potential Renal/Cardiovascular Toxicity

  16. OPIOIDS 1) CODEINE, MORPHINE 2) SEMISYNTHETIC HYDROCODONE BUPRENORPHINE (MIXED AGONIST/ ANTAGONIST) 3) SYNTHETIC METHADONE (DOLOPHINE) FENTANYL (DURAGESIC) TRAMADOL

  17. CONCERNS ABOUT OPIOIDS 1. ADDICTION Physical Dependence and Psychological Craving 2. TOLERANCE Rarely a practical problem. Dose can be increased if tolerance occurs. 3. RESPIRATORY DEPRESSION Rarely a problem when appropriate dose of oral narcotic is titrated to level of pain.

  18. CONCERNS ABOUT OPIOIDS 4. LETHARGY Sleepiness may occur in first hours/days but usually improves. 5. NAUSEA Occurs in less than half of patients. May resolve. 6. CONSTIPATION Frequent problem--should be anticipated with stool softener/laxative on a daily basis. Avoid bulk laxatives.

  19. WORLD HEALTH ORGANIZATION 3 STEP METHOD FOR CANCER PAIN RELIEF(“Analgesic Ladder”) • STEP 1. “NON-OPIOID” +/- ADJUVANT If pain persists or worsens, go to: • STEP 2. MILD OPIOID +/- NON-OPIOID +/- ADJUVANT If pain persists or worsens, go to: • STEP 3. STRONG OPIOID +/- NON OPIOID+/-ADJUVANT

  20. POSSIBLE STEP TWO OPIOIDS (for moderate pain) • CODEINE • TRAMADOL • HYDROCODONE

  21. STEP TWO OPIOIDS CODEINE • 30 mg orally is approximately equal in analgesic effect to 650 mg of aspirin. • When 30 mg codeine and 650 mg aspirin are combined, the analgesic effect equals or exceeds 60 mg codeine.

  22. STEP TWO OPIOIDS HYDROCODONE • May be packaged with paracetamol or ibuprofen. Beware of associated toxicity.

  23. STEP TWO OPIOIDS TRAMADOL • Synthetic mu agonist opioid • Reportedly exerts additional analgesic effect by inhibition of serotonin and noradrenaline reuptake.

  24. STEP THREE OPIOIDS(for severe pain) • MORPHINE • METHADONE (Dolophine) • FENTANYL (Duragesic) • BUPRENORPHINE

  25. STEP THREE OPIOIDS MORPHINE • PROTOTYPE OPIOID • SHORT AND LONG-ACTING TABLETS, LIQUID, CONCENTRATE, SUPPOSITORIES, IV/SUBQ, EPIDURAL, INTRATHECAL • ACTIVE METABOLITES CAN CAUSE TOXICITY IN RENAL FAILURE

  26. STEP THREE OPIOIDS METHADONE (Dolophine) • SYNTHETIC • MU AGONIST AND POSSIBLE NMDA RECEPTOR ANTAGONIST (May help neuropathic pain) • ORAL/IV/SUBQ

  27. STEP THREE OPIOIDS METHADONE (Dolophine) • TRICKY TO TITRATE VARIABLE CLINICAL EFFECT. (May accumulate and cause lethargy and potential respiratory depression. ) • EFFECTIVE IN LOW DOSES IN SOME PATIENTS WITH POOR RELIEF FROM HIGH DOSE MORPHINE.

  28. STEP THREE OPIOIDS FENTANYL(Duragesic) • SHORT-ACTING SYNTHETIC, PACKAGED AS THREE DAY PATCH • 25 MCG PATCH APPROXIMATELY EQUIVALENT TO 15 MG ORAL MORPHINE • NOT FOR QUICK TITRATION (ANALGESIC EFFECT PEAKS ABOUT 17 HOURS AND LINGERS THAT LONG WHEN REMOVED) • MAY BE ABSORBED QUICKLY IF TEMP ELEVATION (BEWARE RESPIRATORY DEPRESSION)

  29. STEP THREE OPIOIDS FENTANYL BEWARE ORAL MUCOSAL PRODUCTS: UNCLEAR DOSING, RAPID ABSORPTION

  30. STEP THREE OPIOIDS BUPRENORPHINE (sublingual tablet, transdermal patch) • CAN BE USED FOR MODERATE TO SEVERE PAIN • MAY INDUCE WITHDRAWAL IN OPIOID DEPENDENT PATIENTS

  31. ADJUVANTS IMPORTANT TO TREATMENT OF NEUROPATHIC PAIN ANTIDEPRESSANTS ANTICONVULSANTS ANESTHETICS

  32. ANTIDEPRESSANTS • TRICYCLICS • amitriptyline(Elavil) • nortriptyline(Pamelor) • SSRI’s • paroxetine(Paxil) • Others: • venlafaxine (Effexor) • mirtazipine (Remeron) • duloxetine (Cymbalta)

  33. ANTICONVULSANTS • gabapentin (Neurontin) • pregabalin (Lyrica) • clonazepam (Klonopin)

  34. ANESTHETICS FOR PAIN • Lidocaine IV, Ointment, Lidoderm Patch • EMLA • Ketamine Oral, IV, Subq OTHER TOPICAL PREPARATIONS • Capsaicin • SUMMARY • CANCER PAIN CAN AND MUST BE RELIEVED • OBTAIN THOROUGH HISTORY AND PHYSICAL EXAM • ADMINISTER MEDICATION ON A REGULAR BASIS • ACCORDING TO THE ANALGESIC LADDER • STEP 1. NON-OPIOID +/- ADJUVANT • If pain persists or worsens, go to: • STEP 2. MILD OPIOID + NON-OPIOID +/- ADJUVANT • If pain persists or worsens, go to: • STEP 3. STRONG OPIOID +/- NON-OPIOID+/-ADJUVANT • OFFER EMOTIONAL SUPPORT • REASSESS PAIN AND EFFECTIVENESS OF TREATMENT • FREQUENTLY

  35. PAIN SUMMARY PAIN MUST BE RELIEVED THOROUGH HISTORY AND PHYSICAL EXAM MEDICATION ON A REGULAR BASIS ACCORDING TO THE ANALGESIC LADDER STEP 1. NON-OPIOID +/- ADJUVANT STEP 2. MILD OPIOID +/- NON-OPIOID +/- ADJUVANT STEP 3. STRONG OPIOID +/- NON-OPIOID+/-ADJUVANT EMOTIONAL SUPPORT REASSESS PAIN AND EFFECTIVENESS OF TREATMENT FREQUENTLY

  36. OPIOID EQUIVALENCE 5 MG OF OF IV OR SUBQ MORPHINE EVERY 4 HOURS = 15 MG OF IMMEDIATE RELEASE ORAL MORPHINE EVERY 4 HOURS = 25 MCG FENTANYL PATCH EVERY 3 DAYS

  37. USEFUL REFERENCES • ASSESSING AND TREATING PAIN; UNIPAC THREE, AAHPM, 2012. • CANCER PAIN RELIEF, WORLD HEALTH ORGANIZATION, GENEVA, 1986. • EDUCATION FOR END OF LIFE CARE (EPEC) PROJECT,2003; NORTHWESTERN UNIVERSITY SCHOOL OF MEDICINE created with AMA & ROBERT WOOD JOHNSON FOUNDATION, CHICAGO, ILL. • FERRANTE, FM; ‘‘Principles of Opioid Pharmacotherapy: Practical Implications of Basic Mechanisms”, J. of PAIN and SYMPTOM MANAGEMENT; May 1996, Vol. 11, No 5. • FOLEY, KM; “The Treatment of Cancer Pain” ,NEJM;1985, 313:84-95. • MANAGEMENT OF CANCER PAIN, Clinical Practice Guideline #9; AHCPR Publication #94-0592, March 1994. • PRIMER OF PALLIATIVE CARE, 5th Edition; AAHPM, 2010.

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