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Pain in the Cancer Patient

Pain in the Cancer Patient. Dr Doris Barwich Pain and Symptom Management FVCC Medical Leader : Hospice Palliative Care Fraser Health Authority. Purpose . Review basic principles of pain management and analgesic therapy

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Pain in the Cancer Patient

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  1. Pain in theCancer Patient Dr Doris Barwich Pain and Symptom Management FVCC Medical Leader : Hospice Palliative Care Fraser Health Authority

  2. Purpose • Review basic principles of pain management and analgesic therapy • Case studies illustrating common pain problems and suggested management including palliative care approaches

  3. Pain in Cancer Patients Incidence - • 30-40% of patients at time of diagnosis or during disease -modifying treatment • 70- 90% in those with advanced disease

  4. Pain in Cancer Patients Etiology • Direct tumour involvement: 62-78% • As a result of diagnostic or therapeutic interventions 19-25% • Post- radiation ( enteritis; nerve injury; osteonecrosis); Post-chemotherapy ( eg mucositis; peripheral neuropathy); Post- operative pain- acute and chronic • Cancer induced syndromes <10% • Constipation, pressure sores, shingles • Pain unrelated to malignancy or treatment 3-10%

  5. Types of Pain • Acute: • Eg procedural pain; pathological fracture; bowel/ureteric obstruction • Chronic • Acute on Chronic (Breakthrough pain) • Malignant; Non-Malignant

  6. Types of Pain • Nociceptive: Direct response to tissue injury • Includes musculoskeletal (somatic) and visceral pain • Neuropathic: Pain associated with damage to the nervous system • Mixed pain syndromes

  7. Goals of Pain Management • In cancer: > 80% will achieve good control 15% will have fair control < 5% will have poor or no control

  8. Impact on Function Sleep Impaired cognitive function Quality of life Outcomes Depression Decreased socialization Increased health care utilization Increased costs Untreated Pain

  9. “Pain is a more terrible lord of mankind than even death itself ” Albert Schweitzer

  10. George • 83 year old widower: Lives alone • Ca Prostate with Bony metastases; Hx OA/ ISHD/ Depression • Brought in by daughter: Won’t leave the house • Increased pain in his shoulder and lower back for 2 weeks • Constipated

  11. Pain Assessment • Listen carefully: What are the words used? • May deny pain but will admit to having “discomfort”, “aching” or “soreness” • Do you hurt anywhere? • Are you uncomfortable? • How does it affect you? • Believe the patient “pain is what the patient says hurts….thebest judge of a patient’s pain is the patient” Bonica • Assess for other symptoms: Portenoy: Study of 243 cancer patients- Average of 11.5 symptoms

  12. Pain Assessment Tools OLD CARTS O: Onset – acute vs gradual L: Location (+ radiation) D:Duration (recent/chronic) C: Characteristics (quality of pain) A: Aggravating factors R: Relieving factors T:Treatments – previously tried - response - dose/duration - why discontinued? S: Severity: Pain Scales: 0- 10; VAS

  13. Please rate your pain by circling the one number that best describes your pain _____________________________________________________________ 0 1 2 3 4 5 6 7 8 9 10 What is your Pain at it’s Best / Worst/ Present/ AverageNo Pain Pain as bad as you can imagine In the past 24 hours, how much RELIEF have pain treatments or medications provided? Please circle the one percentage that most shows how much. _____________________________________________________________ 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

  14. Brief Pain Inventory: Cleeland • Please rate your pain by circling the one number that best describes your pain • ____________________________________________________________ 0 1 2 3 4 5 6 7 8 9 10 No Pain Pain as bad as you can imagine What is your Pain at it’s Best / Worst/ Present/ AverageIn the past 24 hours, how much RELIEF have pain treatments or medications provided? Please circle the one percentage that most shows how much. _____________________________________________________________ 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

  15. OPQRSTUV ONSET: When did it start? P ATTERN: How often; When; How long? Q UALITY: Describe it: sharp, dull... R ELIEVING/AGGRAVATING FACTORS S EVERITY: Scale of 1- 10 T REATMENTS: What helps; For how long U NDERSTANDING: What do you think is causing it?. How does it affect you? V ALUES: Goals Of Care; expectations

  16. Pain History: George • O(nset): Several months/  2 weeks • P(attern): R shoulder/lower back pain. Constant. Increased with movement. • Q(uality): Steady aching pain • R(elief): Medication helps for about 2-3 hrs • S(everity): 6/10. 10/10 with movement • T(reatments): T#3 helps for about 2-3 hours.Takes about 12-15 T#3 a day • U(nderstanding): Not going on any Morphine. I’m not dead yet.

  17. Examination • No evidence of fractures but clearly limited ROM in the shoulder due to pain • No vertebral tenderness and no neurological signs • Bowel and bladder function normal • Xrays show bony mets in shoulder and lumber spine

  18. Pain Assessment • Once assessment complete: • Type of pain • Severity of Pain • Probable cause of pain • Options for pain relief

  19. George – approach to treatment Develop a problem list to resolve • somatic /bone pain • acetaminophen dosing too high (~4 gms) • constipation contributing to pain intensity • compliance issues

  20. How would you better manage George’s pain?

  21. Principles of Pain Management Clarify the goals: • Improved Quality of Life • Improved function • Involve the individual and family in setting priorities Educate: Appropriate medication for the type of pain/severity KEY: Be flexible and creative Monitoring/ Attention to detail

  22. Pain Management Educate patient and family: • Myth: “Save it for when it gets worse” • FACT: Treating early prevents pain • FACT: No ceiling effect of strong opioids • FACT: Tolerance is rare in Palliative Patients/PO route • Myth: “I’ll become addicted” • FACT: Addiction is rare. Boston study- 0.03% • Myth: Treatment worse than pain • FACT: Side effects can be managed/treated

  23. Education Constant pain requires regular dosing • avoid peaks of pain as with prn/bolus dosing • uninterrupted sleep • smoother blood levels can provide more consistent pain control • more convenient • less analgesia over time

  24. Pharmacology of Pain Management • Acetaminophen • NSAIDS • Opioids

  25. Adjuvants/ Co analgesics • Bisphosphonates/Calcitonin • Antidepressants • Anti-convulsants • Disease specific therapies: Radiation/Chemotherapy/Surgery • Steroids

  26. Principles of Opioid Use • Opioids help relieve moderate to severe pain ( and dyspnea) • Episodic pain - Prescribe as needed rather than around-the-clock • Constant pain = Regular dosing PLUS a “breakthrough” PRN dose • Right drug at the Right dose • Monitor number of PRN’s used or persistent pain; Adjust as needed

  27. Analgesics • Step 1: Mild pain: • Acetaminophen: Max 4 gm/day • Can be very effective for mild-moderate pain if given regularly • NSAIDs: Issues re GI and renal toxicity • Concerns in the elderly • Non-specific: Use with GI protection • COX 2 agents safer re GI morbidity and antiplatelet effects

  28. Opioid Analgesics: Step 2 + 3 • Step 2: Codeine • About 10% of population lack enzyme to convert to Morphine • Ceiling effect:> 600 mg/day • Very constipating • Combination product or alone • 1:10 ( Morphine:Codeine) • Sustained release preparation : Codeine Contin 50,100,150, 200 mg

  29. Oxycodone: Moderate ->Strong Opioid • Active at the mu and kappa receptors • Safe with decreased renal function • Potency Oxycodone 1.5 - 2 :1 Morphine • Less constipating than Codeine • Lasts ~ 4-5 hours • No ceiling effect • Alone or with ASA/Acetaminophen • OxyContin 10, 20, 40, 80 mg

  30. Strong Opioids • Morphine still gold standard • Concerns re: metabolites in renal failure; elderly • Hydromorphone: • More soluble. • Few metabolites • 5x more potent than Morphine.

  31. Opioid Pharmacology • Cmax = 60 mins (after PO dose) 45 mins (after SC dose) 30 mins (after IM dose) 6 mins (after IV dose) • t1/2 = 3-4 hours • SS = 20-24 hrs (immediate-release) 48-72 hrs (sustained-release)

  32. Strong Opioids • Fentanyl: Not at mu receptor. More lipophilic • 100x more potent than Morphine. • Less constipation and nausea. • Less histamine release • Useful in true opioid allergy

  33. Fentanyl • Transdermal Patch: 4 strengths in mcg/hour: • 25 ~ 100 mg Morphine/day (45 -134) • 50 ~ 200 mg (135-224), 75 (225-314), • 100 ~ 400 mg (315-404 mg M/day) • Takes ~17 hours to reach steady state • Patch lasts 72 hours in 90% of patients • Sublingual, intranasal, subcutaneous, IV routes

  34. Opioid equi-analgesic doses • 10 mg PO morphine =5 mg SQ/IV morphine (half the oral dose) = 100 mg PO codeine (1/10) = 2 mg PO Hydromorphone (1mg SQ) (5x more potent) = 5 - 7.5 mg PO Oxycodone ( 1.5x) = 0.5- 1 mg PO/pr methadone ( not Q4H) ( ~~10 x more potent)

  35. George Proposed management strategy?

  36. George • 12-15 T#3 = • 3900- 4875 mg acetaminophen plus • 360- 450 mg codeine ~ 36- 45 mg PO morphine (TDD) ~ 7- 9 mg PO hydromorphone (TDD) ~ 25- 30 mg PO oxycodone (TDD) ~Patch? • Concerns re Acetaminophen dose/ Approaching ceiling Codeine

  37. George • Rotation to strong opioid: • Which one? • Dose: ? Equianalgesic • ? Increase dose • ? BT

  38. Opioid Adverse Effects • Constipation: “ The hand that writes the opioid prescription should start the laxative” • Stimulant (+/- softener) (+/- osmotic) • Nausea: • Approximately 50% will have some nausea in first week; 30% after that • In those prone to nausea consider anti-emetic (metoclopramide)

  39. Opioid Adverse Effects • Neurologic: • gait disturbances • dizziness • falls • Cognitive-behavioural effects: • sedation • impaired concentration • Respiratory depression: RARE

  40. George: 2 days later Morphine SR 30 mg BID = 60 mg PLUS 6 BT of 5 mg = 30mg 90mg • Increase to morphine SR 45 mg BID • BT: 10% of TDD or 1/2 of Q4H dose

  41. Bone Pain What role would the following play? • Radiotherapy • NSAIDs • steroids • bisphosphonates • calcitonin • What else might you do?

  42. Bone Pain • Bone metastases are associated with bone destruction and new bone formation • Also compression or pathologic fractures • High density of pain fibres in the periosteum

  43. Bone Pain • Prostaglandins: • Produce both osteolytic and osteoclastic bone changes • Sensitize nociceptors and can produce hyperalgesia

  44. Management • Opioids effective BUT often need adjuvants/co-analgesics • NSAIDS • Radiotherapy • Bisphosphonates • Calcitonin

  45. NSAIDS • Both peripheral and central effects • Inhibit cyclo-oxygenase (COX) enzyme ->  Decreased prostaglandin production • Specific COX 2 inhibitors: Celecoxib, rofecoxib. Less GI effects • Less effect on platelet function • “Selective” COX 2 inhibitors: Diclofenac • Nonacetylated salicylates: Diflunisal

  46. Bisphosphonates • Inhibit osteoclast function ->  production of cytokines  Pain Indications: • Hypercalcemia • Bone pain • Prophylactic use to prevent fractures and bone pain

  47. Bisphosphonates 3 common agents: • Disodium Pamidronate: • 90-120 mg IV over 3-4 hours. • Benefit within 7-14 days. • Benefit seen in ~ 50% • Repeat Q3-4 weeks if beneficial

  48. Biphosphonates • Sodium Clodronate: • 1.5 g IV/SQ initially plus maintenance 1600 mg PO OD • Can be given SQ • Zoledronic Acid: • 4 mg IV over 5-15 min • Lasts ~ 5 weeks • More potent inhibitor of Prostate Ca cell growth than pamidronate

  49. Management of Bone Pain • Radiotherapy: Cochrane review • Complete pain relief in 25% at one month • Reduction in pain in further 41% • Median duration of relief: 12 weeks • In “long bones” may be just one dose • Chemotherapy • Orthopedic: Pre-emptive pinning of an incipient bone fracture; bracing; vertebroplasty

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