Cancer Pain Management 101

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

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

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

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

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

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

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

14. Summary • 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

16. Psychological effects of Pain • 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

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

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

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?

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

22. WHO Ladder

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

24. Antidepressants TCAs for neuropathic pain Anticonvulsants Corticosteroids Neuroleptics Alpha2 – agonists Benzodiazepines Antispasmodics Muscle relaxants NMDA-blockers Systemic local anesthetics Adjuvants

25. 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 Adjuvants

26. Opioids • 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 - 10-20% 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 oxycodone6 times/day = 60mg oxycodonein 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

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

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

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

35. Opioid adverse effects Common Uncommon Constipation Bad dreams / hallucinations Dry mouth Dysphoria / delirium Nausea / vomiting Myoclonus / seizures Sedation Pruritus / urticaria Sweats Respiratory depression Urinary retention

36. Radiation / Nuclear Medicine • Radiation – curative treatment, adjuvant, palliative • Bone metastases – pain response rate 35-60%, duration 12-24 wks • Strontium-89

38. Non-Pharmacologic Management • 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

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?

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

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

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

47. Celiac Plexus Block

48. Celiac Plexus Block

49. Kyphoplasty/Vertebroplasty

50. Kyphoplasty/Vertebroplasty