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Management of Chronic Pain with Reference to Cancer Pain Relief

Dr Gaurav Dhakate. Management of Chronic Pain with Reference to Cancer Pain Relief. University College of Medical Sciences & GTB Hospital, Delhi.

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Management of Chronic Pain with Reference to Cancer Pain Relief

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  1. Dr GauravDhakate Management of Chronic Pain with Reference to Cancer Pain Relief University College of Medical Sciences & GTB Hospital, Delhi

  2. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain)Chronic painis defined as persistent pain, which can be either continuous or recurrent and of sufficient duration and intensity to adversely affect a patient's well-being, level of function, and quality of life.

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

  4. Pain is the 5th vital sign

  5. LEARNING OBJECTIVES After completing this seminar, you will be able to: • Explain the principles of cancer pain management . • Discuss the principles of opioid use in patientswith chronicpain. • Understanding the concept of neurolytic blocks and advanced neuromodulation in cancer pain management

  6. Prevalance • 10 million cancer cases every year globally • 1 million cancer pain patients in India. • Majority present with advanced stage • 60 – 90 % of them will need pain management therapy. • 25 % will die without getting pain management therapy. • 1.World Health Organization. Expert committee report. Cancer pain relief and palliative care. Technical series 804. Geneva: World Health Organization; 1990. • 2. World Health Organization. Cancer pain relief, 2nd ed. With a guide to opioid availability: World Health Organization; Geneva 1996.

  7. Dame Cicely Saunders • Founder of the hospice and palliative care movement worldwide • “we will do everything possible , not only to help you die peacefully , but to live until the last moment of your life” …..Dame cicely saunders

  8. Spiritual Emotional

  9. Clinical Highlights and Recommendations: Cancer pain assessment should include • determining the mechanisms of pain • intensity • quality and onset/duration • functional ability and goals • psychological/social factors such as depression or substance abuse

  10. Pain Assessment • Temporal features • Location/Radiation • Severity/Quality • Aggravating and alleviating factors • Previous history (chronic pain, family) • Medication(s) taken • Dose • Route • Frequency • Duration • Efficacy • Side effects

  11. The goal • Is an emphasis on improving overall functioning. • And providing pain relief. • To let him/ her die in peace and comfort.

  12. Standardized approach to the management of cancer pain with opioids • Comprehensive medical history and examination • Nonopioid and nonmedical approaches should be tried before opioid therapy . • Fully explain the likely benefits and adverse effects • Use adjunctive treatments (medical and nonmedical) • Opioidmonotherapy is rarely successful. • Careful documentation

  13. Symptom Prevalence • Pain • Fatigue/Asthenia • Constipation • Dyspnea • Nausea • Vomiting • Delirium • Depression/suffering • 80 - 90% • 75 - 90% • 70% • 60% • 50 - 60% • 30% • 30 - 90% • 40 - 60%

  14. Causes of cancer pain • Cancer itself : e.g. soft tissue , visceral , bone , neuropathic , metastasis (62 % ) • Treatment related : chemotherapy related , mucositis , postoperative syndromes , radiotherapy induced (20 %) • Debility : e.g. constipation , muscle spasm / tension.(10% ) • Concurrent disorders : spondylosis , osteoarthritis Seemamishra , Sushmabhatnagar , Amitkrsinghal .Recent trends in cancer pain management .indian journal of medical and pediatric oncology 2004 ; 25 : 22 -28.

  15. Prevalance of Cancer pain • Head and neck (67–91%) • · Prostate (56–94%) • · Uterine (30–90%) • · Genitourinary (58–90%) • · Breast (40–89%) • · Pancreatic (72–85%)

  16. Major Categories of Pain Classified by inferred pathophysiology: • Nociceptive pain (stimuli from somatic and visceral structures) • Neuropathic pain (stimuli abnormally processed by the nervous system)

  17. Nociceptive Pain • Mechanism: Pain receptor activation • Subtypes: • Somatic • most common type in cancer patients • bone mets most common cause • characterized by aching, throbbing, gnawing • Visceral • deep, squeezing, crampy

  18. Cancer Pain Nociceptive • Somatic: • intermittent to constant • sharp, knife-like, localized • e.g. soft tissue infiltration

  19. Cancer Pain Nociceptive • Visceral: constant/intermittent • crampy/squeezing • poorly localized, referred • e.g. intra-abdominal mets

  20. Cancer Pain Nociceptive • Bony: constant, dull ache • localized, may have • neuropathic features • e.g. vertebral metastases • pathologic fractures

  21. Neuropathic Pain: • Mechanism: Damage to receptor or nerve • Frequently unrecognized • Types of Syndromes: • Peripheral • chemo induced (Cisplatin, Paclitaxel) • Central • Cord compression

  22. Neuropathic Pain Syndromes: • Post-amputation Limb Pain • Post-thoracotomy Pain • Post-mastectomy Pain syndrome • Brachial Plexopathy • LS Plexopathy • Celiac plexus Infiltration

  23. Cancer Pain • Neuropathic • Destruction/infiltration of nerves • a) dysesthetic: • burning/tingling • constant, radiates • e.g. post-herpetic neuralgia

  24. Cancer Pain • Neuropathic • Destruction/infiltration of nerves • b) neuralgic: • shooting/stabbing • shock-like/lancinating • paroxysmal • e.g. trigeminal neuralgia

  25. Nociceptive soft tissue visceral Agent opioids opioids steroids surgery radiation tx Pain Management

  26. Priority Aims: • Improve the appropriate use of Level I and Level II treatment approaches for adult patients with chronic pain. • Improve the effective use of non-opioid medications • Improve the effective use of opioid medications

  27. WHO 3 Step Ladder of Pain Management: • Step 1 • NSAID’s • Acetaminophen • Non-pharmacological techniques • Step 2 • Mixed opioid + non-opioid • Low dose opioid agonists (tramadol ) • Alternative pharmacological agents • Step 3 • Pure opioids (morphine , oxycodone) • Adjunctive medications • Invasive procedures ( step 4 ?)

  28. Clinically Important Questions: • Current pain level • Average pain level • Worst pain level • Pain relief with medications • Breakthrough pain

  29. Basic rule of opioid administration • Use oral or transdermal formulations if oral not possible • Start with immediate release formulations in patients with significant pain • Use medications round-the-clockfor constant pain (fixed dosing) • Fixed dose interval should be based on T1/2 of the agent • Rescue dose interval should be based on time to peak effect

  30. Opioid Morphine Hydromorphone Oxycodone Methadone Fentanyl Active Metabolites Morphine-6-glucuronide Morphine-3-glucuronide Normorphine Noroxycodone Oxymorphone None known Unknown Opioid Metabolites

  31. Oral morphine • Morphine remains scarce world wide. • Tight regulations by narcotic dept. • India supplies most of the opium for morphine to rest of the world but keeps very little for domestic use . The Hindu. “Experts call to relax narcotic laws.” R. Madhavan Nair March 14, 1998 The Indian Express. “Shortage of morphine hits cancer patients.” June 23, 1998 pg.1 The Indian Express. “Pain relief centers run short of morphine.” June 25, 1998 pg.1

  32. By the mouth By the clock By the ladder Oral morphine • Has been used in doses every 4 hourly from 5 mg upto 1200 mg per day . • Very few need > 200 mg per day. • Slow released are equally efficacious . ( 60 mg twice a day)

  33. EASP guidelines • The opioid of first choice for moderate- severe pain is oral morphine. • Best is oral > subcutaneous (1 : 3 potency to oral )> iv.(do) • Normal release morphine – 4 hrly (dose titration) . Sustained release 12 hrly (maintainance ). • OTFC for breakthrough pain. • Hydromorphone / oxycodone/ methadone are also alternatives to morphine. • Spinal / epidural route.

  34. Opioid Morphine Hydromorphone Oxycodone Methadone Fentanyl Sufentanil Codeine PO IV/SC 10 mg 3 mg 2 mg 1 mg 5 mg 2.5 mg 1 mg 50 mcg 5 mcg 100 mg 50 mg Analgesic Equivalence

  35. Opioid Side Effects • Constipation 46 % • Nausea/vomiting 32 % • Urinary retention • Itch/rash • Dry mouth • Respiratory depression • Drug interactions

  36. Opioid-Induced Neurotoxicity (OIN) • Neuropsychiatric syndrome • Cognitive dysfunction • Delirium • Hallucinations • Myoclonus/seizures • Hyperalgesia/allodynia

  37. OIN: Treatment • Opioid rotation • Reduce opioid dose • Hydration • Circadian modulation • Psychostimulants • Other Rx

  38. Opioid Rotation • Metabolites cause OIN • Change to another opioid analgesic • 25 - 50% dose reduction • Morphine/hydromorphone/oxycodone • Second line agents • fentanyl/sufentanil • methadone

  39. Bone Metastases Frequency of Bone Metastases Associated WithCommon Malignancies Primary tumor Bone mets Breast carcinoma 50%–85% Prostate carcinoma 60%–85% Lung carcinoma 64% Bladder carcinoma 42% Thyroid, kidney carcinoma 28%–60% .

  40. Bone Pain Pharmacologic treatment • Opioids • NSAIDs/steroids/Cox-2 inhibitors • Bisphosphonates • pamidronate • clodronate • zoledronate

  41. Bone pain NSAIDs • Anti-inflammatory, anti-PEG • S/E: gastritis/ulcer, renal failure • K+ , platelet dysf’n • Ibuprofen, naproxen Don’t use both steroids & NSAIDs!

  42. Cox-2 Inhibitors Celecoxib Meloxicam Valdecoxib Anti-inflammatory Anti-prostaglandin S/E: less gastritis no platelet dysf’n renal failure still a problem OD dosing expensive Bone pain

  43. Bisphosphonates: Mechanism of Action Hemopoieticstem cell Physico-chemical Cellular Clodronate Recruitment Fusion Pre-osteoclast Binding to theCa-Ph crystals Osteoclast activity Osteoclast Collagen Mineral Inhibition of dissolution of the mineral phase R. Bartl

  44. Bone Pain Radiation treatment • Single tx (800 cGy) • Multiple tx (200 cGy x 3-5) • Effective immediately • Maximal effect 4 - 6 wks • 60-80% pts get relief

  45. Bone Pain Surgical options • Pathologic # (splint, cast, ORIF) • Intramedullary support • Spinal cord decompression • Vertebral reconstruction

  46. Neuropathic Pain Pharmacologic treatment • Opioids • Steroids • Anticonvulsants • TCAs • NMDA receptor antagonists • Anaesthetics

  47. Adjuvants Steroids •  inflammation •  edema •  spontaneous nerve depolarization • Multipurpose

  48. Adjuvants Anticonvulsants • Pregabalin • Gabapentine • Lamotrigine • Carbamazepine • Valproic acid

  49. Adjuvants Antidepressants • Amitriptyline • Nortriptyline • Desipramine • SSRIs: results disappointing

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