Cancer Pain ManagementCancer Pain Management

ancer

Cancer Statistics: 2010(ACS, 2010)

• One-third of Americans born this year will develop cancer.

• Cancer is the second leading cause of death among Americans, accounting for 1 of every 4 deaths.

• It will occur in approximately 1,529,560 people and account for about 569,490 deaths this year.

• Life-time risk:– Men – 1:2

– Women – 1:3

2010 Estimated US Cancer Cases*

*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2009.Source: American Cancer Society, 2009.

MenMen789,620789,620

WomenWomen739,940739,940

28% Breast28% Breast

14% Lung & bronchus14% Lung & bronchus

10% Colon & rectum10% Colon & rectum

6% Uterine corpus6% Uterine corpus

4% Non-Hodgkin4% Non-Hodgkin lymphoma lymphoma

4% Melanoma of skin 4% Melanoma of skin

5% Thyroid5% Thyroid

3% Leukemia3% Leukemia

3% Pancreas3% Pancreas

3% Ovary 3% Ovary

3% Kidney & renal pelvis3% Kidney & renal pelvis

25% All Other Sites25% All Other Sites

ProstateProstate 28%28%

Lung & bronchusLung & bronchus 15%15%

Colon & rectumColon & rectum 9%9%

Urinary bladderUrinary bladder 7%7%

Melanoma of skinMelanoma of skin 5%5%

Non-HodgkinNon-Hodgkin lymphoma lymphoma4%4%

Kidney & renal pelvisKidney & renal pelvis 4%4%

Oral Cavity & pharynxOral Cavity & pharynx 3%3%

LeukemiaLeukemia 3%3%

PancreasPancreas 3%3%

All Other SitesAll Other Sites 20%20%

2010 Estimated US Cancer Deaths

ONS=Other nervous system.ONS=Other nervous system.Source: American Cancer Society, 2009Source: American Cancer Society, 2009..

MenMen299,200299,200

WomenWomen270,290270,290 26%26% Lung & bronchusLung & bronchus

15%15% BreastBreast

9 %9 % Colon & rectumColon & rectum

5%5% OvaryOvary

7%7% PancreasPancreas

3%3% LeukemiaLeukemia

4%4% Non-HodgkinNon-Hodgkinlymphomalymphoma

3%3% Uterine corpusUterine corpus

2%2% Liver & intrahepaticLiver & intrahepatic

bile duct bile duct

2%2% Brain/ONSBrain/ONS

24% All other sites24% All other sites

Lung & bronchusLung & bronchus 29%29%

ProstateProstate 11%11%

Colon & rectumColon & rectum 9%9%

PancreasPancreas 6%6%

LeukemiaLeukemia 4%4%

EsophagusEsophagus 4%4%

Liver & intrahepaticLiver & intrahepatic 4%4%bile ductbile duct

Non-HodgkinNon-Hodgkin 4%4%lymphomalymphoma

Urinary bladderUrinary bladder 3%3%

Kidney & renal pelvisKidney & renal pelvis 3%3%

All other sitesAll other sites 24%24%

Cancer Pain: Prevalence

• 50% of patients in all stages have pain

• 70% - 90 % of patients with advanced disease have moderate-severe pain

• I

• Inadequate pain control adds to morbidity, mortality, decreased quality of life, and increased costs of care

Prevalence of Cancer-Related Pain

• World Health Organization estimates 3.5 million people suffer from unrelieved cancer pain each day

• Newly diagnosed cancer: 28%

• Actively receiving anticancer treatment: 50-70%

• Advanced disease: 70-80%– 40-50% report it as moderate - severe; up to 30% report their

pain as very severe

• Nursing home residents with cancer:– 45-80% have substantially under-treated pain

Patient is cancer-free and still has pain

• Cancer treatment results in “non-malignant” pain– Post-thoracotomy pain– Post-mastectomy pain– Post-amputation pain

• Phantom Limb pain

• Stump/Neuroma pain

– Chemotherapy-induced painful peripheral neuropathy (CIPN)

– Radiation Therapy injuries

Pain Follow-up

• How do you treat the patient after their cancer has been cured or is in remission?

• The line between “malignant” pain and “chronic” pain becomes obscured

• Standard opioid medication therapy may not be the most appropriate treatment

The Experience of Pain Requires Telling a Personal Story & for Someone to Hear It

• Are there differences in the way one tells a personal story?

• Are there differences in the way one listens to a personal story?

• Are there gender differences?

Is There Time to Hear Our Patient’s Pain Story?

• Time limitations• Competing priorities• Distractions• Distancing

• The average length of a patient’s opening statement is three minutes– 77% of the time, we interrupt within the first 2

minutes– Research shows that 99% of time, once a patient

has been interrupted, he/she does not get a second chance

(Dr. Neil Irick, N., 2004; 29th ONS Congress Lecture)

Pain Assessment in Oncology

• Pain history– Location, intensity, quality, temporal patterns,

aggravating/alleviating factors– Current and past medication use, include OTC– Meaning of pain

• Physical examination

• Laboratory evaluation

• Reassess frequently

Categorizing Cancer Pain

• Acute vs. chronic

• Etiology (related to cancer or its treatment)

• Quality (nociceptive vs. neuropathic)

• Multiple sites and types of pain are common

Pain Syndromes in Oncology: Acute vs. Chronic Pain

• Acute pain– Associated with diagnostic procedures– Associated with therapeutic interventions– Associated with infection– Associated with vascular events

• Chronic pain or persistent

Acute Pain Syndromes in Oncology

• Pain associated with diagnostic procedures– Lumbar punctures– Bone marrow biopsies

• Pain associated with therapeutic interventions– Postoperative pain– Tumor embolization– Pleurodesis for pleural effusions

Acute Pain Syndromes in Oncology

• Pain associated with infection– Acute herpetic neuralgia (shingles)

• Pain associated with vascular events– Deep vein thrombosis– Superior vena cava syndrome

Pain Syndromes in Oncology: Etiology

• Pain associated with the cancer– Bone metastases, liver tumor

• Pain associated with cancer treatment– Painful peripheral neuropathy from chemotherapy,

postsurgical pain, flare from hormonal therapy, osteoradionecrosis from radiation therapy

• Pain unrelated to cancer or its treatment– Arthritis, diabetes

Common Nociceptive Pain Syndromes in Cancer

• Bone pain due to metastases

• Arthralgias due to taxane therapy

• Mucositis pain

• Surgical pain

Bone Pain• >75%

• Dull ache

• Intermittent to continuous

• Continuous with progression of cancer

• May worsen at night

• Reduced function

• Tenderness when tapped

Bone Metastasis

Cancer Frequency

Multiple Myeloma 68-80%

Breast 50-85%

Prostate 50-70%

Hodgkin’s Lymphoma 50-70%

Thyroid 40%

Lung 30-50%

Renal 30-50%

Common Sites

Site Frequency

Rib Cage 58%

Spine 54%

Pelvis 40%

Limbs 32%

Skull 19%

Common Visceral Pain Syndromes in Cancer

• Liver capsule distension

• Malignant bowel obstruction

• Ureteric obstruction

Common Neuropathic Pain Syndromes in Cancer

• Post-radiation plexopathies• Surgical neuropathies – postmastectomy syndrome• Brachial plexus neuropathies – lung or breast cancers• Spinal cord compression• Cranial neuropathies – head & neck, breast or lung

cancers• Chemotherapy-induced neuropathy

– Bortezomib – Taxanes– Cisplatin – Vinblastine– Oxaliplatin – Vincristine

Neuropathic pain: State of the Problem

Jenson, Madsen, Finnerup (2009); Backonja, M & Woolf, G. J. (2010)

• 2/3’s of patients with NP do not get sufficient pain relief by current available treatment

• Review of recent clinical trials: – 30-40% of patients with neuropathic pain may achieve

>40-50% satisfactory pain relief Backonja, M. & Woolf, C. (2010).

• All current treatments for NP are symptomatic rather than disease modifying or curative

APS Principles of Analgesic Use in the Treatment of Acute Pain & Cancer Pain,

6th Edition (2008)

NCCN Guidelines for Adult Cancer Pain 2010

National Comprehensive Cancer Network (www.NCCN.org)

• Consensus statement• Provides algorithms for:

– Pain Assessment• Pain scale suggestions for different populations

– Pain Treatment and dosing suggestions• Opioid• Non-opioid analgesics• Adjuvants

– Very specific and complex

Goals of Cancer Pain Treatment

• Prevention

• Determine patient’s and family’s goals

• Decrease pain

• Prevent/manage adverse effects associated with treatment

• Promote patient safety and function

• Enhance quality of life

Ideal Optimal PharmacologicPain Management Plan

Evidence-Based Plan:• Right pain medication(s)• Right dose(s)• Right route • Right time• Right schedule• Minimal adverse side effects • Optimal outcomes

– Analgesia/Pain relief– Improved function/Activities of Daily

Living– Improved HR-QOL

Management of Cancer Pain

• Treatment of the Cancer– Chemotherapy– Hormonal Therapy– Biological Response modifiers– Bisphosphonates– Radiation Therapy– Surgery– Intraveneous radiopharmaceuticals

• Treatment of the Pain: prevention and management– Pharmacologic strategies: nociceptive & neuropathic– Nonpharmacological strategies

• Treatment of the Person: dimensions of pain

Etiology-Based Pain Management: Pharmacological Interventions

Nociceptive Neuropathic

Somatic Visceral Neuralgia

Neuropathy

Pain

Opioids

Corticosteroids

Tramadol/Tapentadol

NSAIDS

Long-acting Short-actingAnti-Convulsants

Antidepressants

SelectiveNon-Selective

Baclofen

CNS MedicatedCNS Medicated PNS MedicatedPNS Medicated

Pharmacological Management of Cancer Pain

• Nonopioids

• Opioids

• Adjuvants

• Cancer therapies

Special Considerations

• Allergies/sensitivities to medications

• Chronic pain history

• Opioid tolerance

• Chemical-dependence

• Hepatic impairment

• Renal impairment

• Elderly patients

Nonopioids• Acetaminophen

– Analgesic and antipyretic– Use with caution in primary liver or metastatic disease

• Nonsteroidal anti-inflammatory drugs– Analgesic, antipyretic and antiinflammatory– Contraindicated in thrombocytopenia due to chemotherapy or

bone marrow involvement– Contraindicated in renal compromise (esp. multiple myeloma)– Should not be used concomitantly with steroids

Opioid Use in Oncology & EOL

Opioids Used in Oncology

• Fentanyl

• Hydrocodone

• Hydromorphone

• Methadone

• Morphine

• Oxycodone

• Oxymorphone

Opioid Pharmacokinetics

• Most short-acting opioids act in a similar

fashion

– PO: peak 1 hour, duration 3-4 hours

– IV: peak 15 minutes, duration 1-2 hours

Long-acting Opioids

• Morphine

• Oxycodone

• Fentanyl

• Methadone

• Oxymorphone

Opioid Agonists

“Short-acting”• Morphine• Hydromorphone• Oxymorphone• Codeine• Hydrocodone• Oxycodone

“Ultra-short acting”• Fentanyl IV, TM

– Fentora, Actiq, Onsolis

“Longer-acting”• Extended release

morphine– MS Contin, Oramorph

SR, Kadian, Avinza, various generics

• Oxymorphone ER – Opana ER

• Oxycodone ER – Oxycontin

• Hydrocodone ER– Exalgo

• Methadone• Levorphanol• Transdermal fentanyl

Cancer Breakthrough Pain (BTP)

• Defined as a transitory increase or flare of moderate-to-severe pain that occurs in patients in a background of otherwise controlled persistent pain, using regularly scheduled doses of pain medication

• Mean number 6/day

• Average time to peak pain 3 minutes; range 1 second to 30 minutes

• Three subtypes– Movement or incident pain– End of dose failure– Idiopathic (unpredictable, most episodes)

Breakthrough Dosing

• Incident and idiopathic BTP: – may require short-acting pain medications or non-pharmacologic

interventions as needed, along with their scheduled pain medications.

• End-of-dose BTP– may require an increase in the dosage of ATC pain medication or a

decrease in the interval between doses.

• PO – 10 – 20% of 24-hour long-acting opioid dose– Example: Long-acting morphine 200 mg q 12; breakthrough dose

40 – 80 mg of short-acting morphine

• IV or SQ– 50 – 100% of the hourly rate– Example: Continuous infusion IV morphine 6 mg/hour; bolus or

breakthrough dose 3 – 6 mg IV every 15 minutes as needed

Routes of Administration

• Oral • Transdermal

– Passive

– Iontophoretic

• Sublingual• Buccal• Rectal/stomal• Nasal

• Subcutaneous• Intravenous• Epidural• Intrathecal• Intramuscular

– not recommended

Adverse Effects of Opioids

• Sedation• Nausea and vomiting• Urinary retention• Cognitive slowing• Pruritus• Respiratory depression (sedation precedes)

– Use naloxone only when poor oxygenation; administer small increments to prevent withdrawal syndrome

Adverse Effects of Opioids

• Constipation (don’t build tolerance)

• Myoclonus – usually in high doses & renal impairment

• Diaphoresis

• Hormonal changes (lowered testosterone)

• Immune changes

Constipation

• Opioids inhibit peristalsis and increase resorption of fluid into lining of gut

• People with cancer often have multiple etiologies to constipation

• To prevent constipation, use stool softener and a laxative

Methylnaltrexone Bromide Relistor®

Opioid-induced Constipation in Advanced Disease

• FDA approval 2008

• Methylnaltrexone bromide– indicated for the treatment of opioid-induced

constipation in patients with advanced illness who are receiving palliative care, when response to laxative therapy has not been sufficient.

– Subcutaneous injection dosed according to weight every other day with no more than 1 dose in 24 hour period

General Strategies to Manage Opioid Side Effects

• Decrease opioid dose

• Change the route of administration

• Pharmacologic management of side effects

• Opioid Rotation

Opioid Equianalgesic Conversion

• Indications:

– Converting between different opioids• Unresponsiveness to one opioid• Intolerable adverse effects

– Converting an opioid from oral to parenteral route

– Converting an opioid from parenteral to oral route

Equianalgesic Dosing

Drug Oral (mg) IV (mg) Duration (h)

morphine 30 10 3 - 4

hydromorphone 7.5 1.5 3 - 4

oxymorphone 10 1 > 4

methadone 2-5 2-5 6 – 8?

codeine 200 130 3 - 4

oxycodone 20-30 - 3 - 4

hydrocodone 30 - 3 - 4

meperidine 300 100 2 - 3

McPherson, M. L. 2010

Patient Controlled Analgesia

• Intraveneous or Oral

• Assess previous opioid experience

• Indications

• Special Considerations:– Basal rates/demand doses– Education– Proxy administration: family & nurse

Adjuvants

• Corticosteroids

• Antidepressants

• Antiepileptics

• Local anesthetics

Corticosteroids• Inhibit prostaglandin synthesis & reduce edema• Uses: spinal cord compression, neuropathic pain, bone pain and

visceral pain

• Dexamethasone has least mineralocorticoid effect• Due to its long half-life, dexamethasone should be ordered

every morning to prevents sleeplessness when doses are given in the evening.

• Doses: variable and based on pain symptom

• May produce psychosis, euphoria• Long term use (4-6 weeks) can cause proximal muscle wasting• Elevated blood sugar, especially in pancreatic cancer, diabetes

Neuropathic Pain ManagementFirst-Line Medications

Dworkin RH, et al. (2007). Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain, 132(3):237-51.

• Individual variation in the response to the medications used to treat NP is substantial and unpredictable.

• First-line medications (Grade A recommendation)– Tricyclic antidepressants (TCAs)– Selective serotonin and norepinephrine reuptake

inhibitors (SSNRIs)– Calcium channel alpha 2-delta ligands– Topical lidocaine

Tricyclic Antidepresants (TCA)

• Systematic reviews consistently conclude the support the efficacy for TCA therapy in NP (especially PHN & painful DPN)

• Mechanism of action: inhibit presynaptic neuronal reuptake of norepinephrine & serotonin at the descending tract

• Secondary amine TCAs better tolerated & preferred– Nortriptyline & desipramine

• Tertiary amine TCA only if secondary amine not available– Amitriptyline & imipramine

• Major side effects: sedation, dry mouth, blurred vision, weight gain, constipation, urinary retention, orthostatic hypotension

Tricyclic Antidepresants (TCA)

• Precautions: cardiac disease, glaucoma, suicide risk, seizure disorder, concomitant use of tramadol

• Nortriptyline associated with cardiac toxicity risk– sinus tachycardia, increased ventricular ectopy in patients with

ischemic heart disease– increased sudden cardiac death at dosages > 100mg/day

• Recommended: – contraindicated in patients w/ ischemic heart disease & risk for

sudden cardiac death– caution in patient at risk for suicide– screening EKG at initiation for patients > 40 years.

Selective Serotonin & Norepinephrine Reuptake Inhibitors (SSNRI)

• Mechanism of action: inhibit sustained high-frequency neuronal firing by blocking sodium channels after an action potential, reducing excitability in sensitized C-nociceptors

• Duloxetine (Cymbalta®) FDA approved 2004 for DNP pain– Major side effects:

• Palpitations, fatigue, anxiety, hyperhydrosis, decreased libido, decreased appetite, vomiting, loose stools, erectile dysfunction, muscle cramps, weakness, cough, diaphoresis, nasopharyngitis

– Precautions: hepatic dysfunction, renal insufficiency (require dose adjustments), alcohol abuse, concomitant use of tramadol

– Other Benefits: Improvement of depression

– Monitor: blood pressure

Selective Serotonin & Norepinephrine Reuptake Inhibitor (SSNRI)

• Venlafaxine (Effexor®, Effexor XR®) FDA approval 1993; “off label” use for DPN pain

– Major side effects:• Nausea, vomiting, headache, asthenia, somnolence, dizziness, blurred

vision, hypertension, sinus tachycardia, anorexia, insomnia, constipation, nervousness, weight loss, xerostomia, weakness, tremor, neck pain, diaphoresis, impotence

– Precautions: • concomitant use of tramadol, cardiac disease, withdrawal syndrome with

abrupt discontinuation; dose adjustments for renal & hepatic impairment

– Other Benefits: Improvement of depression

– Monitor: blood pressure; LFT & serum creatinine

Calcium Channel alpha2-delta Ligands

• Mechanism of action: – Binds to the 2 subunit of the voltage-dependent

calcium channel; reduce influx of Ca2+, less glutamate released from nerve endings

– inhibit sustained high-frequency neuronal firing by blocking sodium channels after an action potential, reducing excitability in sensitized C fiber nociceptors

• Not metabolized, few drug interactions

Calcium Channel alpha2-delta Ligands

• Gabapentin (Neurontin®) FDA approved 1994– Pain Indications: 2002 – PHN, other painful neuropathies,

& nerve-related pain

– Major side effects:• Somnolance, ataxia, fatigue, nausea, vomiting, peripheral edema

– Precautions: renal insufficiency; dosing in elderly (start low, go slow)

– Other benefits: improved sleep disturbance, no clinically significant drug interactions

– Monitoring: serum creatinine for renal impairment

Calcium Channel alpha2-delta Ligands

• Pregabalin (Lyrica®) FDA approval 2005– Indications: DPN pain, PHN, fibromyalgia (2007)

– Major side effects:• Drowsiness, dizziness, fatigue, nausea, sedation, peripheral edema, visual

disturbance, ataxia, tremor, constipation, dry mouth

– Precautions: renal insufficiency; dosing in elderly (start low, go slow)

– Other benefits: improved sleep disturbance, improved anxiety, no clinically significant drug interactions

– Monitoring: serum creatinine for renal impairment

Lidocaine 5% Patch • FDA approved 1999 for local neuropathic pain syndromes

• Mechanism of action: topical anesthetic; blocks the conduction of impulses & stabilizes neuronal membranes to sodium

•

• Apply patch to intact skin with no blisters to cover most of painful area

• Use up to 3 patches once a day for up to 12 hours on and 12 hours off– Can be kept on 24 hours (Gammaitoni 2002)

• Pain relief is individual and may take anywhere from 4 hours to 14 days according to clinical studies

• Minimal system absorption• • Major side effects: local erythema, rash

• Precautions: blood levels are minimal; however, avoid use in patients receiving oral Class I antiarrhythmic medications

Prescribing Recommendations for First-Line Medications

Medication Class Starting Dose Titration Maximum Dosage

Duration of Adequate Trial

Secondary Amine TCANortriptylineDesipramine

25mg at bedtime Increase by 25mg daily every 3-7 days as tolerated

150 mg daily or divided 4 time/day

6-8 weeks with at least 2 wks at MTD

SSRIDuloxetine

Venlafenxine

30mg once daily

37.5 mg daily or BID

Increase to 60mg once daily after 1 wk

Increase by 75 mg each week

120 mg or 60mg BID

225mg daily

4 weeks

4-6 weeks

Calcium channel alpha2-delta ligandsGabapentin

Pregabalin

100-300mg at bedtime or 100-300mg TID

50 mg TID or 75 mg BID

Onset: 2 weeksIncrease by 300 mg daily every 1-7 days

Onset: more rapid (starting dose is efficacious)Increase to 300 mg daily after 3-7 days, then by 150 mg every 3-7 days as tolerated

3600 mg daily (1200 mg TID; reduce if impaired renal function

600 mg daily (200mg TID or 300mg BID; reduce if renal impaired

3-8 weeks for titration plus 2 weeds at maximum dosage

4 weeks

Topical Lidocaine 5% Maximum of 3 patches daily for a maximum of 12 h

None needed 3 patches daily for 12-18 h

3 weeks

Pharmacological Treatment/ManagementSecond-Line Medications

• Second-line medications: (Grade A recommendations)

• Opioid analgesics

• Tramadol

Treatment of chronic NP with opioid agonists should be generally be reserved for patients who have failed to respond to or cannot tolerate the first-line medications alone or in combination.

Tramadol

• Mechanism of action: weak mu-opioid agonist & also inhibits the reuptake of norepinephrine and sertonin

• Major side effects: somnolence, dizziness, nausea, weakness, dyspepsia, orthostatic hypotension, restlessness, seizures, respiratory depression (not completely reversible with naloxone), serotonin syndrome; abuse potential, but not scheduled

• Precautions: history of substance abuse, suicide risk, seizure disorder, concomitant use of SSRI, SSNRI, TCA

Tramadol (continued)

• Slow titration: increase by 50mg PO every 3 days

• Onset: 1 hour• Peak: 2-3 hours• Duration: approximately 6 hours• Steady-state: 2 days

• High tissue affinity w/ minimal protein binding

• Daily dose not to exceed: 400mg; 300mg for elderly

Tapentadol (NuCynta®)

• Newer than Tramadol

• Stronger µ opioid agonist

• Norepinephrine reuptake inhibitor

• 50-100 mg PO similar in efficacy to oxycodone 10-15 mg

• Schedule II

• Cost can be an issue

Prod Info tapentadol immediate release oral tablets, 2008Prod Info tapentadol immediate release oral tablets, 2008

Prescribing Recommendations for Second-Line Medications

Medication Class Starting Dose

Titration Maximum Dosage

Duration of Adequate Trial

Opioids agonistsMorpine, oxycodone, methadone

10-15 mg morphine equivalent every 3-4 hours as needed

After 1-2 weeks, convert total daily dosage to long-acting opioid analgesic & continue short-acting medication as needed

No maximum dosage with careful titration; consider evaluation by pain specialist at relatively high dosages (100-180mg morphine equivalent daily)

4-6 weeks

TramadolShort-acting & Extended Release Formulations

50 mg once or twice daily

ER: 100, 200, 300 mg doses once daily

Lower starting doses & slower titration in geriatric patients

Increase by 50-100 mg daily in divided doses every 3-7 days as tolerated

ER: Increase the dose by 100 mg every 3-4 days

400 mg daily (100mg four times daily;in patients older than 65 years, 300 mg daily

4 weeks

Mutimodal Pain Management Benefits

• Multiple complex mechanisms may require different medications with different MOA

• Additive or synergistic analgesia

• Lower doses of individual agents may be used to decrease adverse side effects & provide opioid-sparing effects

Interventional Techniques

• Intrathecal implanted pumps; spinal cord stimulators

• Nerve blocks

– Well-localized pain

– celiac plexus block for abdominal pain due to pancreatic cancer

• Vertebroplasty

– Stabilize vertebral body weakened by tumor

• Lesioning of nerves, roots, plexus, spinal cord

– Reserved for small number of individuals who do not obtain relief

with any previous therapies

Anticancer Therapies

• Radiation therapy

– Bone metastases & metastatic lesions (i.e. brain, spinal cord

compression, obstruction)

• Chemotherapy

• Bisphosphonates

– (pamidronate (Aredia) and zolendronic acid (Zometa)

• Octreotide: malignant bowel obstruction, carcinoid syndrome

• Surgery – stents, stabile bony structures -SCC

Radiation for Bone Metastases

• 40% of radiation is given for the goal of palliation of symptoms

• External beam radiation to specific painful site

• Intravenous systemic radioisotope therapy:– Phosphoruous-32– Metastron (Stontium-89)– Quadramet (Samarium Sm-153 lexidronam)

Nonpharmacological Strategies

• Physical– Superficial Heat/Cold

Therapy

– Massage

– Repositioning/bracing

– Transcutaneous Electrical Wave Stimulation (TENS)

• Cognitive– Distraction

• Music, Humor, Activity

– Relaxation, Guided Imagery

– Expressive arts/music

– Biofeedback

– Education

– Support groups

– Spiritual counseling/prayer/meditation

Pain Management at End of Life • Simplify medication regimen

• If patient unable to swallow, consider alternate routes

• If liver and renal dysfunction, drug clearance impaired; may need to reduce dose

• Consult other team members – social work, chaplains, etc

• Support family and other caregivers

Palliative Sedation at End of Life

• When all available treatment options have been exhausted and pain persists, may employ palliative sedation

• Agents used include midazolam, propofol, barbiturates, and others

• Requires consent of patient and family • Education is key: this is not euthanasia or assisted

suicide

Intractable Pain:Principle of Double Effect

Basic Rules:

1. The treatment (ex. high dose opioid) is the only means to meet the end desired (pain relief)

2. The physician must intend only the good effect – relief of pain

3. The good effect must outweigh any unintended bad effect

4. The bad effect (possible earlier death) should not be the means to the good effect (pain relief).

Monitoring Outcomes of Pain Relief Plan

• Analgesia (presence or absence of satisfactory pain relief )

• Activities of daily living (improved function)

• Adverse side effects or toxicities (acceptable or unacceptable)

• Evidence of Aberrant behavior (are potential signs of inappropriate use of opioids present)

• Achievement of goals for pain management (are goals met or need modification)

Passik, S. et al, (2002); Curtiss, C. P. (2010)

Patient/Family Education

• Dispel & clarify any misconceptions/ attitudes/fears toward pain medications

• Pain medications, dose, frequency & schedule

• Expected side effects & their management

• Safety issues

• When to notify MD/RN

Principles of Cancer Pain Management

• Consider variety of cancer pain syndromes

• Conduct thorough pain assessment

• Ascertain patient’s and family’s goals of care

• Incorporate multimodal therapies

• Prevent or rapidly treat adverse effects

• Reassess frequently and change therapies if needed

• Address existential distress

• Educate patients, families, other caregivers