Management of Cancer Pain Prof. Dr. Başak Oyan-Uluç Yeditepe Üniversitesi Hastanesi Medikal...
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Transcript of Management of Cancer Pain Prof. Dr. Başak Oyan-Uluç Yeditepe Üniversitesi Hastanesi Medikal...
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Management of Cancer Pain
Prof. Dr. Başak Oyan-UluçYeditepe Üniversitesi Hastanesi
Medikal Onkoloji Bölümü
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Cancer pain
At diagnosis % 20-50
During treatment % 30-40
Advanced stage %75-90
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Physiological effects of Pain
• Decreased limb movement: increased risk of DVT/PE
• Respiratory effects: shallow breathing, tachypnea, cough suppression resulting increased risk of pneumonia and atelectasis
• Tachycardia and elevated blood pressure
• Increased catabolic demands: poor wound healing, weakness, muscle breakdown
• Increased sodium and water retention (renal)
• Decreased gastrointestinal mobility
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Psychological effects of Pain
• Negative emotions: anxiety, depression
• Sleep deprivation
• Existential suffering
• Patient questions the very foundations of their life:
whether their life has any meaning, purpose or
value
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Immunological effects of Pain
Decrease natural killer cell counts
Tolerance to chemotherapy decrease. infection
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Cancer pain
Physiological effects
Psychological effects
Immunological effects
Decreased quality of life
Shorter survival
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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
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Causes of Cancer-Related Pain• Tumor / Mass effect (70%)
• Bone metastases, soft tissue infiltration, nerve infiltration
• Treatment related (20%)• Post-chemotherapy• Post-radiation (mucositis, enteritis , etc)• Post-surgical (mucositis, neuropathy, G-CSF related bone
pain, etc)
• Other (10%)– Decubitis ulcers, constipation – Postherpetikc neuralgia
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Types of pain
• Somatic pain
• Visceral pain
• Neuropathic pain
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Somatic Pain
• Generally described as musculoskeletal pain• Dull, sometimes sharp• Intermittent or continuous• Well-localized: Because many nerves supply the
muscles, bones and other soft tissues, somatic pain is usually easier to locate than visceral pain.
• Related to tumor / mass effect
• Example: Soft tissue infiltration, bone metastases
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Patient with head and neck cancer: Large right sided mass causing somatic pain
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Visceral Pain
• Infiltration, compression, extension, or stretching of the thoracic, abdominal, or pelvic viscera
• Pressure, deep, squeezing, cramps
• Not well-localized or referred pain
• Intermittent or continuous
• Example: Intraabdominal metastases
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Colorectal cancer with liver metastases:Visceral pain
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Neuropathic Pain
• Causes:
• Cancer compressing or infiltrating nerves/nerve roots/blood supply to nerve
• Nerve damage from treatments
• Types:
• Dysestetic: Burning, “pins & needles”
• Ex: Postherpetic neuralgia
• Neuralgic: Sharp, shooting and paroxysmal pain along the course of a nerve
• Ex: Trigeminal neuralgia
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Neuropathic Pain
• Chemotherapy-induced neuropathies: symmetrical polyneuropathy – localized in hands and feet
• Cisplatin, Oxaliplatin
• Paclitaxel, Thalidomide
• Vincristine, Vinblastine
• Surgical Neuropathies
• Phantom limb pain
• Post-mastectomy syndrome
• Post-thoracotomy syndrome
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Most cancer pts have some sort of combination of somatic, visceral pain and neuropathic pain
Patient with cervival cancer
• Visceral pain due to peritoneal carcinomatosis
• Somatic pain: Due to vertebral metastasis
• Neuropathic pain from nerve root involvement
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Assessment of cancer pain
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Assessment of Pain
• Pain history
• Onset / duration
• Severity of paiN
• Site(s) of pain/radiation
• Type of pain
• What aggravates or relieves pain?
• Impact on sleep, mood, activity
• Effectiveness of medication
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Non-verbal signs of pain• Autonomic changes
– Hypertension, tachycardia, sweating
• Patients with organic brain syndrome: Agitation or confusion
• Patients with cognitive dysfunction: Apathy, inactivity, irritability– Refuse eating– Avoidance of painful site– Painful expression on face
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Principles of Assessment
• A (Ask) Assess and REASSESS
• B (Believe) the patient and care-givers
• C (Choose) Use methods appropriate to cognitive status and context
• D (Deliver)
• E (Empower) Include the family
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• Pain scales– Numeric– categoric– Facial expression pictures
• Body maps
• Pain queries
Assessment of severity of pain
MUST BE FİLLED BY THE PATIENT
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TREATMENT
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MAXIMUM PAIN CONTROL
MINIMUM SIDE EFFECT
INCREASED QUALITY OF LIFE
No pain at rest No pain with activity
No interrruption of sleep due to pain
Aims of Cancer Pain treatment
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Modalities of treatment• Pharmacological Management
• Radiation / Nuclear Medicine
• Non-Pharmacologic Management
• Interventions– Blocks– Epidural or intratecal pain pumps– Palliative surgery (ablative neurosurgery)– Nerve Blocks
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Pharmacological Treatment
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Pharmacologic Management
• WHO Ladder
• Non-opioid therapy / Co-analgesics
• Opioids
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WHO Ladder
(1-3)
(4-6)
(7-10)
Oral
By the clock
Step by step4. Basamak:
Invasive modalities
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Non-Opioids NSAIDS Acetaminophen (Paracetamol) Topicals
Lidocaine, Capsaicin
For mild pain Ceiling effect: increasing doses of a given medication to have
progressively smaller incremental effect Can be combined with opioids-> Opioid dose lower No tolerance and no addiction risk
NSAID: Gastointestinal, renal and hematological side effects
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Adjuvants
• Primary indication other than pain, but have some analgesic properties in some painful conditions
• Usually coadministered with other analgesics
Benzodiazepines Antispasmodics Muscle relaxants NMDA-blockers Systemic local
anesthetics
Antidepressants Anticonvulsants Corticosteroids Neuroleptics Alpha2 – agonists
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Adjuvants for special pain types
• Neuropathic pain: Antidepresants, Anticonvulsants, GABA agonists, etc
• Bone pain: Osteoclast inhibitors (bisfosfonates), radiopharmaceuticals, corticosteroids
• Musculoskeletal pain: Muscle relaxants
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OpioidsStep 2 opioids
Codeine, Oxycodone, tramadol
Step 3 opioids Oxycodone, morphine, fentanyl
AVOID: Meperidine
If pain constant/chronic – use long-acting opioids with short-acting for breakthrough pain
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Principles of analgesic treatment• Patient –specifc treatment: Dose, route
• By clock: Analgesics should be administered at regular intervals, not as needed
• Appropriate dose
• Consider renal and liver functions
• When changing to and other opioid or the route of adb-ministration, use “equal analgesic conversions” guides
• Avoid placebo
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Principles of analgesic treatment
• Be aware of drug side effects and prevent side effects
• Monitor development of tolerance
• DO NOT USE MEPERİDİNE (Dolantin) for cancer pain– Toxic metabolite is normeperidine –> highserum levels can cause
seizures– Short-acting
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Side effects of opioids
Physiological side effectsSedation
Constipation
Nausea-vomiting
Urinary retention
Supression of cough
Toxic side effects
Lethagy
Hallusination
Myoclonik jerks
Supression of respiration
Tolerance to Nausea-vomitingand sedation: Early
Tolerance to constipation: Late
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Success rate of Cancer pain Treatment
• Oral /Transdermal• Administer by clock• Step by step• Patient-specific
• Appropriate– Dose– Route– Dose interval
• Treatment of breakthrough pain
• Treatment od side effects
Success rate>%80
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Reasons for failure to relieve cancer pain
• Inadequate dose of opioids– No ceiling dose for agonist opioids like morphine
– Only dose-limiting factor: Side effects
• In young patients, dose should be higher
Seminars in Oncology, Vol 27. No.1 February 2000: pp 45-63Seminars in Oncology, Vol 27. No.1 February 2000: pp 45-63
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Torkey
Mean: 0.0872
World: Rank number 44
EURO zone Rank number 33
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Torkey
Mean: 0.1763
World: Rank number 106
EURO zone Rank number 42
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Reason for inadequate doing of opioids?
• Physicians’ lack of information about opioids
• Patients’/Relatives’ lack of information about opioids
• Exaggeration of risks
• Side effects
• Risk of addiction
• Legal factors
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Non-Pharmacologic Management
Acupuncture Yoga Guided imagery Cold/heat Massage Vibration TENS units
Exercise programs Hypnosis Music Pet therapy
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Intervensions
Palliative surgery
Nerve Blocks
Kyphoplasty/Vertebroplasty
Epidural
Intrathecal pain pumps
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Celiac Plexus Block
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Kyphoplasty/Vertebroplasty
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Intrathecal Pain Pumps
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Conclusion Cancer pain can effect quality of life and mortality
Ask the patient about pain and REASSESS!
Choose non-opioid / adjuvants carefully paying close attention to side effect profile
Use WHO ladder guidelines when titrating pain medications
Use long-acting opioids for chronic cancer pain
Recognize “4th step” in WHO ladder and utilize your multidisciplinary resources