oncologic pain management final

Oncologic Pain Management : 

Oncologic Pain Management An Over View HOSAM ATEF, MD LECTURER OF ANESTHESIA

Why? : 

Why? After Incurability, Pain was ranked to be the most fearful and the most distressful symptoms Inadequate Pain control associated with profound alteration in nearly all aspect of wellness( activity-mood-rest-nutrition-sexuality..etc) Optimal Pain control, may hasten a return to normality (function-physiologic-spiritual-psychologic,economic,vocational,survivorship) Adequate Pain control, influence outcome and survival…..How? Of many negative associated with a diagnosis with cancer, Pain is one that not only need not to be endured, but when controlled makes other privations more manageable

Epidemiology of Cancer : 

Epidemiology of Cancer Cancer is highly prevalent disorder 6.35 million annual new cases world wide, 50% in developing country 2nd most common cause of death Poor outcome despite the aggressiveness of the new treatment. Poorer in developing country 5y survival rate still 50% in USA and 33% in developed country for the last 40 years One death for every ten deaths is due to cancer

Epidemiology of Cancer Pain : 

Epidemiology of Cancer Pain Despite of the high mortality of cancer,intensive treatment applied hoping for cure,prolong survival or improve quality of life. Ironically Pain and disability are common outcome. Increased survival chance to experience Pain with other symptoms. Asthenia 90% Anorexia 85% Pain 76% Nausea 68% Constipation 65% Pain in cancer population: 1- 66% of all patients 2- 90% of advanced disease 3- 25% of pt.with active ttt. Have significant Pain Fortunately, 70-90% of pt. Got adequate pain control with stabilized guideline The rest 10-30% of pt. Need More invasive procedures

Cancer Pain Syndromes : 

Cancer Pain Syndromes Origin either (T-T-T) Tumor related: 60-80% of patients Therapy induced: 20-25% of patients a-Chemotherapy b-Radiotherapy c-Post surgical syndrome Totally unrelated: 3-10%

Sources of Pain in Cancer Patients : 

Sources of Pain in Cancer Patients 70% of patients with advanced cancer report pain 67% Tumor- Related 23% Treatment- Related 10% Unrelated Bonica J. The Management of Pain. Vol. 1. Phila: Lea & Febiger; 1990.

Origin of Cancer Pain : 

Origin of Cancer Pain

Barriers to Effective Cancer Pain Management : 

Barriers to Effective Cancer Pain Management It is curious , indeed tragic, that despite the availability of straight forward, cost effective therapies, Cancer Pain remains undertreated.( R. Patt. The Patt center for Cancer) The factors contributing to undertreatment are complex, but documented: 1-Knowledge Deficits 2-Beliefs 3-Attitude By: 1-Health Care Providers 2-Health Care System 3-Patient-Family members

Health Care Provider-Related Barriers : 

Health Care Provider-Related Barriers Lake of Education and Knowledge about a- Assessment and management Pain Refractory Pain b- Actual risk of analgesic therapy Misbelieves -Pain is inevitable in advanced ca. -Opioids in doses sufficient to pain reserved for dying patients -Patient’s pain report is unreliable Attitude -Reluctance to utilize triplicate prescription.(cost-effort-fear-limited) .Resultant over reliance on less restricted but less effective medication. -Lake of time, effort, energy, or motivation to make frequent changes often required to maintain control of pain

Culture-Health Care System Related Barrier : 

Culture-Health Care System Related Barrier War on Drugs (illicit(abuse) vs medical use) Lack of information on Medical and Nursing School curricula and Residency training program on Pain Management Acute disease-oriented health care model engenders lake of accountability for control chronic symptoms Lack of recognition of Pain management or palliative care as legitimate medical subspecialty.Resultant of failure to provide hospice benefits and reimbursement by insurance.

Patient Related Barrier : 

Patient Related Barrier Wrong belief (Pain is a must with cancer) Wrong belief (Opioids are bad drugs) War on Drugs: Don’t take opioids under any circumstances (government-family-friends) (Be a good patient) and do not discuss pain with health care provider.

Patient Barrier continue…. : 

Patient Barrier continue…. How to be a good patient? 1-Don’t discuss Pain 2-Don’t ask for pain medication before time 3-Endure pain to the maximum

Management of Oncologic Pain : 

Management of Oncologic Pain A- Assessment General: Complete Broad Base Compassionate Goal:to orient pt.,family,and MRP to what realistically be accomplished. Operationally: Human Disease Pain 1-Psychosocial 2-Oncologic History 3-Pain History Supplement: Appropriate standardized pain questionnaire VAS BPI MPAC ESSCP

a- Patient General History : 

a- Patient General History Attention: Assessment is always two-way street. Pre-assessment: Orientation of the problem Psychosocial History: Medical History: Review System: too often overlooked.The main goal is the best quality of life possible.Failure of pain control is mainly due to other symptoms

Oncologic History : 

Oncologic History Prior Experience with Cancer (self-others) Type, Extend (metastatic status) and Prognosis Prior Antineoplastic Therapies and Outcome

Comprehensive Pain History : 

Comprehensive Pain History Premorbid Chronic Pain (3-10%) Premorbid Alcohol or Drug Abuse Pain Catalogue (number-location) For Each Pain: -Onset and evolution -Site and radiation -Pattern -Intensity -Quality

Pain History Continue……. : 

Pain History Continue……. -Exacerbating factors -Relieving factors -How the pain interferes -Neurologic and motor abnormalities -Vasomotor changes -Other associated factors -Current analgesics -Prior analgesics

Physical Exam : 

Physical Exam It is non invasive, cost effective, time saving means of obtaining information It may be challenging! In one large study, 63% of pt. Referred to cancer pain service, pertinent new finding and 20% of them needed to initiate new antineoplastic therapy General P.E and System review

P.E Continue…… : 

P.E Continue…… Special exam for: -Pain site -Tumor site -Musculoskeletal system -C.N.S Pain, in many time associated with subtle neurological deficit, identified by P.E Urgent diagnostic work up or oncologic emergencies may be the outcome of thoroughly history and physical exam

Slide 25: 

I’ve just done with my last chemo, I’ve to start again from scratch

Important Pain Syndrome : 

Important Pain Syndrome Nociceptive A.Somatic -Bone Pain (the commonest) -Mechanism -Presentation B.Visceral -Presentation Neuropathic -Mechanism -Presentation .Emergency Cord compression Cauda Equina Syndrome 5% -Leptomeningeal mets!

Cancers with Bone Metastasis : 

Cancers with Bone Metastasis Fischer G. Bone metastases: Part I- pathophysiology. Clin J Oncology Nurs. 1997;1(2): 29-35.

Principles of Therapy : 

Principles of Therapy 1- Keep Patient in Control 2-Focus in Whole Family 3-Utilize Team Approach 4-Usage of Multiple Methods for Treatment 5-Treatment of Other Symptoms 6-Environmental Therapy 7-Never Use Placebo 8-Refer When Pain Persists

Slide 29: 

Can any body tell me what is going on ?

Strategies to Attack Cancer Pain : 

Strategies to Attack Cancer Pain 1- Eliminating or modifying the source of pain 2- Modifying the interpretation of the pain message at the level of CNS 3-Interrupting the pain signal En route from periphery to the CNS

Multi-Modal Strategy : 

Multi-Modal Strategy It has been proved that pain modification at multiple site in CNS is an effective therapy. 1-Modify the source of pain a-Surgery (acute pain-post surgical pain syndrome) b-Radiotherapy(post radiation pain) c-Chemo and Hormonal Therapy

2-Modify the interpretation of pain message : 

2-Modify the interpretation of pain message Pharmacological Analgesics Psychological support and Relaxation tech. Pharmacological Analgesics General Principals: up to 90% success rate First line of treatment WHO Analgesic Ladder and NCCN guideline Oral route as long as possible

Continue…… : 

Continue…… Avoid poly-pharmacy unless indicated Avoid starting multiple drugs in the same time New drug in small doses Study the common group of drug in use Have access to reliable inf.on uncommon drugs Acknowledge and Manage the side effect

How to Choose the Analgesic ? : 

How to Choose the Analgesic ? WHO Step Ladder! It is an approach advocated toward cancer pain relief relies primarily on pain intensity. How to choose ? Mild vs Severe Acute vs Chronic When to switch? Who is better than WHO ?

The WHO Analgesic Ladder : 

The WHO Analgesic Ladder Non-Opioid Weak Opioid+ Strong Opioid++ 3 1 2 Severe Pain Moderate Pain Mild Pain

Step 1: NSAID : 

Step 1: NSAID Mechanism: Cyclooxygenase inhibitor (COX-1 and COX-2) PG degradation. Decrease pain by reducing pain receptor sensitivity, reduce the inflammatory process and edema Usage COX-2/COX-1 ratio Ceiling phenomenon Special Consideration High risk patients Monitoring Misoprostol Interindividual Variability Cox-1 sparing NSAID Ketorolac-Bromfenac

Step 2 and 3: Opioids : 

Step 2 and 3: Opioids Indication: Mechanism Weak vs Strong ! Potent vs less Potent Weak Opioid Intermediate Potency Almost in combination With other meds(NSAID..etc) Weakness due to the ceiling dose of NSAID or other When it is used (sole) in equianalgesic doses, control severe pain

Common Weak Opioids! : 

Common Weak Opioids!

Common Strong Opioids : 

Common Strong Opioids

How To Use Opioids? : 

How To Use Opioids? Pure agonist as first line of therapy. Higher incidence of psychotomimetic effect (dysphoria-hallucination) and nausea and vomiting with A-A Never mix agonist with agonist-antagonist Don’t mix two agonist Don’t stay with weak agonist if pain not relieved Oral route whenever possible Round the clock strategy-----important

Continue…… : 

Continue…… NEVER PRN. Continuous pain need continuous analgesic.Prevent resurgence of pain rather to treat it.PRN is illogical, cruel, perpetuate the fear and the memory of pain. It is only acceptable for break through pain.

Opioid Dose Titration : 

Opioid Dose Titration The correct dose of an opioid is that effectively relieves pain without inducing unacceptable side effect. There is no standard or set of doses of narcotics in cancer pain.There is a great variation between individuals. As pain changes through various stages of the disease, doses should be re-adjusted. Recommended doses are derived from acute single dose pain studies are not applicable to chronic cancer pain.The dose of the strong narcotic can be increased almost indefinitely without reaching a ceiling or plateau of maximum effect.(except. Meperidine-A/A) (A report of the Expert Advisory Committee on the Management of Severe Chronic Pain in Cancer Patients)

Continue……… : 

Continue……… Consider adjuvant medication: 1-NSAID-----Bone Mets 2-Anti-depressant------Neuropathic Pain 3-Memberane stabilizer-------Neuropathic Pain 4-Treatment of side effect Use narcotics as part of the: Total Pain Treatment

1- Oral Narcotics : 

1- Oral Narcotics MS first choice Forms (IR vs SR) How often .ATC+PRN Dose calculation Dose titration(Key for succ.) Increase both ATC+PRN in 24 hr Severe Pain(7-10) 50-100% Moderate Pain(4-7) 25-50% Mild Pain (1-3) 25% Do you wake up pt.For dose! Why isn’t it working? -Inadequate Dose -Poor compliance -Vomiting-Drooling -Unresponsive Pain -Needs co-analgesic What about overwhelming Pain?

Management of Opioid Side Effect : 

Management of Opioid Side Effect Constipation GI peristalsis- Secretion aggravated by fluid intake, physical activity and poor diet -Prevention -Treatment Nausea & Vomiting Stimulation of chemoreceptor Prochlorperazine/Haloperidol Delayed gastric emptying Metchlopramide Increased vestibular sensitivity Dimenhydrinate If persist, modify the dose, opioid rotation, change the route

Continue…….. : 

Continue…….. Sedation-Confusion 1-Prevention 2-Modify the doses 3-If persist revaluate 4-Opioid Rotation 5-Change the route Other Route: Why? Rectal : Oxycodon-Hydromorphone Transdermal : Fentanyl Patches.25,50,100ug/hr Subcutaneous Intravenous

Advanced Strategies for Cancer Pain Management : 

Advanced Strategies for Cancer Pain Management Jacox A, et al. AHCPR, 1994. Portenoy R. Oncology 1999;S2:7. 80-90% Adequate Pain Control 10-20% Invasive Therapy Needed

Role of Invasive Procedures : 

Role of Invasive Procedures Invasive Procedures Anti-tumor Therapy Pharmacotherapy Other modalities

Interruption of Pain Signal and Anesthetic Intervention : 

Interruption of Pain Signal and Anesthetic Intervention Neuro-Axial Drug Delivery System Neural Blockade

Neuro-Axial Drug Delivery System : 

Neuro-Axial Drug Delivery System Indication: Route: 1-Epidural 2-Intrathecal (external vs internal pump) 3-Regional Plexus Catheter

Epidural Analgesia Dosage Advantages : 

Epidural Analgesia Dosage Advantages Oral morphine 300 mg/day IV morphine 100 mg/day Epidural morphine 10 mg/day Intrathecal morphine 1 mg/day Krames ES. Intraspinal opioid therapy for chronic nonmalignant pain: current practice and clinical guidelines. J Pain Symptom Manage. 1996 Jun;11(6):333-52.

Reduce Dose – Reduce Side Effects : 

Reduce Dose – Reduce Side Effects 1 mg intrathecal morphine = 300 mg oral morphine Krames ES. J Pain Symptom Manage. 1996 Jun;11(6):333-52.

Side Effects of Systemic vs. Intrathecal Opioids : 

Side Effects of Systemic vs. Intrathecal Opioids Naumann, et al. Neuromodulation. 1999;2(2):92-107.

Slide 54: 

88% Krames, Gershow, 1985 79% Shetter, 1986 84% Penn, Paice, 1987 Follett et al., 1992 77% 76% Devulder, 1996 64% Onofrio, Yaksh, 1990 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Clinical Experience with Intrathecal Therapy 97% Gilmer-Hill,1999 Patients Receiving Good to Excellent Pain Relief Paice et al., 1996 95%

Cancer Pain Trial, 2002 : 

Cancer Pain Trial, 2002 Randomized Prospective International (5 countries) Multicenter (21 centers) Clinical trial of efficacy of combining IDDS (Medtronic SynchroMed® Infusion System) and Comprehensive Medical Management (CMM) vs. CMM alone for patients with persistent cancer pain Journal of Clinical Oncology, Vol 20, No 19, October 1, 2002: 4040-4049.

Patient Selection : 

Patient Selection Patient Selection Chronic Pain (VAS ³ 5) from advanced CA Chronic Pain (VAS ³ 5) from therapy for advanced CA Yes Yes Out ³ 200 mg MSO 4 daily p.o. or the equivalent £ 200 mg MSO 4 daily p.o. or the equivalent, with unacceptable side effects No Out Yes Yes Out No Yes No Yes Yes RANDOMIZE No Yes No ³ 3 mo life expectancy SynchroMed contraindicated Able to complete protocol Informed consent Journal of Clinical Oncology, Vol 20, No 19, October 1, 2002: 4040-4049.

Baseline Characteristics1 : 

Baseline Characteristics1 Journal of Clinical Oncology, Vol 20, No 19, October 1, 2002: 4040-4049.

Reduction in 15 Toxicities(as randomized) : 

Reduction in 15 Toxicities(as randomized) Journal of Clinical Oncology, Vol 20, No 19, October 1, 2002: 4040-4049.

Survival : 

Survival P=0.06 Journal of Clinical Oncology, Vol 20, No 19, October 1, 2002: 4040-4049. Although intrathecal drug delivery treats pain and not the disease, a trend toward improved survival was seen in patients treated with IDDS

Cancer Pain Trial Results : 

Cancer Pain Trial Results Reduced pain Reduced side effects like fatigue and sedation Positive trend toward QOL* and survival More patients achieved clinical success with IDDS Journal of Clinical Oncology, Vol 20, No 19, October 1, 2002: 4040-4049. * Based on the Brief Pain Index Interference scores

Patient Selection for Intrathecal Therapy : 

Patient Selection for Intrathecal Therapy Metastatic cancer (breast, lung, colorectal, prostate, head & neck) Inadequate pain relief on >200 mg oral opioids per day Intolerable side effects on lower doses including: Fatigue Sedation Confusion VAS > 5 No contraindications Journal of Clinical Oncology, Vol 20, No 19, October 1, 2002: 4040-4049.

Trial for Intrathecal Therapy : 

Trial for Intrathecal Therapy To evaluate patient’s response Assess pain relief Evaluate side effects 50% pain reduction considered a positive result Hassenbusch, Stanton-Hicks, Covington. J Pain Symptom Manage. 1995;10(5):527-543.

Implanted Pump and Catheter : 

Implanted Pump and Catheter Pump placement Left or right abdomen Enough tissue for support Catheter placement Tunneled from spinal column to pump Pre-implantation trial Allows efficacy to be tested prior to system implantation

Patient Management and Refills : 

Patient Management and Refills Refills and programming performed by trained clinician (oncologist, nurse, palliative care or pain specialist ) Refill in 15 - 30 min Reimbursable

Contraindications to Intrathecal Therapy : 

Tumor encroachment on thecal sac Emaciation Aplastic anemia Systemic infection Occult infection Medication or materials sensitivities Contraindications to Intrathecal Therapy Krames. J Pain Symptom Manage. 1997;14(S3):S3-S13.

Neural Blockade : 

Neural Blockade 1-With Local Anesthetic Diagnostic Prognostic Pain Emergency Muscle Spasm Herpes Zoster Premorbid Pain Iatrogenic Pain

Neurolytic Neural Blockade : 

Neurolytic Neural Blockade It is more often considered in setting of pain due to cancer as the ongoing tissue injury expected to progress Types: Pain-related indication: 1-Well Characterized 2-Well Localized (exception: Sympathetic blockade Stellate ganglion, Celiac plexus, Hypogastric plexus,lumber sympathetic) 3-Nociceptive rather than neuropathic pain Patient- related indication:

Neurolytic Blockade Contiue…. : 

Neurolytic Blockade Contiue…. Outcomes: Few controlled trials, no blinding or randomized, no controls for technique Efficacy: 50-80% of well selected pt. Duration: avg. 6 month. Complication:less than 5% in well selected pt.with fluoroscopy&CT. Hazards: Neurologic Deficit Damage to nonneurological tissue. Impermanece: non of the ablation tech.reliably produce permanent relief 4.New Pain: 2-28%. Neuritis and dysesthesia. It could be difficult to manage

Common Neurolytic Blockade : 

Common Neurolytic Blockade Celiac Plexus (solar plexus) Block .Classic fluoroscopic posterior approach .CT guided posterior vs anterior approach .Ultrasound guided anterior approach .Endoscopic guided approach .Stellate Ganglion Block .Lumber Sympathetic Block .Splanchic Nerves Block

Kyphoplasty : 

Kyphoplasty Vertebroplasty Kyphoplasty Sacroplasty

RF ablation : 

RF ablation