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Cancer Pain Management

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Suzanne Smokevitch

on 13 April 2012

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Transcript of Cancer Pain Management

Cancer Pain Managment Pain remains one of the most feared aspects of cancer.

Commonly results from tumor compressing or invading soft tissue, bone, or nerves or from diagnostic or therapeutic endeavors.

Optimal pain management: thorough assessment of the patient's pain.
Cancer Pain Managment Peripheral Nerve Root Involvement Neuropathic pain: peripheral nerve roots are involved with a tumor.
Aberrant somatosensory: p.n. is injured by tumor expansion or infiltration.
Description: burning, tingling, numbing, pressing, squeezing, and/or itching; fluctuates in severity, often intolerable. •Nonopioid analgesics
•Opioid analgesics
•Adjuvant medications
•Antineoplastic therapies
•Nonpharmacologic approaches
•Noninvasive neurostimulation
•Regional anesthetic
Neurosurgical approaches
Conventional Pain Management Dosing Schedule for Mild - Moderate Pain Drug Route Equi-Analgesic Dose (mg)[*] Peak Effect (hr) Duration of Effect (hr)
Codeine PO 200 0.5 3–6
Ceiling for analgesia reached at doses >240 mg/day orally.
IV/IM 130 0.5 3–6
Oxycodone PO 30 0.5 3–6
No ceiling dose if given without fixed combinations; parenteral formulation not available.
Hydrocodone PO NA 0.5 4–6
Only available as fixed combination with acetaminophen or aspirin.
Propoxyphene PO NA 1.0 4–6
100 mg napsylate = 65 mg hydrochloride salt. Not recommended for treatment of cancer pain.
Dosing Schedule for Severe Pain Drug Route Equi-Analgesic Dose (mg)[*] Duration of Effect(hr)
Oxycodone PO 20 3–6
PO SR 12
Morphine PO 30 4–6
PO (SR) 8–12
IV/IM 10 3–5
Hydromorphone PO 7.5 3–4
PR (?) Unknown
IV/IM 1.5 3–4
Meperidine PO 300 3–6
IV/IM 75 2–3
Levorphanol PO 4.0 6–8
IV/IM 2.0 6–8
Fentanyl TD (?) ≥12
IV/IM 0.1 0.5-1.0
Methadone[†]PO 10 6–8
Oxymorphone PO 10 7–9
PO SR 12
IV 1 7–9
Oxycodone

Pain Pathophysiology Non Opioid Analgesics site of action of the nonopioids: peripheral nervous system.

Not associated with physical dependence, tolerance, or addiction.

Maximum dose associated with analgesia.

Anti-inflammatory component of aspirin, NSAIDs and COX-2 inhibitors is useful for somatic pain from bone metastasis, inflammation, or mechanical compression of tendons, muscles, pleura, and peritoneum, and for nonobstructive visceral pain.

Note:
Increasing evidence of cardiovascular risk with NSAIDs.

Acetaminophen > 4 grams daily can cause renal and hepatic damage.
Opioid Analgesics Most rely on opioid analgesics for management of cancer pain.

Primary effect: central nervous system
Classification:
1. Morphine
codeine, fentanyl, hydromorphone, morphine, oxycodone, methadone
2. Opioid antagonists
naloxone
3. Mixed agonists-antagonists
pentazocine and butorphanol, or partial agonists: buprenorphine

Administration: prn, po q 4-6 hours to keep pain under control.

Note: If tolerance occurs, most common cause is tumor progression.

Addiction is extremely rare in patients with cancer who are taking opioids for pain relief.

Most opioid side effects can be managed without excessive difficulty.
Opioid Analgesics Constipation
Begin bowel program when initiating therapy.
Stool softeners
Combinations of agents may be useful:
Irritants, bulk laxatives, lubricants, enemas
Nausea and vomiting
Antiemetics: Phenothiazine
Anticholinergic: Promethazine
Prochlorperaxine
Opiate Switch: Olanzapine, 5HT3 antagonists, Scopolamine, Hydroxyzine
Sedation
Stimulants: Dextroamphetamine, Methylphenidate, Modafinil
Pruritus
Antihistamines: Hydroxyzine
Other opiates, avoid morphine.
Diphenhydramine
Myoclonus
Switch opiate or lower opiate dose.
Benzodiazepines
Anxiolytics
Avoid meperidine, especially with impaired renal function.
Withdrawal symptoms
Taper dose, Clonidine
Opioid Side Effect Management Opioid Pathophysiology Neuropathic Pain
Antidepressants
Anticonvulsants

Decrease Opioid Sedations
Psychostimulants

Anti-Inflammatory and Reduce Brain Edema with Epidural Metastases
Glucocorticoids

Muscle relaxants, anxiolytic, antispasmodic, and neuroleptic agents also are administered for specific indications

Reduce Risk of Skeletal Complications in Myeloma and Breast Cancer Pts
Bisphosphonates
Adjuvant Analgesics for Cancer Pain Analgesia by reducing the size of lesions invading or compressing normal tissues.

Radiation therapy
symptomatic bone, brain, epidural, plexus metastases.

Systemic radiopharmaceuticals:
strontium-89 and samarium d/t pain from bone metastases.

Chemotherapy: provides substantial pain relief in malignancies.

Surgery: relieves pain from intestinal obstruction, pathologic fractures, and obstructive hydrocephalus.
Antineoplastic Therapy Neurostimulatory techniques
transcutaneous electrical nerve stimulation

Progressive muscle relaxation

Massage

Hydrotherapy

Guided imagery, breathing

Biofeedback

Hypnosis

Acupuncture Nonpharmacologic Therapy Homeopathy Aurum: Bone pn, worse at night

Angustura: bone/periosteum pn; serious illness;
tetany;

Eupatorium: Bones aching "as if broken," back pn

Hypericum: sharp, shooting nerve pains; injuries to nerves/spine

Syphilinum: bone pains, esp skull and long bones; worse night; Performed infrequently on patients with cancer because of the success of more conservative approaches.
Radiofrequency ablation
Most Common Approach
Open unilateral anterolateral cordotomy
Produces pain relief in the lower part of the body in 80% of patients.
Open cordotomy: performed through a T2 or T3 laminectomy and produces pain relief in the lower part of the body in 80% of patients.
Bilateral cordotomies: higher complication rates.
Percutaneous cordotomy
safer and provides excellent pain relief; pain recurs within 3 months in 50% of pts.
Commissural myelotomy.
Pt with bilateral pelvic and perineal pain.
laminectomy and surgical division of the crossing fibers of the spinal cord.
Can result in pain relief with sphincter sparing, few neurosurgeons have extensive expertise with this procedure.
Neuroablative Procedures
Pain of neuropathic origin

Episodic or incidental pain

Impaired cognitive or communicative skills

History of substance abuse
Difficult to Manage Pain Shock-like pain, with a burning/constricting sensation.

Cause: tumor invading or compressing peripheral nerve, nerve plexus, or spinal cord.
Disorders unrelated to the tumor or treatment.

Optimal therapy for neuropathic pain:
Tricyclic antidepressants (amitriptyline)
Anticonvulsants: with lancinating pain qualities.
Pregabalin
Gabapentin: postherpetic neuralgia and painful diabetic neuropathy.
Reports support the use: carbamazepine, valproic acid, and diphenylhydantoin
Lidocaine patches
Capsaicin: Oral or Topical Pain of Neuropathic Origin Transient, but severe, exacerbations in pain.
Main Therapy: Opioids
Major Locations:
Pelvic metastases, pathologic fractures
Rib metastases
Esophageal, rectal, or bladder lesions

Statistics: Three-quarters of pain is directly related to neoplastic lesions, 20% result from antineoplastic therapy, and the remainder is unrelated to the tumor or treatment.

Treatment:
Anti-inflammatory agents or corticosteroids
Bone or nerve compression pain
Anticonvulsants or tricyclic antidepressants
Neuropathic pain
Antitussives, laxatives, antiperistaltic drugs
Reduce muscle spasms


Episodic or Incidental Pain Causes:
Expressive aphasia

Children and the elderly have special difficulty communicating pain intensity.

Delirious patients: unable to convey the intensity, nature, or location of the pain.

Neurologic events, infections, trauma, bladder distention, fecal impaction, hypoxia, or metabolic abnormalities are common.
Impaired Cognitive or Communicative Function Often have difficulty finding physicians who will provide the high doses of analgesics required.

Can become angry, frustrated, and more persistent in demands.

Pseudo-addiction: a preoccupation with obtaining analgesics, it tends to disappear rapidly with appropriate pain therapy.

Pain management agreements
History of Substance Abuse Cancer pain remains undertreated despite evidence that a careful assessment of cancer pain and the appropriate use of available therapies should result in relief in nearly 95% of patients.






The American Society of Clinical Oncology's policy statement on cancer pain notes, “patients with cancer have a right to effective treatment of pain” and the “evaluation and treatment of cancer pain are an integral part” of each caregiver's responsibilities. Questions? Radiologist guides a small needle through the skin into the tumor. From the tip of the needle, radiofrequency energy (similar to microwaves) is transmitted to the tip of the needle, where it produces heat in the tissues.

The dead tumor tissue shrinks and slowly forms a scar.

Ideal for nonsurgical candidates and those with smaller tumors. The FDA has approved RFA for the treatment of tumors in soft tissue that includes the lung.


Radiofrequency Ablation Open Unilateral Anterolaterol Cordotomy
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