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Cancer Pain

SUNY Upstate
by

D G

on 19 August 2015

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Transcript of Cancer Pain

Michael DeCicca, MD
Daniella Goddard, RN
SUNY Upstate Medical University

cause

extension into soft tissues
visceral involvement
bone involvement
nerve compression
nerve injury
raising intracranial pressure
muscle spasm
lymphedema
constipation
bedsores
chronic post-surgical scar pain
chemotherapy-induced neuropathy
chemotherapy-induced mucositis
phantom pain

spondylosis
osteoarthritis
Caused by Cancer Itself
Related to Cancer
Related to Anticancer
Treatment
Caused by a Concurrent
Disorder
mechanism
Nociceptive
Neuropathic
Sympathetically
Mediated
Types:
visceral
somatic
cutaneous
Types:
nerve compression
nerve injury
central
peripheral "deafferentation pain"
mixed

Commonly described as "burning," "stabbing"
Chemical, mechanical, or thermal stimulation of nerve endings
A-delta and c-fibers
pain associated with signs of autonomic regulation dysfunction
injury to sympathetic nerves

Example:
some chronic post-surgical pains
assess

is activity limited?
is sleep disturbed?
what degree of relief is obtained with medication or pain relief?
formal pain scales
offer choice of descriptors (pressure, aching, burning, stabbing)
relate present pain to past pain, eg toothache
detailed history including location, distribution, quality, severity, continuous or intermittent, attenuating factors
include family members

Patient Interview
Psychological Status
radiographs. Note: inadequate in areas of the body where bone shadows overlap, such as base of skull, C2, C7, T1 vertebral bodies, and the sacrum
isotope bone scan
CT to identify early bony changes
MRI to evaluate vertebral body involvement, epidural spinal cord compression, brain metastases

depression occurs in up to 25% of cancer patients
anxiety, suicidal thoughts, degree of functional incapacity

diagnose
modify
radiotherapy: helpful for patients with painful bone metastases
hormone therapy
chemotherapy
surgery
intervene
support
multi-disciplinary approach including psychiatrists, counselors, support groups
psychological approaches
understanding
cognitive behavioral therapies
family and community involvement
companionship
immobilization
rest
cervical collar or corset
plastic splints or slings
orthopedic surgery
drugs are the most effective method of pain control
effective in 90%+ of cancer pain cases
Cancer Pain
treat
re-evaluate

1. Brown, D.L. Regional Anesthesia and Analgesia. Philadelphia: W.B. Saunders Company; 1996:375-380.
2. Cancer Pain Relief: with a Guide to Opiod Availability, Second Edition. Geneva, Switzerland: World Health Organization; 1996.
3. Cleeland CS, Ryan KM. Pain assessment: global use of the brief pain inventory. Annals Academy of Medicine 1994;23(2):129-38.
4. Cudilo E, Lynch P, McJunkin T. Superior Hypogastric Plexus Block. ArizonaPain.com[website]. http://arizonapain.com/pain-center/pain-treatments/superior-hypogastric-plexus/ Accessed August 13, 2014
5.De Wit R, Van Dam F, Abu-Saad H, et al. Empirical comparison of commonly used measures to evaluate pain treatment in cancer patients with chronic pain. J Clin Oncol 1999; 17(4):1280-1287
6. Miller. Anesthesia (5th edition). Churchill Livingstone, Inc.; 2000:1545-1546
7. Van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, Schouten HC, van Kleef M, Patijn J. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol. 2007;18(9):1437-49.
8. Vyvey M. Steroids as pain relief adjuvants. Can Fam Physician. 2010;56(12):1295-7, e415.

Images
1. Cancer Cell (slide 1). Oeggerli, M. Enhanced scanning electron microscope cancer cell. In: TGR’S Cancer Cell Image Wins Award [website]. http://tgrbio.com/tgrs-cancer-cell-image-wins-award/; 2011.
2. Nociception mechanism (slide 5). Milligan ED, Watkins LR. Pathological and protective roles of glia in chronic pain. Nat Rev Neurosci. 2009;10(1):23-36.
3. Neuropathic mechanisms (slide 6). Chen H, Lamer TJ, Rho RH, et al. Contemporary management of neuropathic pain for the primary care physician. Mayo Clin Proc. 2004;79(12):1533-45.
4. Neuropathic overview (slide 6). The potential mechanism of neuropathic pain. Brevoort JC. Illustrations. [website]. http://www.coroflot.com/redatticstudios/illustrations; 2009.
5. Arterial distribution (slide 13). SmartDraw circulatory system arteries. Pixbim.com [website]. http://pixbim.com/10504/ Accessed August 14, 2014
6. Dermatomes (slide 13, 43). Häggström M. Medical gallery of Mikael Häggström 2014. Wikiversity Journal of Medicine [website]. http://en.wikipedia.org/wiki/Dermatome_(anatomy)#mediaviewer/File:Dermatomes_and_cutaneous_nerves_-_anterior.png Accessed August 13, 2014.
7. Radioisotope bone scan (slide 14). Chong WH, Molinolo AA, Chen CC, Collins MT. Tumor-induced osteomalacia. Endocr Relat Cancer. 2011;18(3):R53-77.
8. Support (slide 16). The relationship of depression and pain. In: Pain and Depression [website]. http://pain-and-depression.com/Library/depression-pain-depression/; 2014.
9. NSAID Selectivity (slide 20). Perry LA, Mosler C, Atkins A, Minehart M. Cardiovascular risk associated with NSAIDs and COX-2 inhibitors. US Pharm. 2014;39(3):35-38.
10. Opioid metabolism (slide 23). Pergolizzi J, Raffa R. Common opioid-drug interactions: what clinicians need to know. Pract Pain Manag. 2012:12(7).
11. Drug classes and pain pathways (slide 40). Multimodal analgesic approach to pain management. Medscape [website]. http://www.medscape.org/viewarticle/581948 Accessed August 13 2014.
12. Celiac Plexus innervation (slide 46). Celiac plexus block: functional anatomy. In: Brown DL, ed. Atlas of Regional Anesthesia. 3rd ed. Philadelphia, Pa: WB Saunders; 2006.
13. Retrocrural approach (slide 49). Celiac plexus block: retrocrural (deep splanchnic) technique. In: Brown DL, ed. Atlas of Regional Anesthesia. 3rd ed. Philadelphia, Pa: WB Saunders; 2006.
14. Antecrural approach (slide 50). Celiac plexus block: antecrural technique. In: Brown DL, ed. Atlas of Regional Anesthesia. 3rd ed. Philadelphia, Pa: WB Saunders; 2006.
15. Fluoro celiac plexus (slide 51). Gauci C. Coeliac plexus block.jpg. IN: Coelic plexus block. www.painclinic.uk.net [website]. http://www.painclinic.uk.net/Coeliac_Plexus_Block.htm Accessed August 13, 2014.
16. Superior hypogastric plexus location (slide 56). Anteroposterior anatomy of the superior hypogastric plexus. In: Brown DL, ed. Atlas of Regional Anesthesia. 3rd ed. Philadelphia, Pa: WB Saunders; 2006.
17. Superior hypogastric plexus block (slide 59). Superior hypogastriac plexus block. IN: Overview of Superior Hypogastric Plexus Blocks. Painmanagementlasvegas.com [website]. http://www.painmanagementlasvegas.com/superior-hypogastric-plexus.htmln Accessed August 13, 2014
18. Fluoro superior hypogastric plexus (slide 60). Cudilo E, Lynch P, McJunkin T. Superior Hypogastric Plexus Block - XRAY. ArizonaPain.com[website]. http://arizonapain.com/pain-center/pain-treatments/superior-hypogastric-plexus/ Accessed August 13, 2014


Imaging
Examples:
hepatic capsule pain
bone pain
cramp
Commonly described as "aching"
Radiographs of the limb may show osteoporosis and an isotope bone scan may contain hot spots which can be mistaken for metastases

If suspected, a diagnostic sympathetic block with local anesthetic should be taken to confirm diagnosis
Peripheral nerve injury pain is dermatomal in distribution

Sympathetically mediated pain has an arterial distribution
start with least invasive therapy at lowest dose and titrate
treat towards specific aims:
increase hours of pain-free sleep
relieve pain when patient is at rest
relieve pain when patient is standing or active
Modify Lifestyle
Modify Pathological Process
First line of treatment

Modify Movement
improve diet
meditate
enhance quality of sleep
activity as tolerated
acupuncture
biofeedback
Nociceptive Pain
Neuropathic Pain
Adjuvant Drugs
NSAIDs, Tylenol, Ibuprofen
Opiods
TO TREAT
bone metastases: decreases high local concentration of prostaglandins in affected bone produced by tumor cells
pain caused by soft tissue and muscle infiltration: reduces inflammation. Watch for “ceiling effect”











for patients with impaired platelet function, use Tylenol or non-acetylated salicylate, e.g. choline magnesium tisalicylate or diflunisal (>1g/day)
risk of liver and kidney damage with Tylenol
synergy
morphine
meperidine
tramadol
hydromorphone
fentanyl patch
oxycodone
buprenorphine
methadone
prescribing considerations
metabolization and clearance
dosing and adverse effects
"Attempting to relieve pain without addressing patient's non-physical concerns is likely to lead to frustration and failure" - World Health Organization

previous opiod exposure
severity and nature of pain
extent of cancer, particularly hepatic and renal involvement
concurrent disease
age of the patient
children: base dose on weight
elderly: start low
opioid elimination dependent on liver function

liver disease is not a contraindication —in patients with liver cirrhosis, oral systemic bioavailability increases for dextropropoxyphene and meperidine

the rate of liver clearance
+ intensity and duration of action
= accentuation of drug effects at comparatively low doses

renal dysfunction can lead to an accumulation of metabolites
corticosteroids
tricylic antidepressants
anticonvulsants
to treat adverse effects
enhance pain relief
treat concomitant psych disturbance
antiemetics
laxatives
corticosteroids
psychotropics
Examples:
spinal cord compression, post-stroke pain
neuroma, nerve infiltration
post herpetic neuralgia
Used in conjunction with opioids for nerve compression pain; pain may not respond to opioid alone

dexamethasone
prednisone
prednisolone

Adjuvant therapy for metastatic bone pain and visceral pain
may allow for reduction in opioid dose
To treat superficial burning pain and spontaneous stabbing pain associated with nerve injury
dose: 10-50mg titrated, qhs
amitriptyline
imipramine
nortriptyline: least sedative effect
desipramine: relatively non-sedative, minimal anti-cholinergic effects
For stabbing neuropathic pain
carbamazepine
causes enzyme auto-induction, thereby enhancing its own metabolism
therefore, initial adverse effects (drowsiness, ataxia) improve over time
occasionally causes leukopenia
may exacerbate pre-existing chemotherapy-induced suppression of bone marrow
do not administer to children under 6
valproic acid
long plasma half-life
sedative
danger of fatal hepatotoxicity in children under 2
withdrawal and tolerance
the right dose is the dose that works

Adverse effects
constipation
nausea and vomiting
pruritis
drowsiness and confusion
respiratory depression
pain management index
pain prevalence method
time to pain control method
prescribe
Nerve Blocks
Neurosurgery
Local anesthetics (lidocaine, bupivacaine)
Type of Cancer
Pooled data from 52 articles
Who experienced pain?
64% of patients who had metastatic or advanced stage disease
59% of patients on anticancer treatment
33% of patients after curative treatment
most commonly used opioid
effective dose varies from 5mg to over 1000mg, start low and titrate
the correct dose is the dose that gives pain relief
rescue dose for severe attacks or breakthrough pain
synthetic, centrally acting analgesic with opiod and non-opiod properties
70% bioavailability when absorbed through GI tract
50-100mg q4 or q6
plasma half-life of 6 hours
duration of action 3-4 hours
starting dose 1 to 2mg PO
injection dose: half or one-third of usual oral dose
synthetic drug similar to morphine
plasma half life of 8 to 80 hours
steady state levels after 1 to 2 weeks
analgesia from 6 to 12 hours
take extra care if psychotropics are administered concurrently
synthetic opioid analgesic
anti-cholinergic properties
analgesia up to 3 hours
adverse CNS effects (twitching, tremor, agitation, convulsions) at doses above 100mg q3
avoid in patients with impaired renal function or who are taking MAOIs, phenobarbital, or chlorpromazine
50% to 70% bioavailability
analgesia from 3 to 5 hours
partial agonist
reduces effect of other opiods when taken concurrently
ceiling of 3 to 5mg per day
onset of action 30 mins; peak 3 hours
duration 6-9 hours
sublingual or parenteral; oral effect reduced by "first pass" hepatic metabolism
celiac plexus
Neurolysis
Alcohol, phenol, chlorocresol, cold, heat
References
Assessment Tools

self-reported pain scale: "now" pain + worst, least, and average pain levels during week
interference of pain with other activities, e.g. working, sleeping, walking
pain
reactive pain
vs
Assess
common sense

2006 study of pain in 313 cancer patients using 4 different pain treatment evaluation tools
patients experiencing inadequate pain control varied from 16% to 90% depending on tool used
measurement tool, rather than intervention, determines treatment success
If measurement tool is necessary, use same tool consistently:
cordotomy
myelotomy
Sympathetically Mediated
Peripheral vs. Sympathetically Mediated
Location
Innervation
Indications
Complications
Techniques
retroperitoneal structure in the upper abdomen at T12 and L1
anterior to the crura of the diaphragm and surrounding the anterolateral abdominal aorta

contains ganglia that receive sympathetic fibers from the greater, lesser, and least splanchnic nerves
receives parasympathetic fibers from the vagus nerve
autonomic nerves supplying the liver, pancreas, gallbladder, stomach, spleen, kidneys, intestines, and adrenal glands, as well as blood vessels, arise in the celiac plexus (sympathetic efferent fibers)

to control pain of the epigastric viscera, especially in primary or metastatic upper abdominal cancers
pneumothorax
kidney puncture
bleeding–due to puncture of the aorta or vena cava
paraplegia–related to damage of the artery of Adamkiewicz
secondary to sympathetic block– hypotension, loose stools

Retrocrural and transcrural most common approaches
CPB is often performed with fluoroscopic or CT guidance
Other techniques include:
transaortic approach
anterior approach
paramedian approach at T-12
transdiscal approach

superior hypogastric plexus
Location
Innervation
retroperitoneal structure just anterior to the vertebral column between the lower third of L5 and upper third of S1


efferent sympathetic fibers to and afferent pain fibers from bladder, urethra, uterus, vagina, vulva, penis, testes, prostate perineum, rectum, descending colon

Indication
Techniques

transdermal patch
dose from 25 to 100 mcg/hour
patch applied every 72 hours
pregabalin
90% bioavailability
peak at 1hr
higher bioavailability and lower dose than gabapentin
for the relief of pelvic pain, often secondary to malignancy

topiramate
activity at voltage gated Na, Ca
weight loss
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