Mary Cunningham MS, RN, CNS
Coordinator Pain and Palliative Care, Ellis Fischel Cancer Center
CANCER PAIN MANAGEMENT
• Pri...
Myofascial Pain Syndromes
• Characterized by hypersensitive points {trigger points}, muscle spasm, tenderness, stiffness, ...
• Defined as drugs with other indications that may be analgesic in specific circumstances
 Multipurpose analgesics
 Drug...
• Multimodality treatment.
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Cancer Pain Management

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Cancer Pain Management

  1. 1. Mary Cunningham MS, RN, CNS Coordinator Pain and Palliative Care, Ellis Fischel Cancer Center CANCER PAIN MANAGEMENT • Priority. • Incidence and severity of pain associated with cancer and cancer treatment. • Negative impact. • Excellence in care requires careful attention to symptom management. • The principles of cancer pain assessment and management are applicable to pain related to non-cancer pain. Cancer Pain Syndromes • Direct tumor involvement:bone, nerve, viscera • Treatment related: acute and chronic • Preexisting conditions Physiologic Consequences of Pain • Increased metabolic rate. • Increased blood clotting. • Water retention. • Tissue breakdown. • Impaired immune function. • Autonomic hyperactivity. • Pulmonary dysfunction. • Delayed return of bowel function. • Development of chronic pain syndromes. Impact of Pain on Activity and QOL. Cleeland C., et. Al. (1994). NEJM 330. Manifestations of Pain Acute Chronic < 6 mths duration. Etiology known. Increased BP, HR, Resp. Dilated pupils. Sweating. Focus. Reports pain. Crying, moans, restless. Grimace. > 3 mths duration. Etiology may not be known. Normal vital signs. Normal pupils. Dry skin. Distraction. No report. Quiet, sleep, rests. Blank or normal facial expression. Key Principles  Reliance on observable physiologic and behavioral manifestations in order to verify existence and severity of pain is inadequate.  Person experiencing pain is the authority. Strategies to categorize pain • Duration: acute, chronic. • Temporal pattern: continuous, intermittent, incident, break through, paroxysmal. • Severity. • Specific cancer pain syndromes. • Neurophysiologic.
  2. 2. Myofascial Pain Syndromes • Characterized by hypersensitive points {trigger points}, muscle spasm, tenderness, stiffness, limitation of movement, weakness, + autonomic dysfunction. • Referred, localized pain. • People with cancer are at significant risk. Risk factors • Peripheral nerve injury. • Musculoskeletal injury. • Deconditioning. • Gait changes. • Fibrosis. • Disuse. • Fatigue. • Stress. IMPORTANT DEFINITIONS • Physical Dependence: involuntary, adaptation, withdrawal will occur with abrupt reduction or discontinuation. • Psychological Dependence: compulsive use despite harm to achieve effects other than pain relief. • Tolerance: decreased effect. Tolerance to analgesics is uncommon. • Pseudoaddiction: behavioral manifestations of inadequate treatment. • Iatrogenic addiction: psychological dependence as consequence of exposure. RARE < 0.1% Treatment Strategies •Therapy directed to etiology. •Analgesic and adjuvant medications. •Physical therapies. •Psychological interventions. •Anesthetic and neurolytic procedures. Pharmacotherapy for Pain Categories of analgesic drugs • Non-opioid analgesics • Adjuvant analgesics • Opioid analgesics Nonopioid analgesics: NSAIDs Mechanism • Inhibit both peripheral and central cyclooxygenase, reducing prostaglandin formation. Properties • Nonspecific analgesics, but greater effectiveness likely in inflammatory pains • Dose-dependent effects, with ceiling dose • Marked individual variation in response to different drugs • Drug-to-drug variation in toxicities partly determined by COX-1/COX-2 selectivity • Side effects. GI, bleeding risk, renal function. Adjuvant Analgesics
  3. 3. • Defined as drugs with other indications that may be analgesic in specific circumstances  Multipurpose analgesics  Drugs used for neuropathic pain  Drugs used for musculoskeletal pain  Drugs used for cancer pain Opioid analgesia • Opioid receptors: CNS (e.g. dorsal horn), pituitary gland, GI tract. • Opioid binding at opioid receptors blocks release of neurotransmitters particularly substance P and pain transmission is inhibited. Potential Side Effects of Opioids • Constipation. • Sedation • Mental clouding • Respiratory depression • Nausea and vomiting • Orthostatic hypotension • Urinary retention • Pruritus • Myoclonus Physical and occupational therapies • Brachial plexus injury. • Post mastectomy pain syndrome. • Long bone infiltration. • Myofascial pain syndromes. • Debility. • Post amputation. • ADLs, independence. Other analgesic approaches • Neural blockade with local anesthetic or neurolytic agent.  Temporary or “permanent” nerve blocks: stellate ganglion block, intercostal nerve block, celiac plexus block • Trigger point injection. • Drug delivery systems. • Psychological approaches. • Physical therapy modalities. • Patient/family education. SUMMARY • Unrelieved pain negatively impacts QOL • Pain is multidimensional, subjective, and uniquely personal.  Person with pain is the authority.  Limited objective measures of the experience.  Pain is more than just nociception. • Comprehensive assessment is the pivotal first step in therapy.
  4. 4. • Multimodality treatment.

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