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Cancer Pain Management

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  • 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. > 3 mths duration. Etiology known. Etiology may not be known. Increased BP, HR, Resp. Normal vital signs. Dilated pupils. Normal pupils. Sweating. Dry skin. Focus. Distraction. Reports pain. No report. Crying, moans, restless. Quiet, sleep, rests. Grimace. 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. 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 •Defined as drugs with other indications that may be analgesic in specific circumstances
  • 3. 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. •Multimodality treatment.