Cancer pain

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  • Cognition and memory play a large role in the experience of pain.10 Fear and depression reduce pain thresholds and produce anatomic changes that accentuate pain. Long-term neuroanatomic changes have been discovered in amygdala and hippocampus, sites that affect pain memory. These changes involve calcium-calmodulin–dependent protein kinases.17
  • Increased catabolic demands: poor wound healing, weakness, muscle breakdownDecreased limb movement: increased risk of DVT/PERespiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasisIncreased sodium and water retention (renal)Decreased gastrointestinal mobilityTachycardia and elevated blood pressureDecreased functional statusDepression/anxietyIsolation – decreased intimacyExistential suffering
  • Increased catabolic demands: poor wound healing, weakness, muscle breakdownDecreased limb movement: increased risk of DVT/PERespiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasisIncreased sodium and water retention (renal)Decreased gastrointestinal mobilityTachycardia and elevated blood pressureDecreased functional statusDepression/anxietyIsolation – decreased intimacyExistential suffering
  • Cancer pain

    1. 1. Cancer Pain ManagementSuzana Makowski, MD MMM FACP FAAHPM
    2. 2. • 50 to 90 percent of oncology inpatients report breakthrough pain• 35 percent of community based oncology practices patients report breakthrough pain• 1 in 3 patients with active cancer report pain• 3 out of 4 of patients with advanced cancer report painPrevalence of Cancer Pain
    3. 3. • Bone metastases• Visceral metastases• Immobility• Neuropathic pain• Soft tissue• Constipation• Esophagitis• Lymphedema• Muscle cramps• Chronic postoperative scar• Adapted from Twycross R, Harcourt J, Bergl S: A survey of pain in patients with advanced cancer. J Pain Symptom Manage 1996;12:273-282.Common Causes
    4. 4. Physical Emotional Existential• Increased catabolic demands: Depression Suffering – poor wound healing, weakness, muscle Anxiety “why me?” breakdown Decreased• Decreased limb movement: intimacy Suicidality increased risk of DVT/PE• Respiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasis• Sodium and water retention Decreased gastrointestinal mobility• Tachycardia and elevated blood pressure• Decreased functional status• Increased chronic pain Effects of under treated pain
    5. 5. Effects of under treated pain
    6. 6. • System barriers to treating pain • Clinical, • Patient-related • System-related• Racial and ethnic barriers exist • Language • Perceptions• Concern about addiction • Differences between addiction, • dependence, • tolerance & • pseudoaddictionBarriers to Pain Control
    7. 7. Intensity • Location • Quality • Timeline •Alleviating factors • Meds triedPain Assessment
    8. 8. What about for patients who cannot self-report?Intensity
    9. 9. Category Cause Symptom ExamplesPhysiologic Brief exposure to a Rapid yet brief pain Touching a pin or hot noxious stimulus perception object Somatic or visceral tissue Moderate to severe pain, Surgical pain,Nociceptive/infla injury with mediators described as crushing or traumatic pain, sicklemmatory having an impact on stabbing cell crisis intact nervous tissue Damage or dysfunction Severe lancinating, Neuropathy, CRPS.Neuropathic of peripheral nerves or burning or electrical Postherpetic Neuralgia CNS shock like pain Combinations of Low back pain, back Combined somatic andMixed symptoms; soft tissue plus surgery pain nervous tissue injury radicular painPain Quality
    10. 10. Timeline
    11. 11. • What worked? • What doses? • What side effects?Prior medications & other tx
    12. 12. Common Rare• Constipation • Respiratory suppression• Nausea • Neurotoxicity• Sleepiness/somnolence • Seizures• Pruritus• MyoclonusSide effects
    13. 13. Opioid Pharmacology
    14. 14. Short-acting Long-acting• Hydrocodone/APAP • Transdermal fentanyl• Oxycodone +/- APAP • methadone• Morphine • morphine ER• Hydromorphone • oxycodone ER• Oral transmucosal fentanyl• Cmax ~ 45 min Cmax and T1/2 vary based on• T1/2 ~ 4 hours formulation and drug• Except fentanyl Opioid Pharmacology
    15. 15. • Conjugated by liver• 90-95% excreted in urine• Dehydration, renal failure, severe hepatic failure • Decrease interval/dosing size • If oliguria/anuria • STOP routine dosing (basal rate) of morphine• Use ONLY PRNOpioid pharmacology
    16. 16. What is the half life (range) for opioids?• 2-4 hoursHow many half lives to get to steady state?• 4-5What do you base your scheduled dosing on: Cmax or T1/2?• T1/2What do you base your breakthrough dosing on: Cmax or T1/2?• CmaxOpioid Pharmacology
    17. 17. Equianalgesic dosing
    18. 18. What is the challengewith Step 2 of theladder? WHO Step-Ladder
    19. 19. Hector G - 65 yo man with colon cancer and bone metastasesYour colleague first started Mr. G on hydrocodone 5 mg +acetaminophen 325 mg one tablet by mouth every 4 hours prn forhis hip and rib pain. He also ordered senna + docusate 2 tabs poqday to prevent opioid‐induced constipation.Today, he tells you he is taking the Vicodin 1 tablet every 4 hoursaround the clock (including at night). His pain is generallyconstant, aching and he rates it as 5/10, but worsens to 8/10 withcertain positions and movements.• How will you titrate his opioid pain medication?Case – part 1 - outpatient
    20. 20. • Convert from Vicodin to Morphine• How to convert to a combination of long- and short- acting morphine (the latter for breakthrough pain)?• What co-analgesics and other treatments might you choose?Case – Part 1
    21. 21. • Hector comes to hospital for a procedure. He is made NPO. His pain has been well managed. How do you manage his pain?• Home regimen: MSContin 30mg BID, Roxanol 10mg q2 hours prn, requiring 2 – 4 doses per day.• What if he were on Oxycodone/Oxycontin instead?Case – Part 2 – NPO inpatient
    22. 22. • Mr. G presents to the ER after several days of escalating hip and rib pain, despite taking the maximum dose of morphine he was prescribed as an outpatient. “I can’t take it anymore.” You admit him for pain management while trying to treat his escalating pain.• Home medications: MSContin PO 30mg bid, Morphine liquid 10mg PO q2 hours prn (taking every dose)In addition to imaging him, calling radiation oncologyfor evaluation, how do you manage his pain?Case – part 3
    23. 23. • This is as much of a crisis as a code (JAMA 2008;299(12):1457-1467. doi: 10.1001/jama.299.12.1457)• http://jama.ama- assn.org/content/299/12/1457.full. pdfPain crisis
    24. 24. Non-interventional Interventional• Methadone (opioid + • Nerve blocks NMDA) • Intrathecal pain pumps• Ketamine (NMDA) infusion• Lidocaine infusionAdvanced paintechniques
    25. 25. • Choosing to be CMO does not automatically increase opioid requirement• Caution with renal failurePain at End-of-Life
    26. 26. • Pain is common in cancer. Undertreated pain worsens prognosis• On a good day, patients should not need PRNs, and on a bad day, should not need it more than 4 times per day.• When converting to IV from PO – don’t forget to include the long-acting opioid.• Opioid conversion is not mysterious• Pain Crises is as serious as a code• Methadone is a great drug – but is complicated• Avoid morphine and hydromorphone in renal failure• Match pain pattern with opioid pharmacology• CMO ≠ continuous morphine only• We’re here to helpSummary: Top 10
    27. 27. • https://cissecure.nci.nih.gov/ncipubs/detail.aspx?prodid= Q014Free CME from NCI

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