Holistic Management Of Cancer Pain

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Talk given at Topeka Cancer Pain Conference April 8th 2010

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  • Highly personal and subjective experience
  • BehaviorsFrown, grimace, fear, sad, muscle contraction around mouth and eyes, restlessness, fidgeting, guarding, rigidity, groaning, moaning, crying, Cultural: pain, hurt, ache
  • Significance of IV route for pain medicinesSignificance of methadone1993 survey of 270 patients with cancer pain – reluctant to report pain and to use analgesicsWard Goldberg 1993
  • Assessment and analgesicsUnpredictabilty of outcomes with nondrug techniques is clearly a disadvantadge
  • Trial and error, openmindness,
  • Holistic Management Of Cancer Pain

    1. 1. Holistic Managementof Cancer Pain:Beyond Opioids<br />Christian Sinclair, MD, FAAHPM<br />Kansas City Hospice & Palliative Care<br />April 8th, 2010<br />
    2. 2. Objectives<br />Clarify the broad umbrella of holistic health<br />Discuss the major elements of a holistic assessment of cancer pain<br />Apply proven holistic therapies for cancer pain<br />
    3. 3. The Impact of Pain<br />Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage<br />
    4. 4. Endocrine<br />Increased<br />ACTH<br />Cortisol<br />ADH<br />Epinephrine<br />Norepinephrine<br />GH<br />Catecholamines<br />Renin<br />Angiotensisin II<br />Aldosterone<br />Glucagon<br />IL-1<br />Decreased<br />Insulin<br />Testoterone<br />
    5. 5. Metabolic<br />Gluconeogenesis<br />Hyperglycemia<br />Glucose intolerance<br />Insulin resistance<br />Muscle protein catabolism<br />Increased lipolyis<br />
    6. 6. Cardiovascular<br />Increased <br />HR<br />Cardiac output<br />Myocardial oxygen consumption<br />Hypertension<br />Hypercoagulation<br />DVT<br />
    7. 7. Pulmonary<br />Decreased<br /> Airflow<br />Volumes<br />Atalectasis<br />Shunting<br />Hypoxemia<br />Cough<br />Sputum retention<br />Infection<br />
    8. 8. GU/GI<br />Decreased<br />Urinary output<br />Retention,<br />Hypokalemia<br />
    9. 9. MSK<br />Fatigue<br />Immobility<br />Muscle spasm<br />
    10. 10. Developmental/Psych<br />Reduced cognitive function<br />Altered mood<br />Increased anxiety<br />Depression<br />Addictive behaviors<br />Future pain disorders<br />Insomnia<br />Suicidal ideation<br />Fear<br />Hopelessness<br />
    11. 11. Holistic?<br />Taking into account all the needs of a patient<br />Physical<br />Social<br />Psychological<br />Spiritual<br />Essential element of palliative medicine<br />
    12. 12. Holistic Can Also Mean<br />‘New Age’<br />Complimentary and Alternative Medicine<br />Herbal medicines or botanical supplements<br />Exotic rituals<br />A natural approach<br />Art and music therapy<br />Hypnosis<br />Imagery<br />Meditation<br />Psychotherapy<br />Spirituality and prayer<br />Yoga<br />
    13. 13. Cancer Pain Assessment<br />Biomedical model<br />Pain scale<br />VAS<br />Are you hurting? Do you have pain?<br />Location, intensity, quality<br />Onset, duration, variations<br />Therapeutic effectiveness<br />Physiologic signs<br />
    14. 14. Cancer Pain Assessment<br />Holistic Model<br />How are you feeling today?<br />Do you have any pain?<br />Include elements of biomedical model<br />Observe patient at rest and with function/movement<br />Cultural considerations<br />Family input<br />Temporal/Contextual considerations<br />
    15. 15. Who is the expert on pain?<br />No objective measures exist<br />Patient report is the gold standard<br />But open to many alterations<br />Interpretation bias from staff/family<br />Important distinction between accepting and believing a patient<br />
    16. 16. Cancer Pain Treatment<br />Education of patient and family<br />Administration<br />Indications<br />Addiction concerns<br />Diversion concerns<br />Tolerance concerns<br />Cultural concerns<br />
    17. 17. Attitudes<br />Patient/Family/Staff exaggerated fears about ‘narcotics’ and addiction<br />Skeptical of health care professionals to relieve pain<br />Lack of access to effective pain control<br />
    18. 18. Non-Drug Approaches to Pain<br />Method can be direct pain reduction<br />Or indirect<br />Making pain more bearable (changing pain threshold)<br />Improved mood<br />Reduced distress and fatigue<br />Increasing control<br />Increasing sleep effectiveness<br />
    19. 19. Non-Drug Therapies<br />Usually inexpensive<br />Low risk<br />Easy to do<br />Readily available<br />Not uniformly effective (intra or interpersonal differences)<br />Usually in addition not substitution of medications<br />Lack strong scientific evidence<br />
    20. 20. Cutaneous Stimulation<br />Heat, cold and vibration have been shown to be effective in various pain types<br />Increase pain tolerance <br />Reduce pain<br />Doesn’t always have to be at site of pain<br />Direct<br />Proximal (between the pain and the brain)<br />Distal (beyond the pain)<br />Contralateral (consensual response v. distraction)<br />
    21. 21. Cold v. Heat<br />Thought to be related to increase or decrease of blood flow<br />Underlying mechanism not clear<br />Both cause decreased sensitivity to pain, decrease muscle spasm<br />Cold – numbness/anesthesia<br />Limited in hospital by physician’s order<br />
    22. 22. Heat<br />Typically 104 to 113F<br />Warms only superficial skin (restinsulated by subcut fat) <br />Can be applied indefinately<br />Avoid immersion<br />Avoid burns<br />Layer between heat source and skin<br />Avoid in irradiated skin – possible increased tissue damage<br />
    23. 23. Cooling<br />Usually around 60F<br />Can cool the muscles in sites with decreased subcut fat<br />10 minutes in slender people<br />30 minutes in obese people<br />Can be applied indefinitely at low level<br />Cold usually relieves pain better longer and faster than heat<br />Alternating probably more effective than either<br />
    24. 24. Vibration<br />Can cause numbness, paresthesia/anesthesia<br />Can change quality of pain (sharp ->dull)<br />Avoid in <br />Patients with easy bruising<br />Thrombophlebitis/clots<br />Injured skin<br />
    25. 25. Distraction<br />A type of sensory shielding<br />Focused attention on other areas decreases pain<br />Can be internal or external<br />Increase pain tolerance and self-control<br />Decrease in intensity<br />Changes in quality of pain<br />Limitations<br />May increase pain<br />More useful in acute pain than chronic pain<br />
    26. 26. Successful Distraction Techniques<br />Interesting to the patient<br />Consistent with patient’s energy level<br />Ability to concentrate<br />Rhythm is emphasized (keeping time)<br />Stimulate all senses<br />Hearing, vision, touch, movement<br />
    27. 27. Visual Distraction Techniques<br />Picture<br />Look at pictures and describe them<br />Hide picture and recall<br />Count or name items or colors<br />Tell a story<br />Mix known vs. new photos<br />Photographs versus art/paintings<br />
    28. 28. Musical Distraction Techniques<br />Pick a song you know the lyrics to<br />Sing (out loud or just mouth the words)<br />Mark time to the song (tap finger/toes)<br />Sing faster/louder if the pain increases<br />
    29. 29. Music Therapy<br />Controlled trials demonstrate<br />Reduced anxiety, stress, depression and pain<br />Decreased HR, RR<br />Trials have demonstrated decreased pain med needs<br />Trials have often been small and exact cause of responses unclear<br />From music or relaxation?<br />
    30. 30. Humor<br />Of questionable impact<br />Studies conflicting<br />But if it helps your patient then use it<br />
    31. 31. Relaxation<br />Alternating tensing and relaxation<br />Progressive relaxation<br />May be combined with imagery/music<br />Tend to have a narrow focus<br />May require practice and motivation<br />Deep breathing<br />Time involved may be a limiting factor<br />Rarely selected non-drug approach<br />
    32. 32. Art Therapy<br />Behavioral modality<br />Enhances coping skills<br />Well studied in children<br />And can be effective outlet for adults<br />Limited evidence, limited availability<br />Often seen in self-motivated individuals<br />
    33. 33. Acupuncture<br />Availability limited by provider availability<br />Evidence is mixed<br />Current Cochrane Collaboration is underway<br />More evidence with nausea/vomiting associated with chemo<br />
    34. 34. Therapeutic Touch/Reiki<br />Often has ties to ‘ancient healing methods’<br />AKA distance healing / energy field manipulation<br />Not connected with faith healing<br />Debunked in JAMA 1998 by an 11 year old<br />Cochrane Review<br />Lack of sufficient data means results are inconclusive, the evidence that does exist supports the use of touch therapies<br />
    35. 35. TENS for Cancer Pain<br />Electrical stimulation via battery<br />Limited use in chronic back pain per Neurology review<br />Not widely used secondary to lack of availability<br />See your local PMR doc<br />Cochrane Collaboration Review<br />‘Insufficient Evidence’<br />
    36. 36. Opioids and Cancer Growth<br />Highlighted in the media end of 2009<br />Based on speculative connections with methylnatlrexone and opioids given at time of surgery<br />In very early stages of research<br />See www.geripal.org for review of the evidence<br />
    37. 37. Summary<br />Medical analgesia should be the main therapy<br />Consider physical, social, psychological, spiritual aspects of patient and family in assessment<br />Get access to experts in these holistic modalities – amateur efforts of minimal help<br />May need to try multiple approaches to non-drug management of cancer pain<br />
    38. 38. Contact Info<br />Christian Sinclair, MD, FAAHPM<br />Kansas City Hospice & Palliative Care<br />Cell: 816-786-8895<br />Email:csinclair@gmail.com<br />Twitter: @ctsinclair<br />Blog: www.pallimed.org<br />
    39. 39. References<br />Oxford Textbook of Palliative Medicine 4thed<br />Pain Clinical Manual 2nded –McCaffery & Pasero<br />Malone MD, Strube MJ, Scogin FR. Meta-analysis of non-medical treatments for chronic pain. Pain. 1988 Sep;34(3):231-44.<br />The Cochrane Review – Pain, Palliative and Supportive Care Group<br />
    40. 40. References<br />Cold and Heat studies: Bini1984,Shere 1986, Collins 1985, Creamer 1996, Lehman 1985, Melzack 1965, Yarnitsky 1997<br />Dubinsky, Miyaski. Assessment: efficacy of TENS in treatment of pain in neurologic disorders. Neurology 74(2) 173-176<br />Rosa, Rosa, Sarner, Barrett. A Close Look at Therapeutic Touc. JAMA 1998; 1005-10.<br />Ward SE et al. Patient-related barriers to management of cancer pain. Pain. 1993 Mar;52(3):319-24.<br />

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