This document discusses managing pain in pancreatic cancer patients. It covers causes of pancreatic cancer pain, use of analgesics for cancer patients near death, the WHO analgesic ladder approach, effectiveness and misinterpretations of the ladder, early pain interventions for pancreatic cancer, and methods and complications of celiac plexus blocks for pain relief. The WHO ladder advocates for individualized oral analgesia using opioids if needed, starting with normal release before extended release. Early pain interventions may improve quality of life and allow better tolerance of cancer treatments. Celiac plexus blocks can provide pain relief but have risks and may not always be useful depending on a patient's situation.

1. Managing Pain in Ca.
Pancreas
Dr. P. Vijayanand
FCARCSI, DPainMed(RCSI), MSc(Pain), FFPMCAI, FFPMANZCA
Director
Axon Multi-disciplinary Pain Management Centre
Hyderabad

2. Causes of pain
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Cancer
Metastases
Investigations
Surgery
Stents
Unrelated
Other symptoms

3. Proportion of cancer patients in the weeks preceding
death who were prescribed analgesics (N=234)
Borgsteede et al 2008

5. WHO Ladder
• Best regarded as a framework of principles and
not a rigid protocol
• Advocates analgesia:
– By the mouth, by the clock, by the ladder
– Individualised to patients
– Attention to detail
• Put oral opioids on the map

6. Effectiveness of the ladder
• Pain relief
– Good 76%
– Satisfactory 12%
– Inadequate 12%
• No differences in pain intensity or relief between types
– but those with NeuP received significantly more coanalgesics
Zech et al 1995 Pain
Grond et al 1999 Pain

7. Common mis-interpretations
• starting at step 1 for moderate to severe pain
• assuming that the ladder is restricted to
opioids
• rotating around analgesics at steps 1 or 2
despite inadequate pain relief

8. WHO ladder
EAPC guidance
By the mouth
oral route preferred
By the clock
start with normal release before
modified release
By the ladder
morphine preferred strong opioid
methadone not recommended for
non-specialists
Individualised for patients
switch opioids if side effects occur

9. • Small doses of strong opioids
• No evidence for improved analgesia on moving
from Step 1 to Step II
• Fear of strong opioids & escalation of NSAIDs –
adverse effects
• ? Strong opioids as StepII
• Invasive procedures considered at all stages

10. Early Interventions – useful?
• Overall favourable risk: benefit ratio
• Better efficacy before extensive perineural
infiltration shelters targeted nerves
• Increased ease and safety prior to development
of massive organomegaly and anatomic
distortion
• Interventions generally better tolerated in less
medically ill patients
• May forestall development of chronic pain
behaviour

11. Early Interventions – useful?
• Improvements in performance status more likely
to meaningfully increase activity and function
• May improve compliance with anti-tumour
therapy
• Improved performance status may enhance
candidacy for investigational therapy
• Collateral effects may result in improved
gastrointestinal motility
• Preliminary evidence of improved survival

13. Methods
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Fluoroscopy-guided
CT-guided
Ultrasound-guided
Endoscopic procedure
Surgical removal

18. Complications
• Neurological –
somatic, dural, Adamkiewicz
• Vascular – large vessel, phenol
• Visceral injury
• Alcohol intoxication
• Orthostatic hypotension
• Diarrhoea
• How to avoid? – land marks, II, contrast

19. Not always useful
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Previous pancreatic surgery
Repeat blocks were unhelpful
Liver enlarged
Fibrosis / scarring around coeliac plexus in
inflammatory disease
• Pain not responsive to NSAIDs
• Head vs body & tail of pancreas.

23. Thank You