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Pain Management
- 2. Types Nociceptive : pain signals from nerve endings Neuropathic : damage to nerve fibres.
- 3. •What Pain Rating Scales Do We Know??
- 5. Numeric pain rating scale
- 6. Wong-Baker faces pain rating scale
- 8. Cancer Pain Nociceptive Somatic: intermittent to constant sharp, knife-like, localized e.g. soft tissue infiltration
- 10. Cancer Pain Nociceptive Visceral: constant/intermittent crampy/squeezing poorly localized, referred e.g. intra-abdominal mets
- 12. Cancer Pain Nociceptive Bony: constant, dull ache localized, may have neuropathic features e.g. vertebral metastasis pathologic fractures
- 14. Cancer Pain Neuropathic Destruction/infiltration of nerves a) dysesthetic: burning/tingling constant, radiates e.g. post-herpetic neuralgia
- 15. Cancer Pain Neuropathic Destruction/infiltration of nerves b) neuralgic: shooting/stabbing shock-like/lancinating paroxysmal e.g. trigeminal neuralgia
- 16. Neuropathc pain Chemotherapy induced Neuropathies • Cisplatin,Oxaliplatin • Paclitaxel,Thalidomide • Vincristine,Vinblastine Surgical Neuropathies • Phantom Limb pain • Post mastectomy syndrome • Post thoracotomy syndrome
- 18. Cancer Pain Breakthrough “Incidental” pain Severe transitory increase in pain on baseline of moderate intensity or less Caused by movement, positioning, cough, wound dressing, etc Often associated with bony metastasis
- 19. Adapted WHO pain ladder.
- 20. Opioid receptors Classically, opioids active on CNS receptors mu (µ) kappa (κ) delta (δ) receptors Now found on: Peripheral Neurons Immune Cells Inflammed Tissue Respiratory Tissue GI Tract
- 21. Opioid Side Effects Common Uncommon Constipation Bad Dreams / Hallucinations Dry Mouth Dysphoria / Delirium Nausea / Vomiting Myoclonus / Seizures Sedation Pruritus / Urticaria Sweats Respiratory Depression Urinary Retention
- 22. Opioid-Induced Neurotoxicity (OIN) Neuropsychiatric syndrome • Cognitive dysfunction • Delirium • Hallucinations • Myoclonus/seizures • Hyperalgesia/allodynia
- 24. Bone Pain Pharmacologic treatment • Opioids • NSAIDs/steroids/Cox-2 inhibitors • Bisphosphonates Pamidronate Clodronate Zoledronate
- 25. Bone Pain Radiation treatment 1. Single treatment (800 cGy) 2. Multiple fraction (200 cGy x 3-5) 3. Effective immediately 4. Maximal effect 4 - 6 weeks 5. 60-80% patients get relief
- 26. Bone Pain Surgical opatientions 1. Pathologic # (splint, cast, ORIF) 2. Intramedullary support 3. Spinal cord decompression 4. Vertebral reconstruction
- 27. Adjuvants NSAIDs Anti-inflammatory, anti-PEG S/E: gastritis/ulcer, renal failure ↑ K+ , platelet dysfunction Ibuprofen, naproxen Don’t use both steroids & NSAIDs!
- 28. Adjuvants Cox-2 Inhibitors Celecoxib Rofecoxib Meloxicam Valdecoxib Anti-inflammatory Anti-prostaglandin S/E: less gastritis no platelet dysf’n renal failure still a problem OD dosing expensive
- 29. Adjuvants Steroids ↓ inflammation ↓ edema ↓ spontaneous nerve depolarization Multipurpose
- 33. Neuropathic Pain Non-pharmacologic Radiation treatment Anaesthetic treatment • Nerve Block • Epidural Block
- 34. Neuropathic Pain Pharmacologic treatment • Opioids • Steroids • Anticonvulsants • TCAs (dysesthetic) • NMDA receptor antagonists • Anaesthetics
- 35. Step 4
- 36. Interventions
- 37. Alternative Therapies Acupuncture Cognitive/behavioral therapy Meditation/relaxation Guided imagery Herbal preparations Magnets Therapeutic massage
- 38. Key Points • Current, accurate information • Use available resources • Involve family & caregivers • Know patient knowledge base • Address patient priorities first • Small doses of useful info (e.g., S/E) • Individualize to patient (social, education level)
- 39. Conclusion Cancer pain can be from the cancer itself, or from cancer-related treatments Can be somatic, visceral, or neuropathic Negative effects of cancer-related pain can effect QOL, mortality Ask the patient about pain and REASSESS!
- 40. Choose non-opioid / adjuvants carefully paying close attention to side effect profile Use WHO ladder guidelines when titrating pain medications Use long-acting opioids for chronic cancer pain Recognize “4th step” in WHO ladder and utilize your multidisciplinary resources
- 41. Can we offer this ?
Editor's Notes
- patient with H&N cancer – large R sided mass – ex. Somatic pain
- Colorectal CA with liver met – left lobe of liver – visceral pain
- Vertebral met – localized somatic pain to vertebrae, visceral pain in abdomen – and neuropathic pain from nerve root involvement – ex – many cancer patients will have several sources and can have a combination of how they’re experiencing pain
- patients can have chemo-related neuropathies – cisplatin, taxol, the vinca alkaloid are well known players – patients usually have a symmetrical polyneuropathy – localized in hands and feet SURGICAL neuropathies – have distinct pain syndromes – phantom limb pain s/p amputation Post-mastectomy syndrome – neuropathic pain in posterior arm, axilla and anterior chest wall – due to the interrupatiention of the intercostal brachial nerve (cutaneous sensory branch of T1-2) – little bit of a misnomer – you see this syndrome in women who have undergone a radical mastectomy, lumpectomy, even just an axillary node dissection ; 5% of women who undergo any of those procedures will have this syndrome (ex. Lady with dcis – b mastectomy- did fine (felt a lump in her axilla – lymph node dissection (fortunately benign) and since then has had debilitating neuropathic pain) Same with post-thoracotomy – neuropathic pain along the distribution of an intercostal nerve following injury or surgery – ex. Lung ca patients s/p lobectomy
- Lastly – what type of neuropathic pain does this picture demonstrate?? – CORD compression – which we’ll talk about later
- Constipation – easier to prevent than treat; all patients on opioids need a bowel regimen, dry mouth, nausea, sedation – usually go away in a few days; always clarify when a patient says they have an allergy to morphine More uncommon adverse effects can combat many side effects with medication, or with opioid rotation The big fear – respiratory depression – patients will fall asleep/somnolent before their resp drive is affected When we see it – patients continuing to get their opioids after they’ve become somnolent – RNs, family pushing pca, combining benzos and opiates; if vitals are stable and patient protecting airway – can just observe – if showing signs of resp depression – then give narcan
- It increases the risk of developing pepatientic ulcers