CANCER PAIN MANAGEMENT

PAMELA M. SUTTON, M.D. FAAHPMDECEMBER 2013

“TOTAL PAIN”

“EVERYTHING HURTS”

• PHYSICAL PAIN

• EMOTIONAL PAIN

• SOCIAL PAIN

• SPIRITUAL PAIN

PAIN ASSESSMENT

PATIENT RATES INTENSITY/SEVERITY OF PAIN ON SCALE OF ZERO TO TEN

• LOCATION• QUALITY (ACHING, BURNING,

SHOOTING)• DURATION (INTERMITTENT OR

CONTINUOUS)• WHAT MAKES PAIN BETTER/WORSE

CAUSES OF PHYSICAL PAIN IN CANCER

• Bone Metastases-50%

• Nerve Injury(neuropathic)or compression-25%

• Cancer treatments-19%

NOCICEPTIVE

vs.

NEUROPATHIC PAIN

TREATMENT OF PHYSICAL PAIN

• TREAT UNDERLYING ILLNESS

• ELEVATE PAIN THRESHOLD

• INTERRUPT PAIN TRANSMISSION

WORLD HEALTH ORGANIZATION 3 STEP METHOD FOR CANCER PAIN RELIEF

(“Analgesic Ladder”)

• STEP 1. “NON-OPIOID” +/- ADJUVANT If pain persists or worsens, go to:

• STEP 2. MILD OPIOID +/- NON-OPIOID +/-

ADJUVANT If pain persists or worsens, go to:

• STEP 3. STRONG OPIOID +/- NON

OPIOID+/-ADJUVANT

ANALGESIC LADDER

ORAL MEDICATION IS PREFERRED

EASE OF ADMINISTRATION

STEADY BLOOD LEVELS

SAFETY

ANALGESIC LADDER

OPIOIDS DO NOT ALWAYS RELIEVE PAIN!

NON-OPIOID ADJUVANTS AND/OR OTHER PAIN METHODS MAY BE NECESSARY.

ANALGESIC LADDER

PAIN TREATMENT SUCCESSFUL IN 90% OF PATIENTS WITH PROPER MEDICATION USE

WORLD HEALTH ORGANIZATION 3 STEP METHOD FOR CANCER PAIN RELIEF

(“Analgesic Ladder”)

• STEP 1. “NON-OPIOID” +/- ADJUVANT If pain persists or worsens, go to:

• STEP 2. MILD OPIOID +/- NON-OPIOID +/-

ADJUVANT If pain persists or worsens, go to:

• STEP 3. STRONG OPIOID +/- NON

OPIOID+/-ADJUVANT

NON-OPIOID ANALGESIC

PARACETAMOL 500-1000 MG EVERY 4-6 HOURS

• Advantages: Available, cheap,

effective for mild pain.

• Disadvantages: Potential liver toxicity.

Not anti-inflammatory.

Not best choice for bone pain.

NON-OPIOID ANALGESICS

NSAID’S

• Advantages: Anti-inflammatory effects helpful for bone pain. Dosage may be less frequent than paracetamol.• Disadvantages: Potential GI/renal side effects and interference with platelet function.

NSAIDS• SALICYLATES

Aspirin• PROPRIONIC ACIDS

Ibuprofen--every 6 hours; liquid

Naproxen--every 12 hours• ACETIC ACIDS

Diclofenac--every 8 hours

Ketorolac (Toradol)--oral or

parenteral; short term use only

NSAIDS

COX 2 INHIBITORS• Celecoxib

• Less GI toxicity (not perfect);• Less anti-platelet activity• Potential Renal/Cardiovascular Toxicity

OPIOIDS1) CODEINE, MORPHINE

2) SEMISYNTHETIC

HYDROCODONE

BUPRENORPHINE (MIXED AGONIST/

ANTAGONIST)

3) SYNTHETIC

METHADONE (DOLOPHINE)

FENTANYL (DURAGESIC)

TRAMADOL

CONCERNS ABOUT OPIOIDS

1. ADDICTION

Physical Dependence and Psychological Craving

2. TOLERANCE

Rarely a practical problem. Dose can be

increased if tolerance occurs.

3. RESPIRATORY DEPRESSION

Rarely a problem when appropriate dose of oral

narcotic is titrated to level of pain.

CONCERNS ABOUT OPIOIDS

4. LETHARGY Sleepiness may occur in first hours/days but usually improves. 5. NAUSEA Occurs in less than half of patients. May

resolve. 6. CONSTIPATION Frequent problem--should be anticipated with

stool softener/laxative on a daily basis. Avoid bulk laxatives.

WORLD HEALTH ORGANIZATION 3 STEP METHOD FOR CANCER PAIN RELIEF

(“Analgesic Ladder”)

• STEP 1. “NON-OPIOID” +/- ADJUVANT If pain persists or worsens, go to:

• STEP 2. MILD OPIOID +/- NON-OPIOID +/-

ADJUVANT If pain persists or worsens, go to:

• STEP 3. STRONG OPIOID +/- NON

OPIOID+/-ADJUVANT

POSSIBLE STEP TWO OPIOIDS (for moderate pain)

• CODEINE• TRAMADOL • HYDROCODONE

STEP TWO OPIOIDS

CODEINE

• 30 mg orally is approximately equal in

analgesic effect to 650 mg of aspirin.

• When 30 mg codeine and 650 mg aspirin are combined, the analgesic effect equals or exceeds 60 mg codeine.

•

STEP TWO OPIOIDS

HYDROCODONE

• May be packaged with paracetamol or ibuprofen. Beware of associated toxicity.

STEP TWO OPIOIDS

TRAMADOL

• Synthetic mu agonist opioid

• Reportedly exerts additional analgesic effect by inhibition of serotonin and noradrenaline reuptake.

STEP THREE OPIOIDS(for severe pain)

• MORPHINE

• METHADONE (Dolophine)

• FENTANYL (Duragesic)

• BUPRENORPHINE

STEP THREE OPIOIDS

MORPHINE PROTOTYPE OPIOID SHORT AND LONG-ACTING TABLETS,

LIQUID, CONCENTRATE, SUPPOSITORIES, IV/SUBQ, EPIDURAL, INTRATHECAL

ACTIVE METABOLITES CAN CAUSE TOXICITY IN RENAL FAILURE

STEP THREE OPIOIDS

METHADONE (Dolophine)

• SYNTHETIC• MU AGONIST AND POSSIBLE NMDA

RECEPTOR ANTAGONIST (May help neuropathic pain)

• ORAL/IV/SUBQ

STEP THREE OPIOIDS

METHADONE (Dolophine)

• TRICKY TO TITRATE

VARIABLE CLINICAL EFFECT. (May accumulate and cause lethargy and potential respiratory depression. )

• EFFECTIVE IN LOW DOSES IN SOME PATIENTS WITH POOR RELIEF FROM HIGH DOSE MORPHINE.

STEP THREE OPIOIDS

FENTANYL (Duragesic)

• SHORT-ACTING SYNTHETIC, PACKAGED

AS THREE DAY PATCH

• 25 MCG PATCH APPROXIMATELY

EQUIVALENT TO 15 MG ORAL MORPHINE

• NOT FOR QUICK TITRATION

(ANALGESIC EFFECT PEAKS ABOUT 17 HOURS

AND LINGERS THAT LONG WHEN REMOVED)

• MAY BE ABSORBED QUICKLY IF TEMP

ELEVATION (BEWARE RESPIRATORY

DEPRESSION)

STEP THREE OPIOIDS

FENTANYL

BEWARE ORAL MUCOSAL PRODUCTS:

UNCLEAR DOSING, RAPID ABSORPTION

STEP THREE OPIOIDS

BUPRENORPHINE

(sublingual tablet, transdermal patch)

• CAN BE USED FOR MODERATE TO SEVERE PAIN

• MAY INDUCE WITHDRAWAL IN OPIOID DEPENDENT PATIENTS

ADJUVANTS

IMPORTANT TO TREATMENT OF NEUROPATHIC PAIN

ANTIDEPRESSANTS

ANTICONVULSANTS

ANESTHETICS

ANTIDEPRESSANTS

TRICYCLICS amitriptyline(Elavil) nortriptyline(Pamelor) SSRI’s paroxetine(Paxil) Others: venlafaxine (Effexor) mirtazipine (Remeron) duloxetine (Cymbalta)

ANTICONVULSANTS

• gabapentin (Neurontin)

• pregabalin (Lyrica)

• clonazepam (Klonopin)

ANESTHETICS FOR PAIN• Lidocaine IV, Ointment, Lidoderm Patch• EMLA • Ketamine Oral, IV, Subq

OTHER TOPICAL PREPARATIONS• Capsaicin

• SUMMARY

• CANCER PAIN CAN AND MUST BE RELIEVED

• OBTAIN THOROUGH HISTORY AND PHYSICAL EXAM

• ADMINISTER MEDICATION ON A REGULAR BASIS • ACCORDING TO THE ANALGESIC LADDER• STEP 1. NON-OPIOID +/- ADJUVANT• If pain persists or worsens, go to:• STEP 2. MILD OPIOID + NON-OPIOID +/- ADJUVANT• If pain persists or worsens, go to:• STEP 3. STRONG OPIOID +/- NON-OPIOID+/-ADJUVANT• OFFER EMOTIONAL SUPPORT• REASSESS PAIN AND EFFECTIVENESS OF TREATMENT • FREQUENTLY

PAIN SUMMARY

•

•

•

PAIN MUST BE RELIEVED

THOROUGH HISTORY AND PHYSICAL EXAM

MEDICATION ON A REGULAR BASIS ACCORDING TO THE ANALGESIC LADDER

STEP 1. NON-OPIOID +/- ADJUVANT STEP 2. MILD OPIOID +/- NON-OPIOID +/- ADJUVANT STEP 3. STRONG OPIOID +/- NON-OPIOID+/-ADJUVANT

EMOTIONAL SUPPORT

REASSESS PAIN AND EFFECTIVENESS OF TREATMENT FREQUENTLY

OPIOID EQUIVALENCE

5 MG OF OF IV OR SUBQ MORPHINE EVERY 4 HOURS =

15 MG OF IMMEDIATE RELEASE ORAL MORPHINE EVERY 4 HOURS =

25 MCG FENTANYL PATCH EVERY 3 DAYS

USEFUL REFERENCES

• ASSESSING AND TREATING PAIN; UNIPAC THREE, AAHPM, 2012.

• CANCER PAIN RELIEF, WORLD HEALTH ORGANIZATION, GENEVA, 1986.

• EDUCATION FOR END OF LIFE CARE (EPEC) PROJECT,2003; NORTHWESTERN UNIVERSITY SCHOOL OF MEDICINE created with AMA & ROBERT WOOD JOHNSON FOUNDATION, CHICAGO, ILL.

• FERRANTE, FM; ‘‘Principles of Opioid Pharmacotherapy: Practical Implications of Basic Mechanisms”, J. of PAIN and SYMPTOM MANAGEMENT; May 1996, Vol. 11, No 5.

• FOLEY, KM; “The Treatment of Cancer Pain” ,NEJM;1985, 313:84-95.

• MANAGEMENT OF CANCER PAIN, Clinical Practice Guideline #9; AHCPR Publication #94-0592, March 1994.

• PRIMER OF PALLIATIVE CARE, 5th Edition; AAHPM, 2010.