Making the Difference in Pain Management: A Case Study Approach

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Transcript Making the Difference in Pain Management: A Case Study Approach

Cancer Pain Management
ancer
Cancer Statistics: 2010
(ACS, 2010)
• One-third of Americans born this year will
develop cancer.
• Cancer is the second leading cause of death
among Americans, accounting for 1 of every 4
deaths.
• It will occur in approximately 1,529,560 people
and account for about 569,490 deaths this year.
• Life-time risk:
– Men – 1:2
– Women – 1:3
2010 Estimated US Cancer Cases*
Men
789,620
Women
739,940
Prostate
28%
28% Breast
Lung & bronchus
15%
14% Lung & bronchus
Colon & rectum
9%
10% Colon & rectum
Urinary bladder
7%
6%
Uterine corpus
Melanoma of skin
5%
4%
Non-Hodgkin
lymphoma
Non-Hodgkin
lymphoma
4%
4%
Melanoma of skin
Kidney & renal pelvis
4%
5%
Thyroid
Oral Cavity & pharynx 3%
3%
Leukemia
Leukemia
3%
3%
Pancreas
Pancreas
3%
3%
Ovary
20%
3%
Kidney & renal pelvis
All Other Sites
25% All Other Sites
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.
Source: American Cancer Society, 2009.
2010 Estimated US Cancer Deaths
Lung & bronchus
29%
Prostate
11%
Men
299,200
Women
270,290
26%
Lung & bronchus
15%
Breast
Colon & rectum
9%
9%
Colon & rectum
Pancreas
6%
5%
Ovary
Leukemia
4%
7%
Pancreas
Esophagus
4%
3%
Leukemia
Liver & intrahepatic
bile duct
4%
4%
Non-Hodgkin
lymphoma
Non-Hodgkin
lymphoma
4%
3%
Uterine corpus
Urinary bladder
3%
2%
Liver & intrahepatic
Kidney & renal pelvis
3%
All other sites
24%
bile duct
2%
24%
ONS=Other nervous system.
Source: American Cancer Society, 2009.
Brain/ONS
All other sites
Cancer Pain: Prevalence
• 50% of patients in all stages have pain
• 70% - 90 % of patients with advanced
disease have moderate-severe pain
• I
• Inadequate pain control adds to morbidity,
mortality, decreased quality of life, and
increased costs of care
Prevalence of Cancer-Related Pain
• World Health Organization estimates 3.5 million people
suffer from unrelieved cancer pain each day
• Newly diagnosed cancer: 28%
• Actively receiving anticancer treatment: 50-70%
• Advanced disease: 70-80%
– 40-50% report it as moderate - severe; up to 30% report their
pain as very severe
• Nursing home residents with cancer:
– 45-80% have substantially under-treated pain
Patient is cancer-free and still has pain
• Cancer treatment results in “non-malignant”
pain
– Post-thoracotomy pain
– Post-mastectomy pain
– Post-amputation pain
• Phantom Limb pain
• Stump/Neuroma pain
– Chemotherapy-induced painful peripheral
neuropathy (CIPN)
– Radiation Therapy injuries
Pain Follow-up
• How do you treat the patient after their
cancer has been cured or is in remission?
• The line between “malignant” pain and
“chronic” pain becomes obscured
• Standard opioid medication therapy may not
be the most appropriate treatment
The Experience of Pain Requires Telling a
Personal Story & for Someone to Hear It
• Are there differences in
the way one tells a
personal story?
• Are there differences in
the way one listens to a
personal story?
• Are there gender
differences?
Is There Time to Hear Our
Patient’s Pain Story?
•
•
•
•
Time limitations
Competing priorities
Distractions
Distancing
• The average length of a patient’s opening statement
is three minutes
– 77% of the time, we interrupt within the first 2
minutes
– Research shows that 99% of time, once a
patient has been interrupted, he/she does not
get a second chance
(Dr. Neil Irick, N., 2004; 29th ONS Congress Lecture)
Pain Assessment in Oncology
• Pain history
– Location, intensity, quality, temporal patterns,
aggravating/alleviating factors
– Current and past medication use, include OTC
– Meaning of pain
• Physical examination
• Laboratory evaluation
• Reassess frequently
Categorizing Cancer Pain
• Acute vs. chronic
• Etiology (related to cancer or its treatment)
• Quality (nociceptive vs. neuropathic)
• Multiple sites and types of pain are common
Pain Syndromes in Oncology:
Acute vs. Chronic Pain
• Acute pain
–
–
–
–
Associated with diagnostic procedures
Associated with therapeutic interventions
Associated with infection
Associated with vascular events
• Chronic pain or persistent
Acute Pain Syndromes
in Oncology
• Pain associated with diagnostic procedures
– Lumbar punctures
– Bone marrow biopsies
• Pain associated with therapeutic
interventions
– Postoperative pain
– Tumor embolization
– Pleurodesis for pleural effusions
Acute Pain Syndromes
in Oncology
• Pain associated with infection
– Acute herpetic neuralgia (shingles)
• Pain associated with vascular events
– Deep vein thrombosis
– Superior vena cava syndrome
Pain Syndromes in Oncology:
Etiology
• Pain associated with the cancer
– Bone metastases, liver tumor
• Pain associated with cancer treatment
– Painful peripheral neuropathy from chemotherapy,
postsurgical pain, flare from hormonal therapy,
osteoradionecrosis from radiation therapy
• Pain unrelated to cancer or its treatment
– Arthritis, diabetes
Common Nociceptive Pain
Syndromes in Cancer
• Bone pain due to metastases
• Arthralgias due to taxane therapy
• Mucositis pain
• Surgical pain
Bone Pain
•
•
•
•
>75%
Dull ache
Intermittent to continuous
Continuous with progression
of cancer
• May worsen at night
• Reduced function
• Tenderness when tapped
Bone Metastasis
Cancer
Multiple Myeloma
Breast
Prostate
Hodgkin’s Lymphoma
Thyroid
Lung
Renal
Frequency
68-80%
50-85%
50-70%
50-70%
40%
30-50%
30-50%
Common Sites
Site
Rib Cage
Spine
Pelvis
Limbs
Skull
Frequency
58%
54%
40%
32%
19%
Common Visceral Pain
Syndromes in Cancer
• Liver capsule distension
• Malignant bowel obstruction
• Ureteric obstruction
Common Neuropathic Pain
Syndromes in Cancer
• Post-radiation plexopathies
• Surgical neuropathies – postmastectomy syndrome
• Brachial plexus neuropathies – lung or breast
cancers
• Spinal cord compression
• Cranial neuropathies – head & neck, breast or lung
cancers
• Chemotherapy-induced neuropathy
– Bortezomib
– Cisplatin
– Oxaliplatin
– Taxanes
– Vinblastine
– Vincristine
Neuropathic pain:
State of the Problem
Jenson, Madsen, Finnerup (2009); Backonja, M & Woolf, G. J. (2010)
• 2/3’s of patients with NP do not get sufficient
pain relief by current available treatment
• Review of recent clinical trials:
– 30-40% of patients with neuropathic pain may achieve
>40-50% satisfactory pain relief Backonja, M. & Woolf, C. (2010).
• All current treatments for NP are symptomatic
rather than disease modifying or curative
APS Principles of Analgesic Use in the
Treatment of Acute Pain & Cancer Pain,
6th Edition (2008)
NCCN Guidelines for Adult Cancer Pain
2010
National Comprehensive Cancer Network (www.NCCN.org)
• Consensus statement
• Provides algorithms for:
– Pain Assessment
• Pain scale suggestions for different populations
– Pain Treatment and dosing suggestions
• Opioid
• Non-opioid analgesics
• Adjuvants
– Very specific and complex
Goals of Cancer Pain Treatment
•
•
•
•
Prevention
Determine patient’s and family’s goals
Decrease pain
Prevent/manage adverse effects associated
with treatment
• Promote patient safety and function
• Enhance quality of life
Ideal Optimal Pharmacologic
Pain Management Plan
Evidence-Based Plan:
• Right pain medication(s)
• Right dose(s)
• Right route
• Right time
• Right schedule
• Minimal adverse side effects
• Optimal outcomes
– Analgesia/Pain relief
– Improved function/Activities of
Daily Living
– Improved HR-QOL
Management of Cancer Pain
• Treatment of the Cancer
–
–
–
–
–
–
–
Chemotherapy
Hormonal Therapy
Biological Response modifiers
Bisphosphonates
Radiation Therapy
Surgery
Intraveneous radiopharmaceuticals
• Treatment of the Pain: prevention and management
– Pharmacologic strategies: nociceptive & neuropathic
– Nonpharmacological strategies
• Treatment of the Person: dimensions of pain
Etiology-Based Pain Management: Pharmacological Interventions
Pain
Nociceptive
Neuropathic
CNS Medicated
Somatic
Non-Selective
Long-acting
Visceral
Neuralgia
Neuropathy
Selective
NSAIDS
Opioids
PNS Medicated
Anti-Convulsants
Short-acting
Corticosteroids
Tramadol/Tapentadol
Baclofen
Antidepressants
Pharmacological Management of
Cancer Pain
• Nonopioids
• Opioids
• Adjuvants
• Cancer therapies
Special Considerations
• Allergies/sensitivities to medications
• Chronic pain history
• Opioid tolerance
• Chemical-dependence
• Hepatic impairment
• Renal impairment
• Elderly patients
Nonopioids
• Acetaminophen
– Analgesic and antipyretic
– Use with caution in primary liver or metastatic disease
• Nonsteroidal anti-inflammatory drugs
– Analgesic, antipyretic and antiinflammatory
– Contraindicated in thrombocytopenia due to
chemotherapy or bone marrow involvement
– Contraindicated in renal compromise (esp. multiple
myeloma)
– Should not be used concomitantly with steroids
Opioid Use in Oncology & EOL
Opioids Used in Oncology
•
•
•
•
•
•
•
Fentanyl
Hydrocodone
Hydromorphone
Methadone
Morphine
Oxycodone
Oxymorphone
Opioid Pharmacokinetics
• Most short-acting opioids act in a similar
fashion
– PO: peak 1 hour, duration 3-4 hours
– IV: peak 15 minutes, duration 1-2 hours
Long-acting Opioids
•
•
•
•
•
Morphine
Oxycodone
Fentanyl
Methadone
Oxymorphone
Opioid Agonists
“Short-acting”
• Morphine
• Hydromorphone
• Oxymorphone
• Codeine
• Hydrocodone
• Oxycodone
“Ultra-short acting”
• Fentanyl IV, TM
– Fentora, Actiq, Onsolis
“Longer-acting”
• Extended release
morphine
– MS Contin, Oramorph
SR, Kadian, Avinza,
various generics
• Oxymorphone ER
– Opana ER
• Oxycodone ER
– Oxycontin
• Hydrocodone ER
– Exalgo
• Methadone
• Levorphanol
• Transdermal fentanyl
Cancer Breakthrough Pain (BTP)
• Defined as a transitory increase or flare of moderate-tosevere pain that occurs in patients in a background of
otherwise controlled persistent pain, using regularly
scheduled doses of pain medication
• Mean number 6/day
• Average time to peak pain 3 minutes; range 1 second to 30
minutes
• Three subtypes
– Movement or incident pain
– End of dose failure
– Idiopathic (unpredictable, most episodes)
Breakthrough Dosing
• Incident and idiopathic BTP:
– may require short-acting pain medications or non-pharmacologic
interventions as needed, along with their scheduled pain
medications.
• End-of-dose BTP
– may require an increase in the dosage of ATC pain medication or a
decrease in the interval between doses.
• PO
– 10 – 20% of 24-hour long-acting opioid dose
– Example: Long-acting morphine 200 mg q 12; breakthrough dose
40 – 80 mg of short-acting morphine
• IV or SQ
– 50 – 100% of the hourly rate
– Example: Continuous infusion IV morphine 6 mg/hour; bolus or
breakthrough dose 3 – 6 mg IV every 15 minutes as needed
Routes of Administration
• Oral
• Transdermal
– Passive
– Iontophoretic
•
•
•
•
Sublingual
Buccal
Rectal/stomal
Nasal
•
•
•
•
•
Subcutaneous
Intravenous
Epidural
Intrathecal
Intramuscular
– not recommended
Adverse Effects of Opioids
•
•
•
•
•
•
Sedation
Nausea and vomiting
Urinary retention
Cognitive slowing
Pruritus
Respiratory depression (sedation precedes)
– Use naloxone only when poor oxygenation;
administer small increments to prevent
withdrawal syndrome
Adverse Effects of Opioids
• Constipation (don’t build tolerance)
• Myoclonus
– usually in high doses & renal impairment
• Diaphoresis
• Hormonal changes (lowered testosterone)
• Immune changes
Constipation
• Opioids inhibit peristalsis and increase
resorption of fluid into lining of gut
• People with cancer often have multiple
etiologies to constipation
• To prevent constipation, use stool softener
and a laxative
Methylnaltrexone Bromide
Relistor®
Opioid-induced Constipation in Advanced Disease
• FDA approval 2008
• Methylnaltrexone bromide
– indicated for the treatment of opioid-induced
constipation in patients with advanced illness
who are receiving palliative care, when
response to laxative therapy has not been
sufficient.
– Subcutaneous injection dosed according to
weight every other day with no more than 1
dose in 24 hour period
General Strategies to
Manage Opioid Side Effects
• Decrease opioid dose
• Change the route of administration
• Pharmacologic management of side effects
• Opioid Rotation
Opioid Equianalgesic Conversion
• Indications:
– Converting between different opioids
• Unresponsiveness to one opioid
• Intolerable adverse effects
– Converting an opioid from oral to parenteral
route
– Converting an opioid from parenteral to oral
route
Equianalgesic Dosing
Drug
Oral (mg)
IV (mg)
Duration (h)
morphine
30
10
3-4
hydromorphone
7.5
1.5
3-4
oxymorphone
10
1
>4
methadone
2-5
2-5
6 – 8?
200
130
3-4
20-30
30
-
3-4
3-4
codeine
oxycodone
hydrocodone
meperidine
300
100
2-3
McPherson, M. L. 2010
Patient Controlled Analgesia
• Intraveneous or Oral
• Assess previous opioid experience
• Indications
• Special Considerations:
– Basal rates/demand doses
– Education
– Proxy administration: family & nurse
Adjuvants
• Corticosteroids
• Antidepressants
• Antiepileptics
• Local anesthetics
Corticosteroids
• Inhibit prostaglandin synthesis & reduce edema
• Uses: spinal cord compression, neuropathic pain, bone pain
and visceral pain
• Dexamethasone has least mineralocorticoid effect
• Due to its long half-life, dexamethasone should be ordered
every morning to prevents sleeplessness when doses are
given in the evening.
• Doses: variable and based on pain symptom
• May produce psychosis, euphoria
• Long term use (4-6 weeks) can cause proximal muscle
wasting
• Elevated blood sugar, especially in pancreatic cancer,
diabetes
Neuropathic Pain Management
First-Line Medications
Dworkin RH, et al. (2007). Pharmacologic management of neuropathic pain: evidencebased recommendations. Pain, 132(3):237-51.
• Individual variation in the response to the
medications used to treat NP is substantial and
unpredictable.
• First-line medications (Grade A recommendation)
– Tricyclic antidepressants (TCAs)
– Selective serotonin and norepinephrine reuptake
inhibitors (SSNRIs)
– Calcium channel alpha 2-delta ligands
– Topical lidocaine
Tricyclic Antidepresants (TCA)
• Systematic reviews consistently conclude the support the
efficacy for TCA therapy in NP (especially PHN & painful
DPN)
• Mechanism of action: inhibit presynaptic neuronal reuptake
of norepinephrine & serotonin at the descending tract
• Secondary amine TCAs better tolerated & preferred
– Nortriptyline & desipramine
• Tertiary amine TCA only if secondary amine not available
– Amitriptyline & imipramine
• Major side effects: sedation, dry mouth, blurred vision,
weight gain, constipation, urinary retention, orthostatic
hypotension
Tricyclic Antidepresants (TCA)
• Precautions: cardiac disease, glaucoma, suicide
risk, seizure disorder, concomitant use of tramadol
• Nortriptyline associated with cardiac toxicity risk
– sinus tachycardia, increased ventricular ectopy in
patients with ischemic heart disease
– increased sudden cardiac death at dosages > 100mg/day
• Recommended:
– contraindicated in patients w/ ischemic heart disease &
risk for sudden cardiac death
– caution in patient at risk for suicide
– screening EKG at initiation for patients > 40 years.
Selective Serotonin & Norepinephrine
Reuptake Inhibitors (SSNRI)
• Mechanism of action: inhibit sustained high-frequency
neuronal firing by blocking sodium channels after an action
potential, reducing excitability in sensitized C-nociceptors
• Duloxetine (Cymbalta®) FDA approved 2004 for DNP pain
– Major side effects:
• Palpitations, fatigue, anxiety, hyperhydrosis, decreased libido, decreased
appetite, vomiting, loose stools, erectile dysfunction, muscle cramps,
weakness, cough, diaphoresis, nasopharyngitis
– Precautions: hepatic dysfunction, renal insufficiency (require dose
adjustments), alcohol abuse, concomitant use of tramadol
– Other Benefits: Improvement of depression
– Monitor: blood pressure
Selective Serotonin & Norepinephrine
Reuptake Inhibitor (SSNRI)
• Venlafaxine (Effexor®, Effexor XR®)
FDA approval
1993; “off label” use for DPN pain
– Major side effects:
• Nausea, vomiting, headache, asthenia, somnolence, dizziness,
blurred vision, hypertension, sinus tachycardia, anorexia,
insomnia, constipation, nervousness, weight loss, xerostomia,
weakness, tremor, neck pain, diaphoresis, impotence
– Precautions:
• concomitant use of tramadol, cardiac disease, withdrawal
syndrome with abrupt discontinuation; dose adjustments for
renal & hepatic impairment
– Other Benefits: Improvement of depression
– Monitor: blood pressure; LFT & serum creatinine
Calcium Channel alpha2-delta Ligands
• Mechanism of action:
– Binds to the 2 subunit of the voltage-dependent
calcium channel; reduce influx of Ca2+, less glutamate
released from nerve endings
– inhibit sustained high-frequency neuronal firing by
blocking sodium channels after an action potential,
reducing excitability in sensitized C fiber nociceptors
• Not metabolized, few drug interactions
Calcium Channel alpha2-delta Ligands
• Gabapentin (Neurontin®) FDA approved
1994
– Pain Indications: 2002 – PHN, other painful
neuropathies, & nerve-related pain
– Major side effects:
• Somnolance, ataxia, fatigue, nausea, vomiting, peripheral
edema
– Precautions: renal insufficiency; dosing in elderly (start
low, go slow)
– Other benefits: improved sleep disturbance, no
clinically significant drug interactions
– Monitoring: serum creatinine for renal impairment
Calcium Channel alpha2-delta Ligands
• Pregabalin (Lyrica®) FDA approval 2005
– Indications: DPN pain, PHN, fibromyalgia (2007)
– Major side effects:
• Drowsiness, dizziness, fatigue, nausea, sedation, peripheral
edema, visual disturbance, ataxia, tremor, constipation, dry
mouth
– Precautions: renal insufficiency; dosing in elderly
(start low, go slow)
– Other benefits: improved sleep disturbance, improved
anxiety, no clinically significant drug interactions
– Monitoring: serum creatinine for renal impairment
Lidocaine 5% Patch
• FDA approved 1999 for local neuropathic pain syndromes
• Mechanism of action: topical anesthetic; blocks the conduction of
impulses & stabilizes neuronal membranes to sodium
•
• Apply patch to intact skin with no blisters to cover most of painful area
• Use up to 3 patches once a day for up to 12 hours on and 12 hours off
– Can be kept on 24 hours (Gammaitoni 2002)
• Pain relief is individual and may take anywhere from 4 hours to 14 days
according to clinical studies
• Minimal system absorption
•
• Major side effects: local erythema, rash
• Precautions: blood levels are minimal; however, avoid use in patients
receiving oral Class I antiarrhythmic medications
Prescribing Recommendations for
First-Line Medications
Medication Class
Secondary Amine TCA
Nortriptyline
Desipramine
SSRI
Duloxetine
Starting Dose
Titration
Maximum
Dosage
Duration of
Adequate Trial
25mg at bedtime
Increase by 25mg daily
every 3-7 days as tolerated
150 mg daily or divided
4 time/day
6-8 weeks with at
least 2 wks at MTD
30mg once daily
Increase to 60mg once daily
after 1 wk
120 mg or 60mg BID
4 weeks
37.5 mg daily or BID
Increase by 75 mg each week
225mg daily
4-6 weeks
3600 mg daily (1200
mg TID; reduce if
impaired renal function
3-8 weeks for titration
plus 2 weeds at
maximum dosage
600 mg daily (200mg
TID or 300mg BID;
reduce if renal impaired
4 weeks
3 patches daily for 1218 h
3 weeks
Venlafenxine
Calcium channel alpha2delta ligands
Gabapentin
100-300mg at
bedtime or
100-300mg TID
Pregabalin
50 mg TID or 75 mg
BID
Topical Lidocaine 5%
Maximum of 3
patches daily for a
maximum of 12 h
Onset: 2 weeks
Increase by 300 mg daily
every 1-7 days
Onset: more rapid (starting
dose is efficacious)
Increase to 300 mg daily
after 3-7 days, then by 150
mg every 3-7 days as
tolerated
None needed
Pharmacological Treatment/Management
Second-Line Medications
• Second-line medications:
(Grade A recommendations)
• Opioid analgesics
• Tramadol
Treatment of chronic NP with opioid agonists should be generally
be reserved for patients who have failed to respond to or cannot
tolerate the first-line medications alone or in combination.
Tramadol
• Mechanism of action: weak mu-opioid agonist & also
inhibits the reuptake of norepinephrine and sertonin
• Major side effects: somnolence, dizziness, nausea,
weakness, dyspepsia, orthostatic hypotension, restlessness,
seizures, respiratory depression (not completely reversible
with naloxone), serotonin syndrome; abuse potential, but
not scheduled
• Precautions: history of substance abuse, suicide risk,
seizure disorder, concomitant use of SSRI, SSNRI, TCA
Tramadol (continued)
• Slow titration: increase by 50mg PO every 3 days
•
•
•
•
Onset: 1 hour
Peak: 2-3 hours
Duration: approximately 6 hours
Steady-state: 2 days
• High tissue affinity w/ minimal protein binding
• Daily dose not to exceed: 400mg; 300mg for
elderly
Tapentadol (NuCynta®)
•
•
•
•
Newer than Tramadol
Stronger µ opioid agonist
Norepinephrine reuptake inhibitor
50-100 mg PO similar in efficacy to
oxycodone 10-15 mg
• Schedule II
• Cost can be an issue
Prod Info tapentadol immediate release oral tablets, 2008
Prescribing Recommendations for
Second-Line Medications
Medication Class
Opioids agonists
Morpine, oxycodone,
methadone
Tramadol
Short-acting &
Extended Release
Formulations
Starting
Dose
Titration
Maximum
Dosage
Duration of
Adequate Trial
10-15 mg
morphine
equivalent
every 3-4
hours as
needed
After 1-2 weeks,
convert total daily
dosage to long-acting
opioid analgesic &
continue short-acting
medication as needed
No maximum
dosage with
careful titration;
consider
evaluation by pain
specialist at
relatively high
dosages (100180mg morphine
equivalent daily)
4-6 weeks
50 mg once or
twice daily
Increase by 50-100 mg
daily in divided doses
every 3-7 days as
tolerated
400 mg daily
(100mg four times
daily;
in patients older
than 65 years, 300
mg daily
4 weeks
ER: 100, 200,
300 mg doses
once daily
Lower starting
doses &
slower titration
in geriatric
patients
ER: Increase the dose
by 100 mg every 3-4
days
Mutimodal Pain Management
Benefits
• Multiple complex mechanisms may require
different medications with different MOA
• Additive or synergistic analgesia
• Lower doses of individual agents may be
used to decrease adverse side effects &
provide opioid-sparing effects
Interventional Techniques
• Intrathecal implanted pumps; spinal cord stimulators
• Nerve blocks
– Well-localized pain
– celiac plexus block for abdominal pain due to pancreatic cancer
• Vertebroplasty
– Stabilize vertebral body weakened by tumor
• Lesioning of nerves, roots, plexus, spinal cord
– Reserved for small number of individuals who do not obtain relief
with any previous therapies
Anticancer Therapies
• Radiation therapy
– Bone metastases & metastatic lesions (i.e. brain, spinal
cord compression, obstruction)
• Chemotherapy
• Bisphosphonates
– (pamidronate (Aredia) and zolendronic acid (Zometa)
• Octreotide: malignant bowel obstruction, carcinoid
syndrome
• Surgery – stents, stabile bony structures -SCC
Radiation for Bone Metastases
• 40% of radiation is given for the goal of
palliation of symptoms
• External beam radiation to specific painful
site
• Intravenous systemic radioisotope therapy:
– Phosphoruous-32
– Metastron (Stontium-89)
– Quadramet (Samarium Sm-153 lexidronam)
Nonpharmacological Strategies
• Physical
– Superficial Heat/Cold
Therapy
– Massage
– Repositioning/bracing
– Transcutaneous Electrical
Wave Stimulation (TENS)
• Cognitive
– Distraction
• Music, Humor, Activity
–
–
–
–
–
–
Relaxation, Guided Imagery
Expressive arts/music
Biofeedback
Education
Support groups
Spiritual
counseling/prayer/meditation
Pain Management at End of Life
• Simplify medication regimen
• If patient unable to swallow, consider
alternate routes
• If liver and renal dysfunction, drug
clearance impaired; may need to reduce
dose
• Consult other team members – social work,
chaplains, etc
• Support family and other caregivers
Palliative Sedation at End of Life
• When all available treatment options have been
exhausted and pain persists, may employ palliative
sedation
• Agents used include midazolam, propofol,
barbiturates, and others
• Requires consent of patient and family
• Education is key: this is not euthanasia or assisted
suicide
Intractable Pain:
Principle of Double Effect
Basic Rules:
1.
The treatment (ex. high dose opioid) is the only means to
meet the end desired (pain relief)
2.
The physician must intend only the good effect – relief
of pain
3.
The good effect must outweigh any unintended bad
effect
4.
The bad effect (possible earlier death) should not be the
means to the good effect (pain relief).
Monitoring Outcomes of Pain Relief Plan
• Analgesia (presence or absence of satisfactory
pain relief )
• Activities of daily living (improved function)
• Adverse side effects or toxicities (acceptable or
unacceptable)
• Evidence of Aberrant behavior (are potential signs
of inappropriate use of opioids present)
• Achievement of goals for pain management (are
goals met or need modification)
Passik, S. et al, (2002); Curtiss, C. P. (2010)
Patient/Family Education
• Dispel & clarify any misconceptions/ attitudes/fears
toward pain medications
• Pain medications, dose, frequency & schedule
• Expected side effects & their management
• Safety issues
• When to notify MD/RN
Principles of Cancer Pain Management
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Consider variety of cancer pain syndromes
Conduct thorough pain assessment
Ascertain patient’s and family’s goals of care
Incorporate multimodal therapies
Prevent or rapidly treat adverse effects
Reassess frequently and change therapies if
needed
• Address existential distress
• Educate patients, families, other caregivers