Transcript 3-Nociceptive rather than neuropathic pain

Oncologic Pain Management
Why?
• After Incurability, Pain was ranked to be the most fearful and the most
distressful symptoms
• Inadequate Pain control associated with profound alteration in nearly
all aspect of wellness( activity-mood-rest-nutrition-sexuality..etc)
• Optimal Pain control, may hasten a return to normality (functionphysiologic-spiritual-psychologic,economic,vocational,survivorship)
• Adequate Pain control, influence outcome and survival…..How?
• Of many negative associated with a diagnosis with cancer, Pain is one
that not only need not to be endured, but when controlled makes other
privations more manageable
Epidemiology of Cancer
• Cancer is highly prevalent disorder
• 6.35 million annual new cases world wide, 50% in
developing country
• 2nd most common cause of death
• Poor outcome despite the aggressiveness of the new
treatment. Poorer in developing country
• 5y survival rate still 50% in USA and 33% in developed
country for the last 40 years
• One death for every ten deaths is due to cancer
Epidemiology of Cancer Pain
• Despite of the high mortality of
cancer,intensive treatment
applied hoping for cure,prolong
survival or improve quality of
life. Ironically Pain and
disability are common outcome.
• Increased survival
chance
to experience Pain with other
symptoms.
• Asthenia 90% Anorexia 85%
Pain 76%
Nausea 68%
Constipation 65%
Pain in cancer population:
1- 66% of all patients
2- 90% of advanced disease
3- 25% of pt.with active ttt.
Have significant Pain
Fortunately, 70-90% of pt.
Got adequate pain control
with stabilized guideline
The rest 10-30% of pt. Need
More invasive procedures
Cancer Pain Syndromes
• Origin either (T-T-T)
Tumor related: 60-80% of patients
Therapy induced: 20-25% of patients
a-Chemotherapy
b-Radiotherapy
c-Post surgical syndrome
Totally unrelated: 3-10%
Origin of Cancer Pain
Types:
Example:
Pt.Perception.
1-Somatic
Bone Mets.
Aching-constant
Well localized
2-Visceral
Ca.Panc. Liver.
Deep-squeeze
Poorly localized
Nociceptive:
Neuropathic:
Plexupathy.Cord Burning-electric
compression
shock
Barriers to Effective Cancer Pain
Management
• It is curious , indeed tragic, that despite the availability of
straight forward, cost effective therapies, Cancer Pain
remains undertreated.( R. Patt. The Patt center for Cancer)
• The factors contributing to undertreatment are complex,
but documented:
1-Knowledge Deficits
2-Beliefs
3-Attitude
By:
1-Health Care Providers
2-Health Care System
3-Patient-Family members
Management of Oncologic Pain
A- Assessment
General: Complete
Broad Base
Compassionate
Goal:to orient pt.,family,and
MRP to what realistically
be accomplished.
Operationally:
Human Disease Pain
1-Psychosocial
2-Oncologic History
3-Pain History
Supplement:
Appropriate standardized
pain questionnaire
VAS BPI MPAC ESSCP
a- Patient General History
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Attention: Assessment is always two-way street.
Pre-assessment: Orientation of the problem
Psychosocial History:
Medical History:
Review System: too often overlooked.The main
goal is the best quality of life possible.Failure of
pain control is mainly due to other symptoms
Oncologic History
• Prior Experience with Cancer (self-others)
• Type, Extend (metastatic status) and
Prognosis
• Prior Antineoplastic Therapies and Outcome
Comprehensive Pain History
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Premorbid Chronic Pain (3-10%)
Premorbid Alcohol or Drug Abuse
Pain Catalogue (number-location)
For Each Pain:
-Onset and evolution
-Site and radiation
-Pattern
-Intensity
-Quality
Pain History Continue…….
-Exacerbating factors
-Relieving factors
-How the pain interferes
-Neurologic and motor abnormalities
-Vasomotor changes
-Other associated factors
-Current analgesics
-Prior analgesics
Physical Exam
• It is non invasive, cost effective, time
saving means of obtaining information
• It may be challenging!
• In one large study, 63% of pt. Referred to
cancer pain service, pertinent new finding
and 20% of them needed to initiate new
antineoplastic therapy
• General P.E and System review
P.E Continue……
• Special exam for:
-Pain site
-Tumor site
-Musculoskeletal system
-C.N.S
Pain, in many time associated with subtle neurological deficit,
identified by P.E
Urgent diagnostic work up or oncologic emergencies may be
the outcome of thoroughly history and physical exam
I’ve just done with my last chemo, I’ve to start again from scratch
Important Pain Syndrome
Nociceptive
A.Somatic
-Bone Pain (the commonest)
-Mechanism
-Presentation
B.Visceral
-Presentation
Neuropathic
-Mechanism
-Presentation
.Emergency
Cord compression
Cauda Equina Syndrome 5%
-Leptomeningeal mets!
Principles of Therapy
1- Keep Patient in Control
2-Focus in Whole Family
3-Utilize Team Approach
4-Usage of Multiple Methods for Treatment
5-Treatment of Other Symptoms
6-Environmental Therapy
7-Never Use Placebo
8-Refer When Pain Persists
Can any body tell me what is going on ?
Strategies to Attack Cancer Pain
1- Eliminating or modifying
the source of pain
2- Modifying the
interpretation of the pain
message at the level of
CNS
3-Interrupting the pain signal
En route from periphery to
the CNS
Multi-Modal Strategy
• It has been proved that pain modification at
multiple site in CNS is an effective therapy.
1-Modify the source of pain
a-Surgery (acute pain-post surgical pain syndrome)
b-Radiotherapy(post radiation pain)
c-Chemo and Hormonal Therapy
2-Modify the interpretation of pain message
• Pharmacological Analgesics
• Psychological support and Relaxation tech.
Pharmacological Analgesics
General Principals: up to 90% success rate
• First line of treatment WHO Analgesic Ladder
and NCCN guideline
• Oral route as long as possible
Continue……
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Avoid poly-pharmacy unless indicated
Avoid starting multiple drugs in the same time
New drug in small doses
Study the common group of drug in use
Have access to reliable inf.on uncommon drugs
Acknowledge and Manage the side effect
How to Choose the Analgesic ?
WHO Step Ladder!
It is an approach advocated
toward cancer pain relief
relies primarily on pain
intensity.
How to choose ?
Mild vs Severe
Acute vs Chronic
When to switch?
Who is better than WHO ?
The WHO Analgesic Ladder
Severe Pain
Moderate Pain
Strong Opioid++ 3
Weak Opioid+
2
Mild Pain
Non-Opioid
1
Step 1: NSAID
• Mechanism: Cyclooxygenase
inhibitor (COX-1 and COX-2)
PG degradation.
• Decrease pain by reducing
pain receptor sensitivity,
reduce the inflammatory
process and edema
• Usage
• COX-2/COX-1 ratio
• Ceiling phenomenon
Special Consideration
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High risk patients
Monitoring
Misoprostol
Interindividual Variability
Cox-1 sparing NSAID
Ketorolac-Bromfenac
Step 2 and 3: Opioids
• Indication:
• Mechanism
• Weak vs Strong !
Potent vs less Potent
Weak Opioid
• Intermediate Potency
• Almost in combination
With other meds(NSAID..etc)
• Weakness due to the ceiling
dose of NSAID or other
• When it is used (sole) in
equianalgesic doses, control
severe pain
Common Weak Opioids!
Percodan
Oxycodone 5mg ASA 325mg
Percocet
Oxycodone 5mg Acetaminophen
325mg
Hydrocodone
Acetaminophen
10mg
650mg
Codeine 30mg Acetaminophen
Codeine 60mg 300mg
Dihydrocodeine Acetam.356mg
16mg
Caffeine 30mg
Lorcet
Tylenol#3
#4
DHC plus
Common Strong Opioids
Generic
Trade
Route
Equi.doses
Duration.avg
Morphine**
(MS)
MSIR
Parenteral
Oral
10mg
30mg
3-4 hr
MS.(S.R)
MS Contin
Oral
30mg
8-12 hr
HyroMorphone
Dilaudid
Parenteral
Oral
1.5mg
7.5mg
3-4 hr
Methadone*
Dolophine
Parenteral
Oral
20mg
10mg
4-8 hr
4-8 hr
Levorphanol LevoDromoran
Parenteral
Oral
2mg
2mg
4-8 hr
Oxycodon SR Oxycontin
Oral
30mg
12 hr
How To Use Opioids?
• Pure agonist as first line of therapy. Higher
incidence of psychotomimetic effect (dysphoriahallucination) and nausea and vomiting with A-A
• Never mix agonist with agonist-antagonist
• Don’t mix two agonist
• Don’t stay with weak agonist if pain not relieved
• Oral route whenever possible
• Round the clock strategy-----important
Continue……
• NEVER PRN. Continuous pain need
continuous analgesic.Prevent resurgence of
pain rather to treat it.PRN is illogical, cruel,
perpetuate the fear and the memory of pain.
It is only acceptable for break through pain.
Opioid Dose Titration
• The correct dose of an opioid is that effectively relieves
pain without inducing unacceptable side effect. There is no
standard or set of doses of narcotics in cancer pain.There is
a great variation between individuals. As pain changes
through various stages of the disease, doses should be readjusted. Recommended doses are derived from acute
single dose pain studies are not applicable to chronic
cancer pain.The dose of the strong narcotic can be
increased almost indefinitely without reaching a ceiling or
plateau of maximum effect.(except. Meperidine-A/A)
(A report of the Expert Advisory Committee on the
Management of Severe Chronic Pain in Cancer Patients)
Continue………
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Consider adjuvant medication:
1-NSAID-----Bone Mets
2-Anti-depressant------Neuropathic Pain
3-Memberane stabilizer-------Neuropathic Pain
4-Treatment of side effect
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Use narcotics as part of the:
Total Pain Treatment
1- Oral Narcotics
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MS first choice
Forms (IR vs SR)
How often .ATC+PRN
Dose calculation
Dose titration(Key for succ.)
Increase both ATC+PRN in 24 hr
Severe Pain(7-10)
Moderate Pain(4-7)
Mild Pain (1-3)
50-100%
25-50%
25%
Do you wake up pt.For dose!
Why isn’t it working?
-Inadequate Dose
-Poor compliance
-Vomiting-Drooling
-Unresponsive Pain
-Needs co-analgesic
What about overwhelming
Pain?
Management of Opioid Side Effect
1. Constipation
GI peristalsis- Secretion aggravated by
activity and poor diet
fluid intake, physical
-Prevention
-Treatment
2. Nausea & Vomiting
Stimulation of chemoreceptor
Prochlorperazine/Haloperidol
Delayed gastric emptying
Metchlopramide
Increased vestibular sensitivity
Dimenhydrinate
If persist, modify the dose, opioid rotation, change the route
Continue……..
• Sedation-Confusion
1-Prevention
2-Modify the doses
3-If persist revaluate
4-Opioid Rotation
5-Change the route
Other Route: Why?
• Rectal :
Oxycodon-Hydromorphone
• Transdermal :
Fentanyl Patches.25,50,100ug/hr
• Subcutaneous
• Intravenous
Interruption of Pain Signal and
Anesthetic Intervention
• Neuro-Axial Drug Delivery System
• Neural Blockade
Neuro-Axial Drug Delivery System
• Indication:
• Route: 1-Epidural
2-Intrathecal (external vs internal pump)
3-Regional Plexus Catheter
Neural Blockade
1-With Local Anesthetic
• Diagnostic
• Prognostic
• Pain Emergency
• Muscle Spasm
• Herpes Zoster
• Premorbid Pain
• Iatrogenic Pain
Neurolytic Neural Blockade
• It is more often considered in setting of pain due to cancer
as the ongoing tissue injury expected to progress
• Types:
• Pain-related indication:
1-Well Characterized
2-Well Localized
(exception: Sympathetic blockade Stellate ganglion, Celiac plexus,
Hypogastric plexus,lumber sympathetic)
3-Nociceptive rather than neuropathic pain
• Patient- related indication:
Neurolytic Blockade Contiue….
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Outcomes:
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1.
Few controlled trials, no
blinding or randomized,
no controls for technique
Efficacy: 50-80% of well
selected pt.
Duration: avg. 6 month.
Complication:less than
5% in well selected
pt.with fluoroscopy&CT.
1.
2.
2.
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4.
Hazards:
Neurologic Deficit
Damage to
nonneurological tissue.
3. Impermanece: non of the
ablation tech.reliably
produce permanent relief
4.New Pain: 2-28%. Neuritis
and dysesthesia. It could
be difficult to manage