Cancer pain management

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Information about Cancer pain management

Published on December 16, 2016

Author: DrShadSalimAkhterAkh


1. Cancer Pain Management Brief Guidelines Prof. Shad Salim Akhtar MBBS, MD, MRCP(UK), FRCP(Edin), FACP(USA) Consultant Medical Oncologist & Medical Director Prince Faisal Oncology Center, KFSH Professor of Clinical Medicine Qassim Medical University Buraidah, Al-Qassim

2. IARC Globocan 2002, Figures based on 1998-2002 prevalence Burden of Cancer

3. Magnitude of the Problem- Future looks GRIM New cases in 2020

4. Cancer Pain 30-50% of cancer pts are on active therapy 5 million or more cancer patients are suffering from pain  With or without adequate therapy 57% patients perceive cancer death painful 69% consider committing suicide due to pain

5. Cancer Related Pain At diagnosis 25% Advanced disease 75% During therapy 30% Goudas LC et al: Cancer Invest 2005;23:519

6. Barriers to Pain Management

7. Neurophysiology Nociceptive receptors  Myelinated fibres  Noxious mechanical stimuli  Rapid conduction  A delta fibres- sharp stinging pain  Unmyelinated fibres  Chemical stimuli  Mechanical stimuli  Thermal stimuli  C fibres- dull burning aching pain

8. Cancer Pain Classification Nociceptive (skin, viscera, muscles, connective tissue)  Somatic pain  Most common type  Bone metastasis most common cause  Visceral pain  Commonly refd to cutaneous sites Neuropathic pain  Injury to peripheral or CNS Caraceni A et al: Oncology 2001;15:1627

9. WHO Three - Step Approach

10. New Concepts of Management Assessment of pain Individualization of therapeutic approach Continual reassessment Simplest approach Continuing communication Define goals Assurance of availability of expertise

11. Universal Screening Screen for pain Quantify pain Pain >0 comprehensive pain assessment  Pain=0 repeat screening at each subsequent visit

12. Clinical Assessment of Pain Believe the patients complaint Careful history Characteristics of each pain List and prioritize each pain complaint Evaluate response to previous therapy Psychological state evaluation Alcohol or drug dependence

13. Comprehensive Pain Assessment Intensity At rest With movement Interference with activities

14. Pain Intensity Numerical Scale Verbal: “How much pain are you having?” from 0 (no pain) to 10 (worst imaginable pain) Written: “Circle the number that describes how much pain you are having.” 0 1 2 3 4 5 6 7 8 9 10 No pain Worst imaginable pain Wong DL et al:2001; Mosby Inc Ess Ped Nurs

15. Pain Intensity Wong-Baker Faces Wong DL et al:2001; Mosby Inc Ess Ped Nurs

16. Pain Intensity Categorical Scale None (0) Mild (1–3) Moderate (4–6) Severe (7–10) Wong DL et al:2001; Mosby Inc Ess Ped Nurs

17. Comprehensive Pain Assessment Location Pathophysiology (Character) Somatic: pain in skin, muscle, bone described as aching, stabbing, throbbing, pressure Visceral: pain in organs or viscera described as gnawing, cramping, aching, sharp Neuropathic: pain caused by nerve damage described as sharp, tingling, burning, shooting

18. History of Pain Other Points Onset Duration Course Referred pain, radiation Aggravating & alleviating factors Associated symptoms Response to current and prior treatment including reasons for discontinuing

19. Etiology (Pain syndromes)  Associated with tumour infiltration  Associated with cancer therapy  Unrelated to cancer therapy Medical history  Current medications including prescribed, over the counter  Complimentary and alternative therapies  Oncologic  Other significant medical illnesses Comprehensive Pain Assessment

20. Psychosocial Aspects of Pain Patient distress Family and other available support Psychiatric history including current or prior history of substance abuse Special issues relating to pain  Meaning of pain for patient/family  Patient/family knowledge and beliefs surrounding pain  Cultural beliefs toward pain  Spiritual or religious considerations

21. Clinical examination Appropriate diagnostic procedures Treat pain as necessary for work up Individualize diagnostic and therapeutic approach Continuity of care Reassess patient for response Discuss advance directive with the pt & family Clinical Assessment of Pain

22. Pain not related to an Oncologic emergency Patient not taking opioids Patient taking opioids

23. Opioid Naive Patient Severity 7-10 Rapidly titrate short-acting opioid  Begin bowel regimen Recognize and treat side effects Co-analgesics as indicated Provide psychosocial support Begin educational activities Repeat comprehensive assessment in 24 hrs

24. Titrate short-acting opioid  Begin bowel regimen Recognize and treat side effects Co analgesics as indicated Provide psychosocial support Begin educational activities Repeat assessment in 24-48 hrs Opioid Naive Patient Severity 4-6

25. Consider NSAID or acetaminophen without opioid if patient is not on analgesics or Consider titrating short-acting opioid  Begin bowel regimen Recognize and treat side effects Co analgesics as indicated Provide psychosocial support Begin educational activities Repeat assessment in 72 hrs Opioid Naive Patient Severity 1-3

26. Approximate Opioid Doses The appropriate dose is the dose that relieves the patient’s pain throughout its dosing interval without causing unmanageable side effects. Pain 7-10 Consider increasing dose by 50%-100% Pain 4-6 Consider increasing dose by 25%-50% Pain 1-3 Consider increasing dose by 25%

27. Pain with Oncological Emergency  Bone fracture or impending fracture of weight bearing bone  Brain metastases  Epidural metastases  Leptomeningeal metastases  Pain related to infection  Perforated viscous  (acute abdomen)  Analgesics as specified by pathway  Specific treatment for oncological emergency as clinically indicated  (eg, surgery, steroids, RT, antibiotics)

28. Consider conversion to SR when 24 hr opioid requirement is stable Extended-release morphine sulfate tablets every 8-24 h depending on brand. Capsules every 8-24 h Extended-release oxycodone hydrochloride tablets every 8-12 h Transdermal fentanyl delivery system every 48-72 h Provide rescue short acting opioids Maintenance Therapy

29. Interventional Strategy Pain likely to be relieved with nerve block  Pancreas/upper abdomen  Celiac plexus block,  Lower abdomen  superior hypogastric plexus block,  Intercostal nerve block  Peripheral nerve block

30. Interventional Strategy Failure of response without side effects  Intraspinal agents  Blocks  Spinal cord stimulation  Destructive neurosurgical procedures  Neurolysis  Thoracic splanchnicectomy  Midline myelotomy  Cordotomy

31. Surgical Procedures for Pain Control

32. Specific Pain Problems Inflammation  NSAIDS  Corticoides Bone pain  Bisphosphonates Neuropathic pain  Tricyclic  Anticonvulsants  Topical agents Cancer chemotherapy/radiotherapy

33. Additional therapeutic modalities Physiotherapy Hypnosis Acupuncture Alternative therapies

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