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The Facts AboutEffectively ManagingIntractable Cancer PainBrian Kahan, D.O.FAAPMR, DABIPP,DABPM, DAOCPMRThe Kahan CenterFor Pain Managementwww.thekahancenter.com
Objectives Describe cancer pain Incidence of cancer pain Identify a team approach totreatment of cancer pain Define the roles of intrathecal drugdelivery systems andneuromodulation in treating cancerpain
Sources of Pain in CancerPatientsCancer pain comprises: Acute pain Chronic pain Tumor-specific pain Treatment-related painCarr D, Goudas L, Lawrence D, et al. Management of cancer symptoms: pain, depression, and fatigue. Evidence report/technologyassessment No. 61 (prepared by the New England Medical Center Evidence based Practice Center under contract No. 290-97-0019).AHRQ Publication No. 02-E032. Rockville, MD: Agency for Healthcare Research and Quality. July 2002. Downloaded athttp://www.ahrq.gov/clinic/epcsums/csympsum.htm on 4/22/2009. http://www.ahrq.gov/clinic/epcsums/cansympsum.pdf. Accessed03/23/2009
n 4947Existence of pain due to cancerMore than two thirds of cancer patients report pain which theyattribute to their cancerT o t a l ( n 4 9 4 7 )P a nc re a t ic ( n 14 2 )B o ne / m us c le ( n 17 3 )B ra in t um o ur ( n 13 5 )N o n- H o dgk ins ( n 6 1)Lung c a nc e r ( n 4 17 )H e a d / N e c k c a nc e r ( n 2 13 )B o we l / C o lo re c t o ra l ( n 5 0 4 )T e s t ic ula r ( n 15 0 )B lo o d bo rne ( n 9 0 )G yna e c a nc e r ( n 4 11)Lym pho m a s ( n 10 2 )B re a s t c a nc e r ( n 14 2 7 )Le uk e m ia ( n 12 5 )P ro s t a t e ( n 6 2 4 775626653Base: all screened – (individual base sizes shown on chart)S4. Have you suffered any pain due to your cancer?No painFrom S5 - Patientscurrently sufferingfrom painMore than 50% of patients withthe following types of cancercurrently suffer from pain:§ Lung§ Pancreatic§ Brain Tumour§ Bone/Muscle§ Blood Borne§ Non-Hodgkins§ Head/Neck§ LeukaemiaPainwww.paineurope.comEuropean Pain in Cancer (EPIC) Global Results Presentation, July 2007
Where We Are Today inManaging Cancer Pain? Minorities, women, and the elderly are particularly at riskfor cancer-related pain.1 One survey found that while health care providers believethey are doing a good job at managing pain and itssymptoms, families do not.2 Cancer pain still pervasive in adults and children.3 Cancer pain is undertreated in all settings where patientswith cancer are managed.31. Carr D, Goudas L, Lawrence D, et al. Management of cancer symptoms: pain, depression, and fatigue. Evidence report/technology assessment No. 61(prepared by the New England Medical Center Evidence based Practice Center under contract No. 290-97-0019). AHRQ Publication No. 02-E032. Rockville,MD:Agency for Healthcare Research and Quality. July 2002. Downloaded at http://www.ahrq.gov/clinic/epcsums/csympsum.htm on mpsum.pdf. Accessed 03/23/20092. Tolle SW. Family reports of pain in dying hospitalized patients: a structured telephone survey. West J Med. 2000;172:374-377.3. Guideline for the Management of Cancer Pain in Adults and Children. 2005. p x.
You Are The Patient’sAdvocate Patients with cancer are often reluctant toreport the extent of their pain1 Fear that reporting pain will takephysician time away from theirtreatment Concern about addiction Beliefs that “good” patients do notcomplain about pain Concern about side effects withescalating doses Result under-treatment of pain1. Ward S, Goldberg N, Miller-McCauley V, et al. Patient-related barriers to management of cancer pain. Pain. 1993;52:319-324.
The Effects of Pain A majority of patients experience pain atsome point during their course of cancertreatment.1 Cancer pain impairs quality of life andfunctionality.1 The cost of inadequate pain control andrelated side effects (of pain medications) ishigh, both in terms of impaired function andquality of life.2-4 Pain interferes with all activities of dailyliving.51. Carr D, Goudas L, Lawrence D, et al. Management of cancer symptoms: pain, depression, and fatigue. Evidence report/technology assessment No. 61 (prepared by the NewEngland Medical Center Evidence based Practice Center under contract No. 290-97-0019). AHRQ Publication No. 02-E032. Rockville, MD:Agency for Healthcare Research and Quality. July 2002. Downloaded at http://www.ahrq.gov/clinic/epcsums/csympsum.htm on mpsum.pdf. Accessed 03/23/20092. Smith TJ, Staats PS, Deer T, Stearns LJ, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractorycancer pain: Impact on pain, drug-related toxicity, and survival. J Clin Oncol. 2002;20(19):4040-4049.3. Cleeland, CS. Undertreatment of cancer pain in elderly patients. JAMA 1998;279(23):1914-1915.4. Stearns L, Boortz-Marx R, Du Pen S, Friehs G, et al. Intrathecal drug delivery for the management of cancer pain: a multidisciplinary consensus of best clinical practices. JSupport Oncol. 2005;3(6):399-408.5. Mystakidou K, Tsilika E, Parpa E, et al.: Psychological distress of patients with advanced cancer: influence and contribution of pain severity and pain interference. Cancer Nurs 29(5): 400-5, 2006 Sep-Oct.
Pain as the “Fifth VitalSign”The Joint Commission on Accreditation of HealthcareOrganizations (JCAHO) issued a comprehensivedescription of patients’ rights and standards of carefor pain management. Recommendation: make painassessment/management priority in daily practice Consider pain intensity the 5th vital sign: measurealong with temperature, pulse, respiration, and bloodpressure Patients’ rights: full pain workup when pain is noteasily characterized or treatedJCAHO, 1999-2000.
Start with a ComprehensivePain AssessmentThe National Cancer Institute recommends that the clinician help the patientdescribe pain1: Location Changes in pattern Intensity or severity Aggravating and relieving factors Cognitive response to pain Goals for pain controlThese are essential to the initial assessment:1 Detailed history1 Physical examination1 Psychosocial assessment2 Diagnostic evaluation11. National Cancer Institute are/pain/HealthProfessional/page3 Accessed May 12, 20092. Otis-Green S, Sherman R, Perez M, et al.: An integrated psychosocial-spiritual model for cancer pain management. Cancer Pract 10(Suppl 1): S58-65, 2002May-Jun.
Assessment Goals Characterize the pathophysiology of pain Determine intensity of pain Determine impact on patient’s ability tofunction1. National Cancer Institute are/pain/HealthProfessional/page3 Accessed May 12, 2009
Cancer Pain Therapy: TheOncologist’s Perspective Systemic pharmacologic therapy Collaboration with pain medicine andpalliative care specialists Good pain management facilitates goodcancer managementLevy MH. Pain control in patients with cancer. Oncology. 1999;13(5 suppl 2):9-14.
Multidisciplinary Approach toChronic Pain ManagementMultidisciplinary SolutionComplex calfactors Pain specialists Psychologists Nurses Social workers Rehabilitationspecialists
Cancer Pain ManagementStrategies Pharmacologic strategies Nonopioid analgesics Acetaminophen Nonsteroidal anti-inflammatorydrugs Opioid analgesics Coanalgesics (adjuvantanalgesics) corticosteroids Physical strategies Massage Exercise Transcutaneous electrical nervestimulation (TENS) Acupuncture Psychological strategies Hypnosis or relaxation withimagery Cognitive-behavioral methods Nerve blocks/Radiofrequency Radiation therapy Chemotherapy1.Guideline for the Management of Cancer Pain in Adults and Children. 2005. p 48-97.
Pharmacological strategies Non-opioid analgesics Decadron and oral corticosteroids Significant reduction in edema and good for acutemetastatic disease and brain involvement NSAID’s Additive effect by inhibiting COX-1 and COX-2 pathwaysand possibly COX-3 Acetaminophen inhibiting COX-1 Anti-epileptic medications Gabapentin has a synergistic effect when combined withmorphine (N Engl J Med 2005;352:1324-34) Bisphosphonates Cannabis
Psychological strategies Coping skillsBiofeedbackMeditationFamily or group
Opioid Analgesics for theTreatment of Cancer Pain Used most often in the management of severe painbecause:1 Effectiveness Ease of titration Favorable risk-to-benefit ratio Routes of administration2 Oral Transdermal Parenteral: Intravenous or subcutaneous Intraspinal: Epidural or intrathecal Consider when other routes of administration cannot control painor when side effects limit further dose escalation1. Guideline for the Management of Cancer Pain in Adults and Children. 2005. p 532. Ibid., p 64.
Intervention techniques Vertebroplasty/ Kyphoplasty Radiofrequency Splanchnic nerves Peripheral nerves C2 Cordotomy Intrathecal drug delivery systems Spinal cord neuromodulation
Radiofrequency Splanchnic nerves Pancreatic cancer Abdominal cancer Chronic abdominal pain Case68 y/o male with history ofneuroendocrine tumorwith metastatic masscompressing celiac plexusand resistant abdominalpain.Raj, Prithvi et al
Radiofrequency Peripheral nerves Case 70 y/o female with historyof facial squamous cell CAwith radical facialresection and chronicneuropathic pain in leftinfraorbital region. Failedto respond to opioids,AED’s, NMDAmedications
Advanced Strategies forIntractable Cancer Pain Management10-20% InvasiveTherapy NeededJacox A, et al. AHCPR, 1994.Portenoy R. Oncology 1999;S2:7.80-90% Adequate Pain Control
Spinal AnatomyEpidural SpaceDuraArachnoidMembraneIntrathecal Space(Subarachnoid Space)Pia MaterSpinal CordNerve Root
Epidural vs. )EpiduralSpace
Physiology of SpinalOpioidsPain Perceived Nociceptors carry a “pain”signal to the dorsal horn. In the dorsal horn neuronsrelease substance P. Substance P triggersascending neurons thatcarry this signal to thebrain. Opioids inhibit the releaseof substance P, blockingthe pain transmission. Perceived pain is reduced.Pain SignalInitiated
Epidural vs. IntrathecalOpioids1. Levy, R. Implanted drug delivery systems for control of chronic pain. Chapter 19 of Neurosurgical Management of Pain. New York, NY:Springer-Verlag;1997.
What is successfulpain management?Success Pain relief – Unmanageableside effects
Approximate Equivalent Daily Dosesof Morphine Administered by VariousRoutesRoute ofAdministrationRelative 00201*Relative approximations based on clinical observationsLamer TJ: Mayo Clin Proc.1994 May;69(5):473-80. Review.
Reduce Dose ReduceSide Effects1 mg intrathecal morphine 300 mg oral morphineKrames ES. J Pain Symptom Manage. 1996 Jun;11(6):333-52.
Intrathecal Drug Delivery:Patient Selection CriteriaI. Symptoms of pain due to advanced stage cancer atpresentation, with a minimum life expectancy of 3months1-4II. Refractory to conventional pain management because ofdrug toxicity or unsatisfactory analgesia1-4III. Visual analog scale (VAS) of 5, despite 200 mg/day oforal morphine or the analgesic equivalent1,3,41. Smith TJ, Staats PS, Deer T, Stearns LJ, et al. Randomized clinical trial of an implantable drug delivery system compared withcomprehensive medical management for refractory cancer pain: Impact on pain, drug-related toxicity, and survival. J Clin Oncol.2002;20(19):4040-4049.2. Stearns L, Boortz-Marx R, Du Pen S, Friehs G, et al. Intrathecal Drug Delivery for the Management of Cancer Pain: AMultidisciplinary Consensus of Best Clinical Practices. J Support Oncol. 2005;3(6):399-408.3. Smith TJ, Coyne PJ. Implantable Drug Delivery Systems (IDDS) After Failure of Comprehensive Medical Management (CMM)Can Palliate Symptoms in the Most Refractory Cancer Pain Patients. J Pall Med. 2005;8(4):736-742.4. Brogan, SE. Intrathecal Therapy for the Management of Cancer Pain. Curr Pain Head Rep. 2006;10:253-259.
Intrathecal Drug Delivery:Patient Selection CriteriacontinuedConsider those on lower doses if opioid side effectsare refractory to conservative treatment andsevere enough to prevent upward titration.1,3,4IV. Consider early evaluation of intrathecal drugdelivery for those with pelvic tumors who mayhave eventual nerve compression.21. Smith TJ, Staats PS, Deer T, Stearns LJ, et al. Randomized clinical trial of an implantable drug delivery system compared withcomprehensive medical management for refractory cancer pain: Impact on pain, drug-related toxicity, and survival. J Clin Oncol.2002;20(19):4040-4049.2. Stearns L, Boortz-Marx R, Du Pen S, Friehs G, et al. Intrathecal Drug Delivery for the Management of Cancer Pain: A MultidisciplinaryConsensus of Best Clinical Practices. J Support Oncol. 2005;3(6):399-408.3. Smith TJ, Coyne PJ. Implantable Drug Delivery Systems (IDDS) After Failure of Comprehensive Medical Management (CMM) CanPalliate Symptoms in the Most Refractory Cancer Pain Patients. J Pall Med. 2005;8(4):736-742.4. Brogan, SE. Intrathecal Therapy for the Management of Cancer Pain. Curr Pain Head Rep. 2006;10:253-259.
Contraindications toIntrathecal Drug Delivery When infection is present When pump implant depth exceeds depth specifiedin pump labeling Intrathecal Drug Delivery Contraindications When body size is not sufficient to accept pumpbulk and weight When contraindications exist relating to the drug Drugs with preservatives Do not use the patient control device, ifapplicable, to administer opioid to opioid-naïvepatients or to administer ziconotideFor a complete list of contraindications, refer to themanufacturer labeling for the specific device.
Medications available FDA approved- first line Morphine Baclofen Ziconotide Not FDA approved- second line Fentanyl Morphine/hydromorphone ziconotide Morphine/hydromorphone bupivacaine/clonidine Third line Clonidine Morphine/hydromorphone/fentanyl\bupivacaine clonidine ziconotide 4th line Sufentanil Sufentanil bupivacaine clonidine ziconotide 5th line Ropivacaine, buprenorphine, midazolam, meperidine, ketorolac 6th line Experimental agents like gabapentin
Which medication to use Hydrophilic better than hydrophobic Morphine hydromorphone fentanyl bupivacaine clonidine Know where catheter tip is
Recommendations for cancer pain patientsbased on disease statePatient characteristicsRecommendationPatient category 1Comprises those patient whose lifeexpectancy is significantly compromisedby their disease and the goal of therapy ispalliativeA pretrial/internalization psychologicalevaluation should be considered optional.It should be done at the discretion of thephysician, with focus on identifyingcancer-and/or pain-related psychologicalfactors potentially amenable topsychological intervention that mayfacilitate patient adjustment and analgesiarather than to clear the patientpsychologically for IT therapyPatient category 2Consists of patients whose diseaseprocess has been arrested, but whereinthere is significant probability ofrecurrenceA pretrial/internalization psychologicalevaluation is encouraged with anemphasis on periodic psychologicalconsultation/intervention to assist withchanges in disease process/recurrenceand copingPatient category 3Comprises patients whose cancer hasbeen eradicated by surgery or othertherapies, but who have residual chronicpain secondary to the medical txPatients should undergo apretrial/internalization psychologicalevaluation approached in much the sameway as those with chronic noncancer pain.Whenever possible the primary caregivershould be included to assess the type anddegree of support
The Kahan Center For Pain Management www.thekahancenter.com. Objectives Describe cancer pain Incidence of cancer pain Identify a team approach to treatment of cancer pain Define the roles of intrathecal drug delivery systems and neuromodulation in treating cancer pain.
