Objectives. Symptom Management: Cancer Pain. Pain. Pain 2/19/2016

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1 Objectives Symptom Management: Cancer Pain Kelley Blake RN, MSN, OCN, AOCNS Valley Medical Center Explore cancer pain Discuss barriers Manage pain in special populations Discuss pain treatment therapies Pain Is whatever the person says it is Existing whenever he or she says it does Pain The International Association for the Study of Pain states: Pain is defined as an unpleasant, multidimensional sensory and emotional experience associated with actual or potential tissue damage or described in relation to such damage 1

2 Cancer Pain Characteristics of Pain It is estimated that 90% of cancer pain can be controlled with currently available medications Acute pain Less than 6 mo. Pain behaviors exhibited Chronic pain Longer than 3 mo. Fatigue/depression common Characteristics of Pain Characteristics of Cancer Pain Breakthrough pain Transient increase over background pain Rapid onset Severe intensity Self-limiting Average duration 30 minutes Refractory/ Intractable pain Inadequately controlled despite aggressive measures Acute and chronic Direct tumor involvement Diagnostic/ therapeutic procedures Cancer treatment May trigger fear Cancer progression Recurrence Worsens with Anxiety Hopelessness Depression 2

3 Types of Pain: Nociceptive Pain Types of Pain: Neuropathic Pain Somatic pain Bone/joint/ connective tissue Sharp/throbbing/ pressure Well localized Visceral pain Distension/ compression Diffuse/aching/ cramping Poorly localized Peripheral neuropathic pain Peripheral nerve injury Numbness/tingling Centrally mediated pain Radiating/shooting Burning/aching Sympathetically maintained pain Centrally generated Autonomic dysregulation Complex regional pain syndrome Physiology of Pain Risk Factors of Cancer Pain Transduction stimulus Transmission Message relay Perception Pain experience Modulation Release of neuromediators Disease Related Type of cancer Bone metastases Visceral pain Nerve compression/injury Treatment Related Chemotherapy Radiation therapy Chronic pain related to cancer surgery 3

4 Barriers: Patient-Related Factors Barriers: Provider-Related Factors Reluctance to report pain Concern about distracting physicians from treatment of underlying disease Fear that pain means disease is worse Lack of knowledge about principles of basic pain management Concern about not being a good patient Reluctance to take pain medications Fear of addiction/being thought of as an addict Worries about unmanageable side effects Concern about becoming tolerant to pain medications Poor adherence to the prescribed analgesic regimen Financial barriers Probable Problems Inadequate knowledge of pain management Poor assessment of pain Concern about regulation of controlled substances Fear of patient addiction Concern about side effects of analgesics Concern about patients becoming tolerant to analgesics Possible Solutions Appropriate pain management education Nurse/patient advocacy Persistence/not pushy Communication What is the plan? Pain clinic referral CAM referrals Manage side effects Barriers: Health Care System-Related Special Populations Low priority given to cancer pain treatment Inadequate reimbursement for pain assessment and treatment The most appropriate treatment may not be reimbursed or may be too costly for patients and families Restrictive regulation of controlled substances Problems of availability of treatment or access to it Opioids unavailable in the patient s pharmacy Unaffordable medication Older adult Polypharmacy Increased sensitivity Appropriate pain scale Confusion/poor vision Home supervision Cost Pediatric Developmental age Appropriate pain scale Dose by weight 4

5 Polypharmacy Polypharmacy Risks and Complications Adverse drug reaction increases with number of drugs Duplication of therapy Drug-drug interactions Drug-disease interactions Adherence Cost Management Questions Indications? Desired effect? Nonspecific symptoms? Dose? Drug-drug interactions? Antineoplastic treatment interference? Drug-tumor interactions? Adherence? Untreated conditions? Special Populations: Patients Addicted to Drugs Analgesics The uncomplicated patient Routine The patient with comorbid psychiatric and coping difficulties Structure Psychotherapy The addicted patient Maximum structure Limited supply Long-acting opioids of low street value Recovery program Psychotherapy Goals of Therapy To reduce the effect of noxious stimuli caused by thermal, chemical, or mechanical injury that elicits pain To improve quality of life Types of Analgesics Nonopioid analgesics Opioids Adjuvants 5

6 Assessment Cancer Pain Assessment Identify Risk for Pain Pain type History of past/current analgesia and effectiveness Side effects from previous regimens Physical exam Current medications Diagnostics Cultural/ethnic background Assess for all types of acute and chronic pain Reassure that most cancer pain can be relieved safely, quickly, and effectively Basic and ongoing professional education for clinicians on effective cancer pain assessment Pain Management Pain Management Neuropathic Pain Trial antidepressant Trial anticonvulsant Consider topical Pain specialist Mild Pain (Level 1-3) NSAID or acetaminophen Short-acting opioid Bowel regimen Treat side effects Nonopioid analgesics Psychosocial support Education Moderate Pain (Level 4-6) Titrate short-acting opioid Bowel regimen Treat side effects Nonopioid analgesics Psychosocial support Education Severe Pain (Level 7-10) Titrate short-acting opioid Bowel regimen Treat side effects Nonopioid analgesics Psychosocial support Education Reassess and modify Long-acting opioid Specific pain problems Specialty consultation 6

7 Pharmacological Therapies: using WHO stepladder approach Step 1: Non-opioids +/- Adjuvant Step 2: Opioids for mild to moderate pain +/- Nonopioids +/- Adjuvants Step 3: Opioids for moderate to severe pain +/- Non-opioids +/- Adjuvants Acetaminophen: Step 1 To reduce pain and fever Treatment of mild to moderate pain May cause liver damage Do not exceed 4g/24 hours Anti-Inflammatory Agents: Step 1 To reduce inflammation and pain Treatment of mild to moderate pain Symptom management Boney metastases Addition of NSAIDs can reduce opioid dose requirements Anti-Inflammatory Agents: Step 1 Commonly Used NSAIDs in Cancer Propionic Acids Ibuprofen Acetic Acids Ketorolac Oxicam Piroxicam Salicylates Aspirin Cyclo-oxygenase-2 Selective Inhibitor Celecoxib 7

8 Anti-Inflammatory Agents: Step 1 Anti-Inflammatory Agents: Step 1 Corticosteroids Used in the Treatment of Cancer Short-Acting (8-12 hr) Hydrocortisone Intermediate-Acting (12-36 hr) Prednisone Long-Acting Dexamethasone Potential adverse effects Renal toxicity Cardiac toxicity Risk factors for NSAID toxicities Age greater than 60 Thrombocytopenia Renal insufficiency Comorbid disease Multiple myeloma Anti-Inflammatory Agents: Step 1 Opioids: Step 2-3 Adverse Effects of NSAIDs Related to Cancer Central Nervous System Cardiovascular Hematologic Platelet aggression Adverse Effects of Corticosteroids Related to Cancer Psychiatric disturbances Immunosuppression Most appropriate dose controls pain through 24 hours Long-acting and breakthrough options with constant pain Effective titration Breakthrough dose 10%--20% of long-acting dose 8

9 Opioids: Step 2-3 Opioids: Step 2-3 Tolerance: when taken regularly Physical dependence: all patients when taken regularly Psychological dependence: ADDICTION Potential Adverse Effects Dependence Drug interactions Abnormalities in absorption Opioid Withdrawal Nausea/vomiting/diarrhea Tachycardia Chills Anxiety/paranoia insomnia Opioids: Step 2-3 Opioids: Managing Adverse Effects Adverse Effects of Opioids Gastrointestinal Respiratory Central nervous system Potential Adverse Effects Caused by Compromised Organ Systems Hepatic insufficiency Central nervous system Respiratory Antiemetic Prophylaxis for Constipation V/S Pupil size Sedation/RR Neuro Safety 9

10 Opioids: Managing Constipation Universal side effect Prophylaxis Stool softener Bowel stimulant Decrease intestinal secretion/peristalsis Increase muscle tone Increase segmental contractions of bowel Decrease stool volume/ frequency Increase water/ electrolyte absorption Adjuvants: Anxiolytics/Sedative- Hypnotics To reduce pain associated with anxiety Benzodiazepines Other medications Selective serotonin reuptake inhibitors Serotonin norepinephrine reuptake inhibitors Adjuvants: Anxiolytics/Sedative- Hypnotics Adjuvants: Antidepressants Potential Adverse Effects CNS effects Delirium Respiratory suppression Drug Interactions Alcohol Inhibitors or inducers of hepatic enzyme CYP3A4 To treat depression associated with chronic pain As adjuvant pharmacologic pain management in pain conditions Postherpetic neuralgia 10

11 Adjuvants: Antidepressants Adjuvants: Anticonvulsants Common Antidepressants Tricyclic Antidepressants Serotonin Reuptake Inhibitors Mixed-Action Agents Potential Adverse Effects Drug-drug interactions Dietary restrictions As adjuvant pharmacologic therapy for pain with neurologic cause Peripheral neuropathy Valproic acid Lamotrigine Adjuvants: Anticonvulsants Patients at risk for neurologic pain Chemotherapy Paclitaxel Vincristine Oxaliplatin Adverse Effects Nausea Sedation Irritability Headaches Depression Liver failure Adjuvants: Miscellaneous Interventions Pharmaceuticals for Bone Metastases Radionuclides Bisphosphonates Intraspinal Analgesia Epidural Intrathecal implantable pump Radiation Therapy Bone metastases Reduce bulky tumors 11

12 Adjuvants: Miscellaneous Interventions Interventional/Surgical Strategies Nerve blocks Neurostimulation Percutaneous kyphoplasty Debulking Nonpharmacologic Interventions CAM Interventions to Increase Comfort Patient/family education Complementary and Integrative Modalities Alternative medical systems Energy therapies Exercise therapies Manipulative and bodybased methods Mind-body interventions Nutritional therapeutics Pharmacologic and biologic treatments Spiritual therapies Has been used for medicinal purposes for thousands of years Illegal in the US, however legal in WA and other states Not approved by FDA for medical treatment Cannabis Points to remember Treat the underlying cause of pain Administer around the clock Manage breakthrough pain Oral preferred route Minimize side effects Review patient instructions 12

13 References References American Pain Society. (2005). Guideline for the management of cancer pain in adults and children. Glenview, IL. Balducci, L., Goetz-Parten, D., & Steinman, M. A. (2013). Polypharmacy and the management of the older cancer patient, Annals of Oncology 23 (Sup 7): vii36-vii40, doi: /annonc/mdt266. Retrieved from on July 3, Brant, J., Visich, K.L., Sterling, B., & Irwin, M. (2014). Pain. In M. Irsin & L. Johnson (Eds.). Putting evidence into practice: P pocket guide to cancer symptom management (pp ). Pittsburgh, PA: Oncology Nursing Society. Brant J.M., & Stinger, L.H. (2015). Pain. In C.G Brouwn (Ed.). A guide to oncology symptom management. 2 nd ed., pp ). Pittsburgh, PA: Oncology Nursing Society. Itano, J. K., editor (2016). ONS Core curriculum for oncology nursing, 5 th ed., Elsevier, St. Louis, Missouri, pp National Comprehensive Cancer Network. (2015). NCCN Clinical Practice Guidelines in Oncology: Adult cancer pain [v ]. Retrieved from Pain pdq & CAM pdq, National Cancer Institute Office of Cancer Complimentary and Alternative Medicin (NCI OCCAM, 2015). Treating cancer pain in patients addicted to drugs, (Feb 2007). The journal of supportive oncology. Vol 5:no 2. pp

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