Cancer patients at End-of-Life: Multidimensional Pain Requiring Multimodal Therapy

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1 Cancer patients at End-of-Life: Multidimensional Pain Requiring Multimodal Therapy Presented by: Marsha Farrell BSN, RN-BC, CHPN Pathways to Success Conference by the Bay November 12, 2014

2 Conflict of Interest Disclosure Marsha Farrell RN-BC, CHPN: NO Conflict of Interest A conflict of interest is a particular financial or non-financial circumstance that might compromise, or appear to compromise, professional judgment. Anything that fits this should be included. Examples are owning stock in a company whose product is being evaluated, being a consultant or employee of a company whose product is being evaluated, etc. Taken in part from On Being a Scientist: Responsible Conduct in Research. National Academies Press

3 Incidence of Pain in Cancer Patients Pain is a common symptom experienced by patients with cancer. 1 Pain is one of the problems patients with cancer fear most. 2 Cancer pain is frequently assessed and treated inadequately. 1

4 Incidence of Pain in Cancer Patients Two thirds of cancer patients experience pain sometime during their disease. 3 20%-75% of adult cancer patients have pain at time of diagnosis. 2 17%-57% of patients being treated for the disease have pain. 2

5 Incidence of Pain in Cancer Patients 23%-100% of patients in advanced and terminal stage of cancer experience pain. 2 Pain present in 62% of children at time of diagnosis. 2 25%-85% of children experience pain during treatments. 2

6 Why is good pain management Important at End-of-Life (EOL)

7 Relief of Pain at End-of-Life Affects Multiple People

8 Importance of Pain End-of-Life Patient is comfortable Improve function Quality of Life (QOL) Family less anxious Better memories of last days

9 Peaceful Death

10 Good Death Definition from The Institute of Medicine 1 Free from avoidable distress and suffering for patients, families, and caregivers In accordance with the wishes of the patient and his family Consistent with clinical, cultural, and ethical standards.

11 Physical Pain is not universal with every death, but discomfort is usually present.

12 Dame Cicely Saunders Multi-Dimensional Concept of Total Pain

13 Dame Cicely Saunders Total Pain

14 Ira Byock, MD Pain Concerns Palliative Care Physician Never purely physical Abandonment Undignified state Burden to family Financial hardship

15 Pitfall in End-of-Life Pain Management for Cancer Patients Assume that a comprehensive pain assessment isn t necessary in end-stage disease Assume that increased pain at EOL is due to advanced disease National Comprehensive Cancer Network (NCCN) clinical practice guidelines for cancer pain management

16 Pain is Multi-dimensional Affects multiple people: the patient, family members and medical staff Never purely physical Multiple domains: Physical, Spiritual, Social & Psychological (emotional) Takes an Interdisciplinary Team to address multiple domains

17 Physical Pain Types of Pain Nociceptive pain Somatic Visceral Bone pain Neuropathic pain

18 Types of Pain Nociceptive pain Somatic Visceral Bone pain Neuropathic pain Cancer Pain - Physical

19 Different Types of Pain Need Different Somatic Pain Medication(s) Drug Class Acetaminophen/ NSAIDS Muscle relaxant (e.g.bacolfen) Opioids

20 Different Types of Pain Need Different Medication(s) Visceral Pain Opioids NSAIDS Drug Class Corticosteroids

21 Different Types of Pain Need Different Neuropathic Pain Medication(s) Drug Class *First Line Treatment Anticonvulsants: gabapentin; carbamazepine, clonazepam, pregabalin

22 Different Types of Pain Need Different Drug Class TCA: Nortriptyline, desipramine, SNRI antidepressants: duloxetine, venlafaxine Corticosteroids Topical anesthetic, lidocaine patch 5% Opioids Medication(s) Neuropathic Pain

23 Different Types of Pain Need Different Bone Pain Medication(s) Drug Class NSAIDS: celecoxib, ibuprofen, naproxen, ketorolac Corticosteroids Bisphosphonates Radiation therapy Opioids

24 Epidural Spinal Cord Compression ESCC BE ALERT to any complaint of increasing back pain because this may be a sign of pending ESCC. Hospice Emergency!

25 Cancer Pain Incidence of Cancer Pain Cancer pain affects multiple people EOL Pain is multidimensional Total Pain Multimodal drug therapy for different types of pain

26 Why Multiple Drug Therapies Opioids Acetaminophen/ NSAIDS Anticonvulsants Antidepressants Corticosteroids Topical Anesthetic

27 Different Drugs - Different Actions

28 A N A L G E S I A Different Medications Different Actions

29 Bind to opioid receptor sites Mu, delta, kappa Multiple subtypes Opioids

30 NSAIDS/ Acetaminophen May inhibit synthesis of prostaglandin in the CNS May block COX-3 found in CNS Inhibit enzyme COX (1 & 2) thereby inhibiting prostaglandin synthesis.

31 Anticonvulsants Hyperexcitability Neuroplasticity-nervous system morphs Increase & abnormal expression of sodium channels Decreases conductance in Na+ Channels & inhibits ectopic discharges. McCaffery M, Pasero C. Pain: Clinical Manual, 2nd ed. St. Louis: Mosby, 1999; p 319.

32 Increase levels of serotonin (5-HT) & norephinephrine (NE) Blocks reuptake of 5-HT & NE TCA & SNRIs Effective at lower doses than for treatment of depression Antidepressants

33 Multiple Drugs /Different Actions

34 Multimodal Approach

35 Best possible analgesia Opioid sparing Fewer opioid side effects Optimal Outcomes Multidimensional, Multiple drugs, Multimodal Pain Approach

36 Careful assessment of cancer pain at EOL is essential Address all pain domains, not just physical Nip pain with multiple drugs using different actions Include multimodal approaches Remember

37 References 1. Ferrell, Betty. Pain Management at the End of Life. November 04, Retrieved 2/22/ Leleszi, Jimmie; Lewandowski, Jeanne. Pain Management in End-of-Life Care. JAOA: Journal of the American Osteopathic Association, March 1, 2005 vol. 105 no Retrieved 2/22/ Arthritis Is Frequent Cause of Pain at End of Life, Researchers Say. WebMD Health News. November 1, Retrieved 2/22/ McCaffery M, Pasero C. Pain: Clinical Manual, 2nd ed. St. Louis: Mosby, Dobbins, Elizabeth. Helping your patient to a good death. Nursing 2005, February p Miaskowski C, Cleary J, Burney R, Coyne P, Finley R, Foster R, et al. (2005). Guideline for the Management of Cancer Pain in Adults and Children, Glenview, IL: American Pain Society.