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1 Disclosure Faculty: Jordi Perez Relationships with commercial interests: Grants/Research Support: None to declare Speakers Bureau/Honoraria: None to declare Consulting Fees: None to declare
2 1.Epidemiology of Cancer Pain 2.Barriers to Managing Cancer Pain 3.Challenging Cancer Pain Cases 4.Rewarding Cancer Pain Cases
3 EPIDEMIOLOGY CANCER PAIN Van den Beuken-van Everdingen MHJ. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Annals of Oncology 2007; 18: Van den Beuken-van Everdingen MHJ. Update on Prevalence of Pain in Patients With Cancer. J Pain Symp Manag 2016;51: Pain prevalence by cancer stage During treatment 55 % Advanced, metastatic or terminal 66.4 % After curative 39.3 % Pain prevalence by severity Mild 4/10 62% Moderate-Severe >4/10 38% Determinants Asia H&N, Lung, Breast ECOG 1
4 EPIDEMIOLOGY CANCER PAIN All cases 53 Carolyn Middleton. Understanding the physiological effects of unrelieved pain. Nursing times; 2003: 37 Cancer Survivors Advanced stages During treatment At diagnosis Cardiovascular system Sympathetic tone Oxygen consumption Hypercoagulation Gastrointestinal system gastric emptying bowel motility Respiratory system Resp movements Atelectasis and pneumonia Alveolar ventilation Genitourinary system Na/water retention Fluid overload MSK system Muscle spasm Mobility Immune system Immunity
5 EPIDEMIOLOGY CANCER PAIN All cases 53 Barry J Sessle. Unrelieved pain: A crisis. Pain Res Manag. 2011; 16: Reduced quality of life Cancer Survivors 33 Negative impact on relationships Job loss or reduced job responsibilities Advanced stages 64 Increased rates of depression Twice the average likelihood of suicide During treatment 59 Strang P. Existential consequences of unrelieved cancer pain. Palliat Med. 1997;11: At diagnosis Fear about the future Worries about pain progression General anxiety hampering their daily living Future of their families total pain
6 All cases Cancer Survivors EPIDEMIOLOGY CANCER PAIN Cancer pain patients live shorter Pain Predicts Overall Survival in Men With Metastatic Castration-Refractory Prostate Cancer. Halabi S. J Clin Oncol 2008 Advanced stages 64 During treatment 59 At diagnosis
7 All cases Cancer Survivors Advanced stages EPIDEMIOLOGY CANCER PAIN Cancer pain patients live shorter Randomized Clinical Trial of an Implantable Drug Delivery System Compared With Comprehensive Medical Management for Refractory Cancer Pain: Impact on Pain, Drug-Related Toxicity, and Survival. Smith TJ. J Clin Oncol 2008 During treatment 59 At diagnosis
8 All cases 53 EPIDEMIOLOGY CANCER PAIN Cancer patients now live longer Cancer Survivors 33 Advanced stages 64 During treatment 59 At diagnosis
9 All cases 53 EPIDEMIOLOGY CANCER PAIN Cancer patients now live longer Cancer Survivors 33 Advanced stages 64 During treatment 59 At diagnosis
10 System Barriers Lack of communication between specialists and primary care providers Lack of coordination of care A priority on curing cancer over caring for patients with cancer Regulatory barriers to effective pain management Provider Barriers Lack of awareness of patient s pain Inadequate cancer pain assessment and management training Lack of time and resources to address cancer pain Higher priority given to cure rather tan treating symptoms Concern about legal and regulatory sanctions for opioid use Concern about opioid derived side effects BARRIERS TO MANAGING CANCER PAIN Patient and Family Barriers Belief that pain is inevitable in cancer and non treatable Fear of addiction and dependence on opioids Fear drugs will lose their effectiveness Fear that reporting pain will exclude patient from clinical trials or cancer treatments Failure to mention pain to providers Lack of adherence to treatment regiments Hight cost of medications and treatments Cognitive impairment hindering symptom assessment
11 R Rapid Tolerance A Alcoholism P Incidental BTP Psychological factors I Delirium D Neuropathic pain N
12 Reason #1 Disease progression Reason #2 Unrelieved pain Reason #3 Opioid pharmacology Treatment #1 Reassess RAPID OPIOID TOLERANCE Reason #4 Emotional suffering Treatment #2 Psychology Treatment #3 Pharmacological options
13
14 Figure from Bie and Pan, Mol Pain, 2007 Figure from Ritter and Hall, Nat Rev Mol Cell Biol, 2009
15 Cancer Pain and Psychosocial Factors: A Critical Review of the Literature. Zaza 2002
16 Improved Pain Control in Terminally Ill Cancer Patients by Introducing Low-Dose Oral Methadone in Addition to Ongoing Opioid Treatment Establishing Best Practices for Opioid Rotation: Conclusions of an Expert Panel. Fine PG. J Pain Symp Manag 2009 Fürst P. J Palliat Med 2017
17 ADDICTIONS & CANCER PAIN Webster LR, Webster R. Predicting aberrant behaviors in Opioid treated patients: preliminary validation of the Opioid risk too. Pain Med Risks for Possible and Probable Opioid Misuse Among Recipients of Chronic Opioid Therapy in Commercial and Medicaid Insurance Plans: the TROUP Study. Sullivan MD. Pain 2010 Non Modificable factors Age <35 y/o Back pain Multiple pain complaints Hx substance abuse disorders Modificable factors High daily dose (>120 mg MED) Short acting opioid agents Anxiety Depression
18 INCIDENTAL PAIN
19 INCIDENTAL PAIN LONG ACTING OPIOID FORMULATIONS Hydromorphone Codeine Morphine Tramadol Fentanyl (*) Tapentadol Oxycodone Oxycodone/Naloxone Buprenorphine (*) Buprenorphine/Naloxone Methadone * Transdermal SHORT ACTING OPIOID FORMULATIONS o Hydromorphone o Morphine o Oxycodone o Buprenorphine (TBA) o Codeine o Tramadol o Tapentadol RAPID ONSET OPIOID FORMULATIONS o Fentanyl BOLD= not in RAMQ
20 DEPRESSION & CANCER PAIN
21 DELIRIUM & PAIN Pain assessment in elderly adults with dementia. Hadjistavropoulos T. Lancet Neurol 2014
22 NEUROPATHIC CANCER PAIN Fallon MT. Neuropathic pain in cancer. BJA 2013
23 NEUROPATHIC CANCER PAIN DN4 Questionnaire QUESTION 1: Does the pain have any of the following characteristics? 1. Burning 2. Painful sensation of cold 3. Electric shocks QUESTION 2: Is the pain associated with any of these symptoms in the same area? 4. Tingling 5. Pins and needles 6. Numbness 7. Itching QUESTION 3: Is the pain located in an area with any of these findings? 8. Hypoesthesia to touch 9. Hypoesthesia to prick QUESTION 4: Is the pain provoked or increased by the following? 10. Brushing Bouhassira D, et al. Pain. 2005, 114 :29-36.
24 NEUROPATHIC CANCER PAIN Moulin DE at al. Pharmacological management of chronic neuropathic pain: Revised consensus statement from the Canadian Pain Society. Pain Res Manag 2014
25 REWARDING CANCER Paclitaxel-induced peripheral painful neuropathy Head & Neck cancer pain Duloxetine Methadone
26 REWARDING CANCER Pancreatic cancer pain (early) Vertebral collapsed fracture Vertebroplasty Celiac plexus neurolysis
27
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