Managing Your Pa,ent s Complex Cancer Pain. Dr Eoin Tiernan Consultant in Pallia,ve Medicine UCD Associate Clinical Professor 30 th March 2019.

Transcription

1 Managing Your Pa,ent s Complex Cancer Pain Dr Eoin Tiernan Consultant in Pallia,ve Medicine UCD Associate Clinical Professor 30 th March 2019.

2 Terminology Background pain: Present for >12 hours a day during the previous week, or would be present if the pa,ent was not taking analgesia may be managed with regularly administered slow release analgesic prepara,ons Breakthrough pain: a transitory exacerba,on of pain experienced by the pa,ent with stable and adequately controlled baseline (background) pain. The use of a pharmacological rescue or breakthrough dose of analgesia is widely accepted as the management of breakthrough pain Incident pain: Incident pain is a varia,on of breakthrough pain, normally precipitated by a movement or ac,on of the pa,ent, or another iden,fiable precipitant such as a wound dressing change.

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4 More terminology Nocicep,ve pain pain that is associated with s,mula,on of nociceptors. These are sensory receptors that respond to actual,ssue damage. If these receptors are located in the musculoskeletal system they are referred to a soma%c nociceptors and the resul,ng pain as soma%c pain Pain that is well- localised, throbbing and pressure- like is probably soma,c nocicep,ve pain, such as pain post- surgery or pain from bone metastases If these receptors are associated with internal organs, they are referred to as visceral nociceptors and the resul,ng pain as visceral pain. Pain that is described as diffuse, aching, cramping or poorly- localised is frequently visceral pain, secondary to compression, infiltra,on or disten,on of abdominal or thoracic viscera

5 More terminology Neuropathic pain a result of nerve damage to the central or peripheral nervous system frequently described as shoo,ng, burning or s,nging. Up to 40% of cancer- related pain may have a neuropathic mechanism involved may have associated features indica,ve of nerve malfunc,on, such as hypersensi,vity,,ngling, numbness and weakness in the area of distribu,on of the affected nerve.

6 More terminology Hyperalgesia: An exaggerated response to noxious s,muli (a s,mulus that is normally painful) Allodynia: An exaggerated response to an innocuous s,mulus (that does not normally provoke pain) Paraesthesia: An abnormal sensa,on, whether spontaneous or evoked Dysaesthesia: An unpleasant, abnormal sensa,on, whether spontaneous or evoked by rubbing or touching Neuralgia: Pain in the distribu,on of a nerve or nerves.

7 1. WHO ANALGESIC LADDER Relief from pain STEP 3 Severe pain Strong opioid (Morphine sulphate/oxycodone/ Hydromorphone/ Fentanyl) +/- Non-opioid +/- Adjuvant 7 to 10 out of 10 STEP 2 mild to moderate pain Pain persisting or increasing Weak opioid (Codeine/ Tramadol) +/- Non-opioid +/- Adjuvant 3 to 6 out of 10 Pain persisting or increasing STEP 1 mild pain Non-opioid (Paracetamol/ NSAID) +/- Adjuvant 1 to 2 out of 10 Figure 1 Adapted from World Health Organisation analgesic ladder from World Health Organisation. Cancer Pain Relief, 2nd ed. Geneva: WHO, 1996.

8 Step 3 opioids Morphine Oxycodone Hydromorphone Fentanyl Alfentanil Buprenorphine Methadone FOR WHAT TYPE OF PAIN? Visceral.Wonder ful!! Soma,c.Reason able Neuropathic..Poor

9 Which opioid? Key finding The available evidence demonstrates that the efficacy and tolerability of morphine sulphate, oxycodone, hydromorphone and methadone are equivalent, and these agents are all valid choices as first and subsequent choice opioids for moderate to severe cancer pain. Transdermal opioids such as fentanyl and buprenorphine are valid alternatives in selected patients; they may be associated with less constipation and good patient compliance, but their pharmacokinetic and dynamic characteristics present challenges. Key recommendations B B D D 8.1 Oral morphine sulphate, hydromorphone and oxycodone may be used as first line treatment in the management of moderate to severe cancer pain. 8.2 Transdermal opioids such as fentanyl and buprenorphine are valid alternatives in selected patients. 8.3 Methadone may be used for the treatment of moderate or severe cancer pain. 8.4 Methadone use is only advised through the guidance of specialist palliative care professionals. Caraceni A, Pigni A, Brunelli C. Is oral morphine s,ll the first choice opioid for moderate to severe cancer pain? A systema,c review within the European Pallia,ve Care Research Collabora,ve guidelines project. Palliat Med. 2011;25(5): 402-9

10 Patches: fentanyl & buprenorphine For stable pain only Absorp,on, compliance Can cut matrix patches * seek specialist advice when rota,ng from a patch to an oral or SC opioid, (or vice- versa) Fentanyl 72hrly: 12, 25, 50, 100mcg/hr/ 72hr Buprenorphine BuTrans 7 day patch (5,10,20mcg/ hr), Transtec 4 day patch (35, 52.2, 70mcg/hr)

11 Fentanyl transmucosal prepara,ons Effentora, Ac,q, Pecfent, Abstral CAUTION: dependency Pt selec,on Max 4 doses/24hr period NOT if opioid naïve Dose independent of baseline opioid

12 Opioid side effects vs opioid toxicity

13 Treatment of opioid toxicity Look at the causes: 1. Pain relieved by other measures (radiotherapy, chemotherapeu,c response, nerve block) 2. Infec,on 3. Renal failure 4. Other.? Reduce dose if pa,ent is pain free Rotate opioid, if has pain **Really really really rarely do you need to use naloxone

14 OPIOID ROTATION

15 Rota,on Opioid rotation is the term given to the clinical practice of substituting one opioid the initial opioid - with another, in order to obtain a satisfactory balance between pain relief and side-effects (226). Necessary in approx 20-44% of pts (1a) Opioid rota,on leads to clinical improvement in more than 50% of pts with a poor response to one opioid (2b) Dale O, Moksnes K, Kaasa S. European Palliative Care Research Collaborative pain guidelines: Opioid switching to improve analgesia or reduce side effects. A systematic review. Palliat Med. 2011;25(5): Cherny NJ, Chang V, Frager G, Ingham JM, Tiseo PJ, Popp B, et al. Opioid pharmacotherapy in the management of cancer pain: a survey of strategies used by pain physicians for the selection of analgesic drugs and routes of administration. Cancer. 1995;76(7): Sarhill N. Parenteral opioid rotaion in advanced cancer: a prospective study. Abstracts of the MASCC / ISOO 13th International Symposium Supportive Care in Cancer, Copenhagen, Denmark, June Supportive Care in Cancer 2001;9

16 When do I rotate? If opioid toxicity present and pain control is adequate a reduc,on in opioid dose is indicated (as well as trea,ng any possible precipitants such as infec,on and dehydra,on, or deteriora,ng renal func,on). If opioid toxicity present but pain control is inadequate, rota,on to an alterna,ve opioid may allow,tra,on to adequate analgesia without the same disabling effects.

17 How does rotation work? Pharmacology of opioid rota,on Opioid rotation utilises inter-individual variability and the phenomenon of incomplete cross- tolerance in order to maximise the analgesic effect of a new opioid while minimising side effects. Incomplete cross- tolerance describes the phenomenon of reduced tolerance to a new opioid compared to a previously used opioid. This allows for a lower equivalent dose of a new opioid to achieve similar pain control as the higher dose of the ini,al opioid, thus poten,ally reducing side- effects. Dale O, Moksnes K, Kaasa S. European Pallia,ve Care Research Collabora,ve pain guidelines: Opioid switching to improve analgesia or reduce side effects. A systema,c review. Palliat Med. 2011;25(5): Droney J, Riley J. Recent advances in the use of opioids for cancer pain. J Pain Res.

18 2. TYPES OF MEDICATIONS CONTINUED Adjuvants These medications can be used throughout all steps of the WHO analgesic ladder where appropriate. Some common examples are provided in table 3. Note they may have an opioid sparing effect and reduction of opioid may be required. Table 3 Adjuvant medications and treatments for relief of cancer pain Adjuvant medications and treatments Examples Corticosteroids Dexamethasone where present e.g. liver capsule pain; nerve root/ trunk compression Anti-spasmodics Hyoscine butylbromide (buscopan) Baclofen To relieve pain due to visceral spasm To relieve pain due to muscle spasm Anti-depressants Tricyclics (amitryptiline) For neuropathic pain Anti-epileptics Muscle relaxants Gabapentin, pregabalin Clonazepam Diazepam Local anaesthetic or steroid injections For neuropathic pain To relieve pain due to muscle spasm For trigger point pain Bisphosphonates Zoledronic acid For metastatic bone pain

19 Quick user guides Opioids - 10 pg booklet Ini,a,on/,tra,on opioids Alterna,ve routes of admin Opioid SE & mgt toxicity Rota,on & equianalgesic tables Renal - 6pg booklet Hepa,c - 4 pg booklet

20 Pallia,ve Care... Therapies to Modify disease Hospice Benefit Palliative Care Presentation Therapies to relieve suffering and/or improve quality of life 6m Death Bereavement Care

21 Early Referral to PalliaEve Medicine Pa,ents with advanced cancer who were randomly assigned to receive early vs delayed pallia,ve care lived longer (median 1 year survival 63% vs 48%)

22 Early Referral to PalliaEve Medicine Interven,on within 6 days reduces cost of hospital stay by 14%, but interven,on within 2 days reduced cost by 24%

23 PAL.M.ED Pallia,ve Medicine in the Emergency Department Improving the Recogni,on of Pallia,ve Care Needs of Pa,ents Apending the Emergency Department Pallia,ve Care at the Front Door

24 Early Referral Research at Beacon Ini,al avoidance and resistance to referral 9 of 20 felt the name should be changed 15 of 20 felt more informa,on should be given, ideally at diagnosis, by consultant or GP More public informa,on Re- framing of referral Many felt pallia,ve care should be a standard part of the treatment offering

25 Pallia,ve Medicine at the Beacon Weekly outpa,ent clinic (Wednesday aternoon) Consult- based service Take Over Care TOC Direct Admission Contact Clinical Nurse Specialist (Paul or Lianne ) Contact my PA Sandra on