Management of Chronic Pain for Cancer Survivors Paul A. Sloan, M.D. Professor and Vice Chair for Research Associate Program Director, Pain Medicine Fellowship Department of Anesthesiology University of Kentucky Paul.Sloan@uky.edu Editor-in-Chief Journal of Opioid Management University of Kentucky HealthCare, Lexington, KY Disclosures Analgesic interactions of cannabinoids and opioids. UK Center for Clinical and Translational Science Buprenorphine subdermal implants for management of patients with opioid dependence. Braeburn Pharmaceuticals Modulating neuropathic pain with transcranial direct current stimulation. University of Kentucky Smartphone App for management of postoperative pain U of Kentucky, College of Nursing 1
Cancer Pain Acute Subacute Chronic End-of-life Final hours Sloan PA. J Supp Oncology 2004; 2:491 1970 s: Cancer Pain Therapy Dr. Balfour Mount Mount BM, Ajemian I, Scott J. Can Med Assoc J 1976; 115:125 Pain in Cancer Survivors Cancer survivors living longer Both cancer-related, and noncancer chronic pain becomes prevalent Prevalence estimated at 10-40% Pain usually accompanied by other symptoms (fatigue, n&v, weight loss, SOB etc) Multiple reasons for chronic pain: Table 2 & 3 Glare P. J Clin Oncol 2014; 32:1739 2
Glare P. J Clin Oncol 2014; 32:1739 Chronic Nonmalignant Pain: -low back pain, neck pain, joint pain, myofascial pain, osteoarthritis, peripheral painful neuropathy, abdominal pain, pelvic pain, CRPS Paice PA. J Clin Oncol 2016; 34:3325-3345 Barbara 66 yr woman; history of peritoneal carcinomatosis recently diagnosed Hx Etoh abuse (none in 6 months); daily MJ for appetite Hx gastritis Hx abdominal pain, possibly exacerbated by recent chemotherapy, but same as chronic noncancer pain of many years duration Pain relieved with hydrocodone 10 mg daily UDS appropriate Plan: continue hydrocodone, discontinue marijuana Brenda 33 yr woman; history of gyn cancer since 2013, treated with surgery. Recurrence in 2014 with more surgery, chemotherapy and radiation Main pain is low back pain for 10 years. Injection therapy was helpful Hx prescription opioid addiction. Previous suboxone treatment On gabapentin and ibuprofen Plan: injective spine therapy 3
Loretta 30 yr woman; history of cervical cancer s/p surgery, chemo, and XRT No known recurrence Initial eval: ongoing chronic LBP along with pelvic pain Comes on oxycodone/acetaminophen TID Rates pain at 10/10 Initial UDS: negative for any opioid. This was the first UDS patient had received by any treating physician Pain in Cancer Survivors: Management Make a full pain assessment History, history, history; exam, exam, exam, extent of disease, UDS Make a pain diagnosis/diagnoses! -distinguish cancer-related from chronic noncancer pain As for CNMP; nonopioid therapies first: -NSAIDs, acetaminophen, antidepressants, anticonvulsants, topical analgesics Some evidence for nonmedication therapies such as physical therapy, exercise, cognitive therapy, alternative modalities, chronic pain clinic techniques, massage, music therapy Pain in Cancer Survivors: Management For patients who do not respond to conservative nonopioid management: -consider a trial of opioid therapy -assess for risk of opioid misuse -educate patient and family regarding risks -Monitor effectiveness, side effects, functioning and compliance 4
Long-term Opioid Risk Assessment: Opioid Risk Tool Webster LR, Webster RM. Pain Medicine 2005; 6:432-442 Butler SF. Pain 2004; 112:65 Oxymorphone ER for Chronic Pain: 1-Year follow-up results Prospective, Open-label 70 Mean Pain Intensity Score (VAS) 60 50 40 30 20 10 0-10 1 2 3 4 5 6 7 8 9 10 11 12 Month Cancer Pain Nonmalignant Pain Sloan PA. Support Care Cancer 2005; 13:57-65. McIlwain H. Am J Therapeutics 2005; 12:106-112. 5
Oxymorphone ER for Chronic Pain: 1-Year follow-up results Mean Average Daily Oxymorphone Dose (mg) 300 200 Cancer Pain 100 0 Nonmalignant Pain 0 100 200 300 400 500 Days Sloan PA. Support Care Cancer 2005; 13:57-65. McIlwain H. Am J Therapeutics 2005; 12:106-112. Adverse Effects from Long-term Opioids Typical: constipation, N&V, sedation Hyperalgesia tolerance Opioid overuse headache Restricted automobile driving? Immunosuppression Hypogonadism Depression Tool for suicide-death from overdose Aberrant opioid-related behavior Rare: hypoglycemia, respiratory depression central sleep apnea, nocturnal hypoxemia Cognitive dysfunction Death Benyamin R. Pain Physician 2008; 11:S105 Birthi P, Nagar V, Nickerson R, Sloan PA. J Opioid Manage 2015; 3:255. Harned M, Sloan PA. Exp Opin Drug Safety 2017; In Press. Davis MP. Curr Oncol Rep 2016; 18:71 Opioid Treatment Agreement Issues (Patient Responsibilities) Comply with overall Rx plan. Only one pharmacy. Only one physician (clinic). No other controlled substances. Education of patient and family regarding opioid use and adverse effects Random UDS, blood screen, pill count. Report any ED visit to obtain opioids. Store opioids responsibly. Keep scheduled clinic visits for reevaluation. Consequences of noncompliance. 6
Use of cellular telephone and images for pill counts at a distance in buprenorphine maintenance treatment Welsh C. J Opioid Management 2016; 12:217 Risk factors for opioid misuse in adolescents and young adults with focus on oncology setting 20% of adolescents have used prescription opioids for nonmedical use, with onset around age 13, and peaking at 16 yr Oncology patients are not immune to medication misuse Risk factors for young oncology patients: Age, sex, multiple opioid prescriptions, academic struggles, problem behaviors, hx drug abuse, family hx drug abuse, hx sexual abuse, psychological conditions Dec, 2016 Peck R. J Opioid Management 2016; 12:205 Long-Term Opioid Therapy Opioid choice: no one opioid is preferred no opioid route of administration is preferred Lauche R. Opioids in chronic noncancer pain-are opioids different? A systematic review. Schmerz 2015; 29:73 opioid guidelines have strong support for opioid initiation as trial opioid rotation is not well studied opioid guidelines divided in preference of LA versus SA opioids Recent study from VA data from 2000-2009: total of 319 unintentional overdose events patients started on LA opioids had a 2.3 increased risk of overdose compared with patients started on SA opioids. Risk of OD was greatest during the first 2 weeks of therapy. Miller M. JAMA Intern Med 2015; 175:1584 7
Monitoring of Opioid Therapy Analgesia Activities of daily living-function Adverse side effects Aberrant drug-taking behaviors Assessment ongoing (misuse risk, addiction, diversion) -Beware high-dose opioid pt (>100 mg OME/d) OTA violation of CNMP Treatment Retrospective study over 6 month period; chronic pain patients 234 subjects 38% discharged from clinic for OTA violation 89% with inappropriate UDS Discharged a mean of 7.4 months after initial visit Of the UDS: most common (40%) was illicit drug use, MJ the most common drug Therefore: monitor UDS every patient, every visit Summers P. J Opioid Manage 2015; 11:501 Enforce Compliance Claims investigated from 2005-08 295/1627 total claims for chronic pain patients. 51 claims for medication management. Medication claims were younger, male, back pain, opioids (94%), additional psychoactive meds (58%). Most (84%) with at least one risk factor for med misuse; and 24% with 3 or more risk factors!!! Death the most common outcome in the claims. Most (84%) involved patients who did not cooperate in their care. Factors associated with death: long-acting opioids, concomitant psychoactive drugs, and 3 or more risk factors for med misuse. Median payout-$174k; range: 20,000-1.2 million. Awards to 40% of plaintiffs. Malpractice Claims Associated with Opioid Management for CNMP Fitzgibbon DR, et al. Anesthesiology 2010; 112:948 8
Roger 66 yrs man; s/p maxillectomy for cancer of nose Chronic facial pain; as well as chronic LBP Oxycodone/aceta 10 mg TID Because of inadequate analgesia; trial of methadone 10 BID UDS inappropriate: positive for oxycodone, methadone, tramadol and buprenorphine Because of cancer history, trial of tramadol alone UDS then inappropriate: lab called: industrial strength tramadol level with evidence of pill shaving. No tramadol metabolite present Non-opioid therapy only Pat 74 yr woman; history of lung cancer in remission PMH: CHF, HTN, COPD, psoriatic arthritis Chronic pain: low back, hip, hands and knees for years No pain on initial eval, but other days she describes moderate to severe pain Impression: chronic pain related to arthritis. Patient comes to you on morphine ER 30 BID, and lortab QID Plan: maintain the morphine; taper and discontinue the lortab Follow Up: patient felt much better with the lower opioid daily dose, and with same degree of pain relief as previous Dec, 2016 9
Ms. H 35 woman, breast cancer with brain mets Long history of LBP Methadone 10 mg TID Physical exam and imaging suggestive of lumbar facet arthropathy Plan: LES injection with excellent pain relief, and decrease of methadone to 10 mg/d Pain in Cancer Survivors: Summary Make a full pain assessment including diagnosis As for CNMP; nonopioid therapies first Some evidence for nonmedication therapies such as physical therapy, exercise, cognitive therapy, alternative modalities Risk assessment for any opioid consideration Opioids as a trial. Consider limiting opioid dose <100 mg/d Monitoring as for CNMP on opioids-udt Goals clarification: function, compliance, tolerable pain level, side effect management Evaluation for social pain, emotional pain, financial pain, spiritual pain, psychological pain 10