pain management
TRANSCRIPT
Pain Management
in Cancer Patients
ByDr.Ayush Garg
Types
Nociceptive : pain signals from nerve endings
Neuropathic : damage to nerve fibres.
•What Pain Rating Scales Do
We Know??
Descripatientive pain rating scales
Numeric pain rating scale
Wong-Baker faces pain rating scale
Verbal Pain Scale
Cancer PainNociceptiveSomatic:
intermittent to constantsharp, knife-like, localizede.g. soft tissue infiltration
Cancer PainNociceptiveVisceral: constant/intermittent
crampy/squeezingpoorly localized, referrede.g. intra-abdominal mets
Cancer PainNociceptiveBony: constant, dull ache
localized, may haveneuropathic featurese.g. vertebral metastasis pathologic fractures
Cancer PainNeuropathic
Destruction/infiltration of nervesa) dysesthetic:
burning/tinglingconstant, radiatese.g. post-herpetic neuralgia
Cancer PainNeuropathic
Destruction/infiltration of nervesb) neuralgic:
shooting/stabbingshock-like/lancinating
paroxysmale.g. trigeminal neuralgia
Neuropathc pain Chemotherapy induced Neuropathies• Cisplatin,Oxaliplatin• Paclitaxel,Thalidomide• Vincristine,Vinblastine
Surgical Neuropathies• Phantom Limb pain• Post mastectomy syndrome• Post thoracotomy syndrome
Cancer PainBreakthrough “Incidental” painSevere transitory increase in pain on
baseline of moderate intensity or lessCaused by movement, positioning, cough,
wound dressing, etcOften associated with bony metastasis
Adapted WHO pain ladder.
Opioid receptorsClassically, opioids active on CNS receptors mu () kappa () delta () receptorsNow found on:
Peripheral NeuronsImmune CellsInflammed TissueRespiratory TissueGI Tract
Opioid Side Effects Common UncommonConstipation Bad Dreams /
HallucinationsDry Mouth Dysphoria / Delirium
Nausea / Vomiting Myoclonus / SeizuresSedation Pruritus / UrticariaSweats Respiratory Depression
Urinary Retention
Opioid-Induced Neurotoxicity (OIN)
Neuropsychiatric syndrome• Cognitive dysfunction• Delirium• Hallucinations• Myoclonus/seizures• Hyperalgesia/allodynia
Pain ManagementNociceptive Soft Tissue Visceral
Agent Opioids Opioids Steroids Surgery Radiation Treatment
Bone PainPharmacologic treatment• Opioids• NSAIDs/steroids/Cox-2 inhibitors• Bisphosphonates
Pamidronate Clodronate Zoledronate
Bone PainRadiation treatment1. Single treatment (800 cGy)2. Multiple fraction (200 cGy x 3-5)3. Effective immediately4. Maximal effect 4 - 6 weeks5. 60-80% patients get relief
Bone PainSurgical opatientions1. Pathologic # (splint, cast, ORIF)2. Intramedullary support3. Spinal cord decompression4. Vertebral reconstruction
AdjuvantsNSAIDs
Anti-inflammatory, anti-PEGS/E: gastritis/ulcer, renal failure K+ , platelet dysfunctionIbuprofen, naproxen
Don’t use both steroids & NSAIDs!
AdjuvantsCox-2 InhibitorsCelecoxib Rofecoxib MeloxicamValdecoxib
Anti-inflammatoryAnti-prostaglandinS/E: less gastritisno platelet dysf’nrenal failure still a problemOD dosingexpensive
AdjuvantsSteroids
inflammation edema spontaneous nerve depolarizationMultipurpose
AdjuvantsAnticonvulsants
Gabapentin Lamotrigine Carbamazepine Valproic acid
AdjuvantsAntidepressants
Amitriptyline Nortriptyline DesipramineSSRIs: results disappointing
AdjuvantsNMDA Receptor Antagonists(N-methyl-D-aspartate)
KetamineDextromethorphanMethadone
Neuropathic PainNon-pharmacologic Radiation treatment Anaesthetic treatment
• Nerve Block• Epidural Block
Neuropathic PainPharmacologic treatment• Opioids• Steroids• Anticonvulsants• TCAs (dysesthetic)• NMDA receptor antagonists• Anaesthetics
Step 4
Interventions
Alternative TherapiesAcupuncture Cognitive/behavioral therapyMeditation/relaxationGuided imageryHerbal preparationsMagnetsTherapeutic massage
Key Points• Current, accurate information• Use available resources• Involve family & caregivers• Know patient knowledge base• Address patient priorities first• Small doses of useful info (e.g., S/E)• Individualize to patient (social, education
level)
Conclusion Cancer pain can be from the cancer
itself, or from cancer-related treatments Can be somatic, visceral, or neuropathic Negative effects of cancer-related pain
can effect QOL, mortality Ask the patient about pain and
REASSESS!
Choose non-opioid / adjuvants carefully paying close attention to side effect profile
Use WHO ladder guidelines when titrating pain medications
Use long-acting opioids for chronic cancer pain
Recognize “4th step” in WHO ladder and utilize your multidisciplinary resources
Can we offer this ?