paul daeninck cancercare manitoba wrha palliative care program university of manitoba effective pain...

Paul Daeninck

CancerCare Mani toba

WRHA Pal l ia t ive Care Program

Univers i ty o f Mani toba

Effective Pain Management in Palliative Care

Patients

Describe the prevalence of pain in patients near the end of life

Discuss the concept of total pain

Demonstrate pain assessment

Manage pain using a variety of modalities

Objectives

BRIAN

Brian

59 yo, married, truck driver

35 pack yr hx of smoking, chronic cough

Diagnosed with NSCLC lung (SCC)

Home visit: tells nurse he has pain

Pain is a frequent problem that is due to patients’ presenting illness or secondary to other factors

A physical symptom that patients and families may fear most

Although clinicians now have effective treatments at their disposal, pain remains one of the most poorly assessed and treated physical symptoms

Introduction…

Lack of knowledge and inexperienced health care providers as well as patient / family myths about pain, opioids and addiction continue to be significant barriers to good pain management

…Introduction

Effective Care of the Dying Involves:

1. Adequate knowledge base

2. Attitude / Behaviour / Philosophy

Active, aggressive management of suffering

Team approach

Recognizing death as a natural closure

Broadening your concept of “successful” care

Dr. Mike Harlos, Personal Communication

Pain is a common symptom for pts with advanced progressive illnesses, especially cancer

Most prevalent in advanced cancer patients, reaching 70–90% prevalence in latter stages of illness

Pain Prevalence

PainFatigue/Asthenia

Constipation

Dyspnea

Nausea

Vomiting

Delirium

Depression/suffering

Symptom Prevalence

80 – 90+%75 - 90%

70%

60%

50 - 60%

30%

30 - 90%

40 - 60%

“We can give you enough medication to alleviate the pain, but not enough to make it

fun.”

Acute or chronic

Nociceptive or neuropathic

in cancer, inflammatory mechanisms for nociceptive pain more established

Pain Classification

Involves direct stimulation of intact thermal, mechanical or chemical sensors (nociceptors), specialized sensory neurons and conversion of stimulus into electrical impulses

transmission of electrical impulse along normally functioning nerves to spinal cord and brain

Nociceptive Pain

Somatic pain (e.g., skin, soft tissue, muscle, bone)

well-localized, sharp, aching or throbbing

Visceral pain (e.g., cardiac, lung, GI, GU)

stimulation of pain receptors associated with autonomic nervous system

difficult to describe or localize

Nociceptive Pain

Disordered function of peripheral or central nervous system due to a number of causes

Described as burning, tingling, shooting, stabbing, numbness, or electric-like feelings

Neuropathic Pain…

Characteristic features include radiation of pain along nerve or dermatomal regions and lancinating pain (sharp, brief ‘electric shock-like’ pains at rest)

Changes in sensation include hyperalgesia and allodynia (non-painful stimulation such as light touch is perceived as painful)

…Neuropathic Pain

Previously, cancer pain was thought to be the result of tissue injury from tumour invasion

Recent evidence suggests cancer pain more complex: neurobiological and molecular mechanisms

These include nociceptors, inflammatory/chemical factors, mechanical factors

Cancer Pain

“A Friend’s Story” by Robert Pope, © Robert Pope Foundation

Physical Source

Emotional State

Personality

Family

Patient / Family

Context

Health Care ProfessionalsHistory /

Exposure

Total Pain

Total Pain = Suffering

BRIAN

Brian

59 yo, married, truck driver

35 pack yr hx of smoking, chronic cough

Diagnosed with NSCLC lung (SCC)

Home visit: tells nurse he has pain

History

Physical exam

Imaging

Blood testing

Pain Assessment

Most important aspect of pain assessment inter-professional team activity

collects information from pt/family/cg

complete picture of pt experience

One component of comprehensive assessment of palliative care patient

Pain History

Temporal featuresDaily frequencyLocation/RadiationSeverity/QualityAggravating and

alleviating factorsPrevious history (chronic pain, family)Meaning

Pain History

Medication(s) taken

Dose

Route

Frequency

Duration

Effect

Side effects

No objective measures of pain

Intrinsic difficulties in measuring a symptom that is entirely subjective and so multidimensional

Variety of tools have been developed used to assess pain

Not all measure all aspects of pain

Pain Assessment Tools

History

Physical exam

Imaging

X ray, CT scan (MRI, bone scan)

Blood testing

Liver/renal function, WBC

Pain Assessment

Culture has an impact on pain expression

Care providers need to be culturally competent with pts to fully understand how that person may express pain

Cultural Issues

May express pain differently

Studies have established high prevalence of pain in the elderly, yet widespread under-treatment of pain in this group

Increasing age brings more difficulty in using assessment tools

Pain in the Elderly

Cognitive impairment due to underlying primary brain disorders, secondary brain dysfunction (meds such as opioids and sedatives), or delirium secondary to infections and metabolic causes

Pain and Cognitive Impairment

Although the pt may appear impaired, ask if he/she is experiencing pain

Many pts can provide consistent, useful information about their pain

Pain assessment tools for cognitively impaired pts exist, but few subjected to extensive reliability, validity tests

Pain and Cognitive Impairment

BRIAN

Presented with difficulty swallowing x 3 mo

CXR: 3 cm nodule in RUL CT=LN mass around esophagus

Full staging includes sclerosis of L4/L5 vertebral body

Had chest RT for symptoms

Refused chemotherapy

BRIAN

He has aching back pain, 7/10, especially with movement

Also has mild pain on swallowing

Tylenol #3s help, but makes him nauseated

Says his friend Jack helps out a lot…

Jack Daniels

Perception that opioids used for pain management frequently causes addiction is prevalent

Part of this arises from confusion about differences between addiction and physical dependence

Addiction and Tolerance

Drug addiction: impaired control over drug use, compulsive use and craving, and continued use despite harm

Pseudo-addiction: situations where a patient’s behavior appears drug-seeking but is a need for more medication to achieve pain control

Definitions…

Drug (physical) dependence: physiologic changes in the presence of opioids, whereas drug addiction is behavioral

Pharmacologic tolerance: reduced effect-iveness of a given dose of medication over time

…Definitions…

“What a coincidence, Mrs. Marble. You’ve become addicted to the same drugs as I’m

addicted to!”

Pain in addicted patients

Assessment includes careful disease assessment, thorough addiction history, specific validated scales and tools, urine drug testing, careful monitoring of prescription medication use

Develop clinical judgement as to appropriateness and reasonable dosing for pain syndrome

Addictions

Pain: Treatment Spectrum

PHYSICAL PSYCHOSOCIAL PHARMACOLOGIC SURGICAL

Normal activities

Aqua-fitnessPhysio• Passive• Active

Stretching

Conditioning

Weight training

TENS

TCNS

Massage

Chiropractic

Acupuncture

HypnosisStress ManagementCognitiveBehaviouralFamily therapyPsychotherapy

OTC medication

Alternative therapy

Topical medications

NSAIDs

Tricyclics

Anticonvulsants OPIOIDSLocal anesthetics• Blocks• Oral congeners

Muscle relaxants

Sympathetic agents

NMDA blockers

OrthopedicNeurotomyNeurectomyImplantable stimulatorsImplantable pain pump

Dependent upon functional state

Active:

Normal activities

Physio Passive / Active / Stretching

Aqua-fitness

Conditioning exercises / weight training

Massage

Physical Modalities

Low activity level:

Physio Passive / Stretching

TENS / TCNS

Massage

Acupuncture

Physical Modalities

Hypnosis /distraction

Stress management

Dignity therapy

Cognitive /behavioural therapy

Family therapy

Psychotherapy

Psychosocial



Normal activities


Stretching

Conditioning

Weight training

TENS

TCNS

Massage

Chiropractic

Acupuncture


OTC medication

Alternative therapy

Topical medications

NSAIDs

Tricyclics


Muscle relaxants

Sympathetic agents

NMDA blockers


Mild pain (0-3)

Moderate (4-6)

Severe (7-10)

By the mouthBy the clockBy the ladder

Acetaminophen & NSAIDs

Codeine + Step 1

Morphine + Step 2

WHO Analgesic Ladder

Targeted Rx may be added at any step

Acetaminophen1 g three times daily, extra dosesLonger acting preparations

NSAIDS / COX-2 inhibitorsEffective in inflammatory conditionsGI, kidney side effectsCancer prevention?Gastric protection recommended

Non-opioid Analgesics

Opioid Choice in Canada

PO IV PR LA TD TMMorphine X X X X XOxycodone X X X XHydromorphone X X X X X

Methadone X X X XFentanyl X X XSufentanil X X

----------------------------------------

PO: oral, IV: intravenous/subcutaneous, PR: rectalLA: long acting, TD: transdermal, TM: sublingual

Opioid Choice in Canada

PO IV PR LA TD TMCodeine X X X Tramadol/tapentadol X X Buprenorphine X X

PO: oral, IV: intravenous/subcutaneous, PR: rectalLA: long acting, TD: transdermal, TM: sublingual

OpioidCodeineTramadol/tapentadolMorphineOxycodone

Hydromorphone

Methadone

Fentanyl

Sufentanil

Analgesia Equivalence

PO IV/SC100 mg 50 mg75 - 150 mg? 10 mg 5 mg 5 mg

2 mg 1 mg

1 mg

50 mcg

5 mcg

-----------------------------------------------------------------------------

Morphine (po)45-69 mg

60-134 mg135-180 mg135-224 mg225-314 mg315-404 mg

Fentanyl patch (TD)

12 µg/h25 µg/h37 µg/h50 µg/h75 µg/h

100 µg/h

Morphine to Fentanyl Equivalency

Duragesic® insert, Janssen-Ortho, Inc.

Tramacet Ralivia Zytram / Nucynta

Active at the µ-opioid receptorWeak inhibitor of epinephrine, serotonin

uptake (TCA-like)Metabolism by CYP2D6, 3A4Caution: SSRIs, SNRIs increase levelsFavourable S/E profile (less constipation ?less

nausea)

Tramadol/Tapentadol

Methadone Morphine (po) Morphine: Methadone

For methadone equianalgesic ratio varies by morphine dose

30–90 mg 4:1

90–300 mg 8:1

300–500 12:1

> 500 15–20:1

Methadone

Oral

Transmucosal

Enteral via g-tube

ParenteralSC, IV, IM

Rectal

Transdermal

Neuraxial

Routes of Administration

Opioid Metabolism & Excretion

MetabolismExcretion

Codeine Hepatic (2D6/3A4)

RenalTramadol Hepatic (2D6)

RenalMorphine Hepatic (2D6)

RenalOxycodone Hepatic (2D6)

RenalHydromorphone Hepatic (?)RenalMethadone Hepatic

Intestinal

(2D6/1A2/3A4)

Fentanyl Hepatic (3A4)

TissuesSufentanil Hepatic (3A4)

Tissues

-----------------------------------------------------------------------------

Brian is prescribed Tylenol ES and hydromorphone LA twice daily. 3 wks later at follow-up, he states his pain is better, but he is constipated, and feel nauseated at times.

BRIAN

Risk increases with age (10-25% if >60 y)

Ass’d with females, small size, poor liver/renal function, # Rx, prior A/E

Changes in drug distribution, metabolism, elimination

Same dose of opioid may give higher plasma concentrations and A/E

Opioid Adverse Effects

GI Constipation, nausea, vomiting, GE reflux (rare)

Autonomic Dry mouth, urinary retention, postural hypotension

CNS Drowsiness, delirium, resp depression (rare)

Cutaneous Itch, sweating


Reduce opioid dose

Symptomatic management of adverse effect

Opioid rotation (or switching)

Switching route of administration

Treatment of Adverse Effects

ASCO Consensus statement, JCO 2001

Onset of confusion

Bad dreams, hallucinations

Restlessness, agitation

Significantly depressed LOC

Myoclonic jerks or seizures

Opioid Toxicity

Bad dreams / nightmares may occur

Many patients on opioids report some degree of short-term memory loss, variable degrees of loss of ability to concentrate

All of this is influenced by illness progression

Adverse Cognitive Effects

Many clinicians have exaggerated view of risk of respiratory depression when using opioids to relieve pain

Pain is a potent stimulus to breathe, and tolerance to resp depression develops quickly

Opioid naïve pts ≠ opioid tolerant pts

As doses increase, depression is not sudden

Adequate assessment, appropriate titration

Respiratory Depression

Brian benefits from the addition of laxatives, and enjoys a few weeks at the cottage. At follow-up, he states his pain has changed and now is a constant burning radiating down his L leg.

He is drowsy at times, but sleeps poorly, mostly because of the pain.

BRIAN



Normal activities


Stretching

Conditioning

Weight training

TENS

TCNS

Massage

Chiropractic

Acupuncture


OTC medication

Alternative therapy

Topical medications

NSAIDs

Tricyclics


Muscle relaxants

Sympathetic agents

NMDA blockers


Opioids

Tramadol

Morphine

Oxycodone

Hydromorphone

Fentanyl

Methadone

Receptor Specific

TCAs

Anti-convulsants

SNRIs

NMDA antagonists

Cannabinoids

Corticosteroids

α-adrenergic agonists

(clonidine)

Targeted Therapies

NMDA

Presynaptic Neuron

V-G N

a+

Relea

se

V-G N

a+

Cytoplasm

Postsynapti

c Neuron

AMPA

AMPA AMPA

AMPA

DEPOLARIZATION

NMDANMDA NMDA

NMDA

α2

α2

V-G

Ca2

+

V-G

Ca2

+

μ μ

Ca2+

Ca2+

Mg2+

Ca2+

Ca2+

Glu

Glu

Na+Na+

Glu

Glu

μ μ

5HT

NE

Na+

NMDA

Presynaptic Neuron

V-G N

a+

Relea

se

V-G N

a+

Cytoplasm

Postsynapti

c Neuron

AMPA

AMPA AMPA

AMPA

DEPOLARIZATION

NMDANMDA NMDA

NMDA

α2

α2

V-G

Ca2

+

V-G

Ca2

+

μ μ

Ca2+

Ca2+

Mg2+

Ca2+

Ca2+

Glu

Glu

Na+Na+

Glu

Glu

μ μ

5HT

NE

Na+

Lidocaine

Clo

nid

ine

TCA

Gab

ap

en

tin

Ketamine

Neuropathic Pain Therapy

TCA Gabapentin or Pregabalin

SNRI Topical Lidocaine

Tramadol Opioid Analgesics

Fourth-line Agents

Moulin et al Pain Res Manage 2007;12:13-21

AnticonvulsantsPregabalin (Lyrica )

Gabapentin (Neurontin )

Carbamazepine (Tegretol )

Topiramate (Topamax )

Lamotrigine (Lamictal )

Targeted Therapy

AntidepressantsTCAs

(amitriptyline, nortriptyline, desipramine)SNRIs

(venlafaxine, duloxetine)

Targeted Therapy

Original Contribution | April 03, 2013

Effect of Duloxetine on Pain, Function, and Quality of Life Among Patients With Chemotherapy-Induced Painful Peripheral Neuropathy A Randomized Clinical Trial Ellen M. Lavoie Smith et al

JAMA. 2013;309(13):1359-1367.

doi:10.1001/jama.2013.2813.

SNRI Use

SNRI Use

Steroids inflammation / edema spontaneous nerve depolarizationDexamethasone 4-12 mg dailyMultipurpose

nausea, appetite, energyLong term use = adverse effects

Targeted Therapy

Titrate these meds every 3–7 days depending on adverse effects

May take up to 4 wks to see significant effect

If no benefit, move on to other meds

General Issues

Fourth-line agents: Methadone, ketamine

Cannabinoids

Lidocaine infusion

Clonidine

Targeted Therapy

Moulin et al Pain Res Manage 2007;12:13-21

Neuropathic pain

Very high opioid doses

Reactions/adverse effects to Rx

Severe neurotoxicity

Significant addictions history

Cost of Rx is an issue

When to Use Methadone?

Cannabinoids in Canada

Product monographs: Marinol, Cesamet, Sativex

Nabiximols (2.7mg THC + 2.5mg CBD)Oromucosal spray1 spray qHS; incr 1 spray q6h or more prn; ave 9 – 15 sprays per dayApproved for MS-associated neuropathic pain & cancer pain

Nabilone (0.25 - 1.0mg)Oral capsule0.25 to 0.5mg qHS and slowly titrate to bid as toleratedApproved for chemotherapy-induced nausea and vomiting

Dronabinol/THC (2.5 - 10mg)Oral capsuleStart with 2.5mg qHS and increase up to 5mg bidApproved for CINV and anorexia associated with HIV/AIDS

Herbal cannabis (12.5% THC)Authorized use via Marihuana Medical Access Regulations (MMAR)Average 2 grams per day (4 joints)Not formally approved as prescription drug

“A brain tumour? Thank goodness-all this time I thought you were on medical marijuana!”

His pain is well controlled with the hydromorphone LA, duloxetine and a small dose of dexamethasone. One day, as he is getting out bed, he slips and lands heavily on the floor. His pain immediately increases, and his wife takes him to the ER. An X-ray reveals fracture of L5, and involvement of L2-S1

BRIAN



Normal activities


Stretching

Conditioning

Weight training

TENS

TCNS

Massage

Chiropractic

Acupuncture


OTC medication

Alternative therapy

Topical medications

NSAIDs

Tricyclics


Muscle relaxants

Sympathetic agents

NMDA blockers


Pharmacologic treatment

Opioids

NSAIDs/steroids

Bisphosphonates

pamidronate (Aredia )

zoledronic acid (Zometa )

Calcitonin (Miacalcin )

Denosumab? (Prolia /Xgeva)

Bone Pain

Pathologic # (splint, cast, ORIF)

Intramedullary support

Spinal cord decompression

Vertebral fusion / reconstruction

Vertebroplasty

Amputation

Surgical options

Neuraxial opioids and local anesthetics

Nerve blocks

Implantable pain pumps

Other Modalities

Complementary therapies, although evidence is lacking for sustained effects in pain

Other Modalities

One of the most important aspects of pain control is evaluation of outcomes of pain management plan

Must be discussed with every patient, family and health care team

Monitoring Patients

Follow up with pts who are just starting meds or who are changing dosages within 72 hrs

phone / email / text; any team member

Monitor for adverse effects

Involve patient, family in monitoring of pain

Pain diary, assessment scales, spreadsheet

Be accessible 24/7 if problems develop

Monitoring Patients

Following his verterbroplasty and RT, Brian’s pain improves, but he spends more time in bed due to general weakness and fatigue. A rotation to the fentanyl patch goes well, and he stays at home with the support of the palliative care team. His wife calls one morning to tell you that Brian hasn’t woken up, and she thinks he is close to death. The visiting nurse is present when he dies, and the family are thankful of his peaceful demise.

BRIAN

Questions?

“Death is taking another holiday. I’m the fat lady who sings”

Transitory flares of pain, called breakthrough pain, experienced by many patients both at rest and during movement

When such pain lasts for longer than a few minutes, extra doses of analgesics, i.e., breakthrough or rescue doses, will likely provide additional relief

Breakthrough Dosing

Time

Incident Incident Incident

Pai

nExcessive sedation

Baseline dose

To be effective and to minimize risk of adverse effects, consider IR preparation of same opioid

When methadone or transdermal fentanyl is used, use alternative short-acting opioid, e.g., morphine or hydromorphone, as rescue dose

Sublingual immediate-acting fentanyl available

Breakthrough Dosing

For each breakthrough dose, offer 5–15% of the 24-hour dose

Extra breakthrough dose can be offered q 1 hour orally, or possibly less frequently for frail patients; q 30 min SC / IM, q 10–15 min IV

Breakthrough Dosing

Pain Classification

Assessment

Management

Targeted Analgesics

Other Modalities

“The pain, Mr. Renfrew, is nature’s way of having fun”

paul daeninck cancercare manitoba wrha palliative care program university of manitoba effective pain...

Documents

cancer pain

prevalence of pain

radiation of pain

somatic pain

pain assessment

visceral pain

brain nociceptive pain

painful neuropathic