2/19/2016

1

Symptom Management: Cancer Pain

Kelley Blake RN, MSN, OCN, AOCNS

Valley Medical Center

Objectives

• Explore cancer pain

• Discuss barriers

• Manage pain in special populations

• Discuss pain treatment therapies

Pain

Is whatever the person says it is

Existing whenever he or she says it does

Pain

The International Association for the Study of Pain states:

Pain is defined as an unpleasant, multidimensional sensory and emotional experience associated with actual or potential tissue damage or described in relation to such damage

2/19/2016

2

Cancer Pain

• It is estimated that 90% of cancer pain can be controlled with currently available medications

Characteristics of Pain

• Acute pain

– Less than 6 mo.

– Pain behaviors exhibited

• Chronic pain

– Longer than 3 mo.

– Fatigue/depression common

Characteristics of Pain

• Breakthrough pain

– Transient increase over background pain

– Rapid onset

– Severe intensity

– Self-limiting

– Average duration 30 minutes

• Refractory/ Intractable pain

– Inadequately controlled despite aggressive measures

Characteristics of Cancer Pain

• Acute and chronic

• Direct tumor involvement

• Diagnostic/ therapeutic procedures

• Cancer treatment

• May trigger fear

– Cancer progression

– Recurrence

• Worsens with

– Anxiety

– Hopelessness

– Depression

2/19/2016

3

Types of Pain: Nociceptive Pain

• Somatic pain

– Bone/joint/ connective tissue

– Sharp/throbbing/ pressure

– Well localized

• Visceral pain

– Distension/ compression

– Diffuse/aching/ cramping

– Poorly localized

Types of Pain: Neuropathic Pain

• Peripheral neuropathic pain

– Peripheral nerve injury

– Numbness/tingling

• Centrally mediated pain

– Radiating/shooting

– Burning/aching

• Sympathetically maintained pain

– Centrally generated

– Autonomic dysregulation

– Complex regional pain syndrome

Physiology of Pain

• Transduction

– stimulus

• Transmission

– Message relay

• Perception

– Pain experience

• Modulation

– Release of neuromediators

Risk Factors of Cancer Pain

Disease Related

• Type of cancer

• Bone metastases

• Visceral pain

• Nerve compression/injury

Treatment Related

• Chemotherapy

• Radiation therapy

• Chronic pain related to cancer surgery

2/19/2016

4

Barriers: Patient-Related Factors

Reluctance to report pain

Concern about distracting physicians from treatment of underlying disease

Fear that pain means disease is worse

Lack of knowledge about principles of basic pain management

Concern about not being a “good” patient

Reluctance to take pain medications

Fear of addiction/being thought of as an addict

Worries about unmanageable side effects

Concern about becoming tolerant to pain medications

Poor adherence to the prescribed analgesic regimen

Financial barriers

Barriers: Provider-Related Factors

Probable Problems

Inadequate knowledge of pain management

Poor assessment of pain

Concern about regulation of controlled substances

Fear of patient addiction

Concern about side effects of analgesics

Concern about patients becoming tolerant to analgesics

Possible Solutions

Appropriate pain management education

Nurse/patient advocacy Persistence/not pushy

Communication What is the plan?

Pain clinic referral

CAM referrals

Manage side effects

Barriers: Health Care System-Related

• Low priority given to cancer pain treatment

• Inadequate reimbursement for pain assessment and treatment

• The most appropriate treatment may not be reimbursed or may be too costly for patients and families

• Restrictive regulation of controlled substances

• Problems of availability of treatment or access to it

• Opioids unavailable in the patient’s pharmacy

• Unaffordable medication

Special Populations

• Older adult

– Polypharmacy

– Increased sensitivity

– Appropriate pain scale

– Confusion/poor vision

– Home supervision

– Cost

• Pediatric

– Developmental age

– Appropriate pain scale

– Dose by weight

2/19/2016

5

Polypharmacy

Risks and Complications

Adverse drug reaction increases with number of drugs

Duplication of therapy

Drug-drug interactions

Drug-disease interactions

Adherence

Cost

Polypharmacy

Management Questions

Indications?

Desired effect?

Nonspecific symptoms?

Dose?

Drug-drug interactions?

Antineoplastic treatment interference?

Drug-tumor interactions?

Adherence?

Untreated conditions?

Special Populations: Patients Addicted to Drugs

• The uncomplicated patient

– Routine

• The patient with comorbid psychiatric and coping difficulties

– Structure

– Psychotherapy

• The addicted patient

– Maximum structure

– Limited supply

– Long-acting opioids of low street value

– Recovery program

– Psychotherapy

Analgesics

Goals of Therapy

To reduce the effect of noxious stimuli caused by thermal, chemical, or mechanical injury that elicits pain

To improve quality of life

Types of Analgesics

• Nonopioid analgesics

• Opioids

• Adjuvants

2/19/2016

6

Assessment

Identify Risk for Pain

Pain type

History of past/current analgesia and effectiveness

Side effects from previous regimens

Physical exam

Current medications

Diagnostics

Cultural/ethnic background

Cancer Pain Assessment

• Assess for all types of acute and chronic pain

• Reassure that most cancer pain can be relieved safely, quickly, and effectively

• Basic and ongoing professional education for clinicians on effective cancer pain assessment

Pain Management

Neuropathic Pain

• Trial antidepressant

• Trial anticonvulsant

• Consider topical

• Pain specialist

Mild Pain (Level 1-3)

• NSAID or acetaminophen

• Short-acting opioid

• Bowel regimen

• Treat side effects

• Nonopioid analgesics

• Psychosocial support

• Education

Pain Management

Moderate Pain (Level 4-6)

• Titrate short-acting opioid

• Bowel regimen

• Treat side effects

• Nonopioid analgesics

• Psychosocial support

• Education

Severe Pain (Level 7-10)

• Titrate short-acting opioid

• Bowel regimen

• Treat side effects

• Nonopioid analgesics

• Psychosocial support

• Education

• Reassess and modify

• Long-acting opioid

• Specific pain problems

• Specialty consultation

2/19/2016

7

Pharmacological Therapies: using WHO stepladder approach

Step 1: Non-opioids +/- Adjuvant

Step 2: Opioids for mild to moderate pain +/- Non-opioids

+/- Adjuvants Step 3: Opioids for

moderate to severe pain +/- Non-opioids

+/- Adjuvants

Acetaminophen: Step 1

• To reduce pain and fever

• Treatment of mild to moderate pain

• May cause liver damage

• Do not exceed 4g/24 hours

Anti-Inflammatory Agents: Step 1

To reduce inflammation and pain

Treatment of mild to moderate pain

Symptom management

Boney metastases

Addition of NSAIDs can reduce opioid dose requirements

Anti-Inflammatory Agents: Step 1

Commonly Used NSAIDs in Cancer

• Propionic Acids – Ibuprofen

• Acetic Acids – Ketorolac

• Oxicam – Piroxicam

• Salicylates – Aspirin

• Cyclo-oxygenase-2 Selective Inhibitor – Celecoxib

2/19/2016

8

Anti-Inflammatory Agents: Step 1

Corticosteroids Used in the Treatment of Cancer

• Short-Acting (8-12 hr) – Hydrocortisone

• Intermediate-Acting (12-36 hr) – Prednisone

• Long-Acting – Dexamethasone

Anti-Inflammatory Agents: Step 1

Potential adverse effects

• Renal toxicity

• Cardiac toxicity

Risk factors for NSAID toxicities

• Age greater than 60

• Thrombocytopenia

• Renal insufficiency

• Comorbid disease – Multiple myeloma

Anti-Inflammatory Agents: Step 1

Adverse Effects of NSAIDs Related to Cancer

• Central Nervous System

• Cardiovascular

• Hematologic

• Platelet aggression

Adverse Effects of Corticosteroids Related to Cancer

• Psychiatric disturbances

• Immunosuppression

Opioids: Step 2-3

▫Most appropriate dose controls pain through 24 hours

▫Long-acting and breakthrough options with constant pain

▫Effective titration

Breakthrough dose

10%--20% of long-acting dose

2/19/2016

9

Opioids: Step 2-3

• Tolerance: when taken regularly

• Physical dependence: all patients when taken regularly

• Psychological dependence: ADDICTION

Opioids: Step 2-3

Potential Adverse Effects

Dependence

Drug interactions

Abnormalities in absorption

Opioid Withdrawal

• Nausea/vomiting/diarrhea

• Tachycardia

• Chills

• Anxiety/paranoia

• insomnia

Opioids: Step 2-3

Adverse Effects of Opioids

Gastrointestinal

Respiratory

Central nervous system

Potential Adverse Effects Caused by Compromised Organ Systems

Hepatic insufficiency

Central nervous system

Respiratory

Opioids: Managing Adverse Effects

• Antiemetic

• Prophylaxis for Constipation

• V/S

• Pupil size

• Sedation/RR

• Neuro

• Safety

2/19/2016

10

Opioids: Managing Constipation

• Universal side effect

• Prophylaxis

– Stool softener

– Bowel stimulant

• Decrease intestinal secretion/peristalsis

• Increase muscle tone

• Increase segmental contractions of bowel

• Decrease stool volume/ frequency

• Increase water/ electrolyte absorption

Adjuvants: Anxiolytics/Sedative-Hypnotics

To reduce pain associated with anxiety

Benzodiazepines

Other medications

Selective serotonin reuptake

inhibitors

Serotonin norepinephrine reuptake inhibitors

Adjuvants: Anxiolytics/Sedative-Hypnotics

Potential Adverse Effects

• CNS effects

• Delirium

• Respiratory suppression

Drug Interactions

Alcohol

Inhibitors or inducers of hepatic enzyme CYP3A4

Adjuvants: Antidepressants

• To treat depression associated with chronic pain

• As adjuvant pharmacologic pain management in pain conditions

– Postherpetic neuralgia

2/19/2016

11

Adjuvants: Antidepressants

Common Antidepressants

• Tricyclic Antidepressants

• Serotonin Reuptake Inhibitors

• Mixed-Action Agents

Potential Adverse Effects

• Drug-drug interactions

• Dietary restrictions

Adjuvants: Anticonvulsants

As adjuvant pharmacologic therapy for pain with neurologic cause

Peripheral neuropathy

• Valproic acid

• Lamotrigine

Adjuvants: Anticonvulsants

Patients at risk for neurologic pain

Chemotherapy Paclitaxel

Vincristine

Oxaliplatin

Adverse Effects

• Nausea

• Sedation

• Irritability

• Headaches

• Depression

• Liver failure

Adjuvants: Miscellaneous Interventions

Pharmaceuticals for Bone Metastases

• Radionuclides

• Bisphosphonates

Intraspinal Analgesia

Epidural

Intrathecal implantable pump

Bone metastases

Reduce bulky tumors

Radiation Therapy

2/19/2016

12

Adjuvants: Miscellaneous Interventions

Interventional/Surgical Strategies

• Nerve blocks

• Neurostimulation

• Percutaneous kyphoplasty

• Debulking

Nonpharmacologic Interventions

CAM

Patient/family education

Interventions to Increase Comfort

Complementary and Integrative Modalities

• Alternative medical systems

• Energy therapies

• Exercise therapies

• Manipulative and body-based methods

Mind-body interventions

Nutritional therapeutics

Pharmacologic and biologic treatments

Spiritual therapies

Cannabis

Has been used for medicinal purposes for thousands of years

Illegal in the US, however legal in WA and other states

Not approved by FDA for medical treatment

Points to remember

• Treat the underlying cause of pain

• Administer around the clock

• Manage breakthrough pain

• Oral preferred route

• Minimize side effects

• Review patient instructions

2/19/2016

13

References

• American Pain Society. (2005). Guideline for the management of cancer pain in adults and children. Glenview, IL.

• Balducci, L., Goetz-Parten, D., & Steinman, M. A. (2013). Polypharmacy and the management of the older cancer patient, Annals of Oncology 23 (Sup 7): vii36-vii40, doi: 10.1093/annonc/mdt266. Retrieved from http://annonc.oxfordjournals.org/ on July 3, 2015.

• Brant, J., Visich, K.L., Sterling, B., & Irwin, M. (2014). Pain. In M. Irsin & L. Johnson (Eds.). Putting evidence into practice: P pocket guide to cancer symptom management (pp. 177-184). Pittsburgh, PA: Oncology Nursing Society.

• Brant J.M., & Stinger, L.H. (2015). Pain. In C.G Brouwn (Ed.). A guide to oncology symptom management. 2nd ed., pp. 505-526). Pittsburgh, PA: Oncology Nursing Society.

References

• Itano, J. K., editor (2016). ONS Core curriculum for oncology nursing, 5th ed., Elsevier, St. Louis, Missouri, pp. 287-426.

• National Comprehensive Cancer Network. (2015). NCCN Clinical Practice Guidelines in Oncology: Adult cancer pain [v.2.2015]. Retrieved from http://www.nccn.ort/professionals/physician_gls/pdf/pain.pdf

• Pain pdq & CAM pdq, National Cancer Institute Office of Cancer Complimentary and Alternative Medicin (NCI OCCAM, 2015). http://www.cancer.gov

• Treating cancer pain in patients addicted to drugs, (Feb 2007). The journal of supportive oncology. Vol 5:no 2. pp. 63-64. www.SupportiveOncology.net