1 Prof. Krishna Boddu. MBBS, MD (Anes), DNB, FANZCA, MMEd. Director, Regional Anaesthesia Anaesthesia & Pain Medicine Royal Perth Hospital

2 (Treats 115,000 patients/year and Employs 19,000)

 Certified Level I trauma centers in the greater Houston  > Emergency and trauma care patients a year  Life Flight® air ambulance service – Providing emergency rescue and air transport services  165,000-square-foot HVI for latest innovations in cardiology programs and treatment.  30-story medical office building (Medical Plaza), an Ambulatory Care Center, retail shops, services, restaurants etc 3 We are proud of our institutions in many ways

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 >6.35 million new cases / year  WHO Estimate: By 2021, 15 million new cases/ year  Only 50% of cases are undergoing treatment  > 90% of patients with advanced cancer have pain. 5 Portenoy RK, Cancer Pain: Epidemiology and syndromes Cancer 1989; 63:2307 WHO Cancer Pain Relief % Tumor involvement of organic structures 25% Pain due to cancer therapy 10% Past Chronic Pain 25% 70-75% 10%

6 Non-opioid (Tylenol + NSAID + Tramadol) Non-Opioids +Codine Non-Opioids + Opioid + Interventional Cancer Pain After Surgery Cancer Pain Where do we stand in providing good pain control For Cancer Pain Patients?

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Chronicity Intensity Pathophysiology Consider Interventional Pain Rx When: Comprehensive Trial of Pharmacological Therapy Failed To Provide Adequate Pain Control or Leads to Unacceptable Side Effects Old Concept

9 Advanced Cancer Rx Prolongation of Life Span Such Success has an ARTIFACT Accentuates: Pain & Suffering Increased Need of Palliative Care Services Advanced Pain Rx Better Pain Control Methods Available to Provide Cost Effective Interventional Pain Relief Minimize pain and suffering that incur considerable loss — of time, experience, and sense of self For the patient who is dying from end-stage terminal illness, such suffering can purloin what time is remaining, and thus diminishes the capacity for meaningful reflection and relational closure with loved ones, and the life-lived, in general Clearly, Moral Obligation Exists to Relieve Pain & Suffering When cure is impossible, palliation remains the only viable alternative. But, Technically Effective Care Must Also Be Rendered

o Pain o Fatigue o Dyspnea o Anorexia/ Cachexia o Nausea/ Vomiting o Depression o Anxiety o Constipation o Insomnia 10 o Opioid Tolerance o Fatigue o Resp Depression o Anorexia o Nausea/ Vomiting o Urinary Retention o Itching o Constipation o Insomnia/Hallucinations

Nerve Blocks Catheters in Palliative Care

1. Claimed Not Worth the Cost 2. Analgesia From Interventional Techniques Is Short Acting for the Cost when compared with long- term use of systemically administered primary and djunctive/adjuvant analgesics, interventional techniques reveal a very favorable cost:benefit ratio It is a misconception given that analgesia from neurolytic blocks typically lasts for months Need To Repeat Pain Procedures May Be Unjustifiably Burdensome To Patients At End Of Life, Or Who Require Long-term Care It is a fact that interventional pain management procedures were originally developed for use in the frail elderly who were unable to tolerate polypharmacologic or surgical interventions 4. Lack of Availability Of Interventional Pain Specialists To Render Treatment Within The Cancer/ Palliative Care Setting Is Limited All most all urban areas, multispecialist interventional pain specialists can be found

o Single procedure, the patient can be afforded months of pain relief o Significant reduction in opioid dose, thereby increasing the response to opioids and/or non- opioid agents o Often the best, or perhaps the only way to manage certain pain syndromes that are commonly encountered in the cancer care setting 13

Opioids : Sub Cu/ Epidural/ Spinal Morphine: 3mg PO=1mg IV =0.1mg Epidural=0.01mg Spinal 14 Refractory Cancer Pain Life Expectancy < 3mo Life Expectancy > 3mo Single Shot Intrathecal Trial Implant Pump Medical Management >50% Pain Relief Some Pain Relief Epidural Catheter Tunneled IT Catheter Trial

15 Local Anaesthetic Nerve BlocksNeurolytic Nerve Blocks Diagnostic Nerve Blocks Therapeutic Nerve Blocks AlcoholPhenolRF Cryo Chemical Heat Cold Painful/ Not Painful on injection Onset of action varies Several Months Relief