1. In the name of God

2. Cancer Pain Management Kermanshah University Of Medical Science By Dayani.MD

3. Epidemiology 19 million new cases of cancer each year More than 7 million cancer death Many of this patients suffer from cancer pain

4. Causes of Pain in Cancer Patients  Tumor / Mass effect  Post-chemotherapy  Post-radiation  Post-surgical  Pain associated with direct tumor involvement is the most common cause of cancer pain, occurring in as many as 85% of patients

5. Common type  1.Bone pain is the most common type  2.tumor infiltration of nerve  3.hollow viscus organs  Primary tumor type( breast & prostate: bone met)  Stage of disease  Close proximity to neural structure  Patients variable( anxiety, depression, Hx of substance abuse )

6.  10% of patients with cancer have pain caused by non-cancer-related problems, with pain syndromes reflecting the common causes of pain in the general population  Chronic pain is also prevalent in cancer survivors, with prevalence rates ranging from 5% to 40% of patients and varying by tumor type and trearment type

7. Types of Pain Nociceptive Somatic: Tumor / Mass effect Musculoskeletal Dull, sharp, localized, knife-like intermittent to constant

10. Visceral Pain infiltration, compression, extension, or stretching of the thoracic, abdominal, or pelvic viscera pressure, deep, squeezing not well-localized referred

13. Cancer Pain Neuropathic Destruction/infiltration of nerves burning/tingling constant, radiates

15. Chemotherapy Induced Neuropathies Platinum – based drugs Proteasome inhibitors Other agents Taxanes Vinca alkaloids

16. Clinical Assessment of Pain  Believe the patient's complaint of pain.  Take a careful history of the patient's pain complaint.  Evaluate the patient's psychological state.  Perform a careful medical and neurologic examinations.  Order the appropriate diagnostic studies and personally review the results.  Treat the pain to facilitate the appropriate workup.  Reassess the patient's response to therapy.  Individualize the diagnostic and therapeutic approaches.  Discuss advance directives with the patient and family.

17. Pain Assessment Temporal features Location/Radiation Severity/Quality Aggravating and alleviating factors Previous history (chronic pain, family) Meaning Medication(s) taken Dose Route Frequency Duration Efficacy Side effects

18. Pharmacologic Management of Cancer Pain Analgesic Drug Therapy The Mainstay of Cancer Pain Management

19. GUIDELINES FOR THE RATIONAL USE OF ANALGESICS IN THE MANAGEMENT OF CANCER PAIN  Start with a specific drug for a specific type of pain  Know the pharmacology of the drug prescribed  Know the relative potency of the drug  Know the duration of the analgesic effect  Know the pharmacokinetics of the drug  Know the equianalgesic doses for the drug and its route of administration

20. The World Health Organization Cancer Pain Guidelines  Three-step analgesic ladder  Standardized approach to cancer pain management using the algorithm provided more effective analgesia than routine oncology care

21. Mild-Moderate pain (0-3) Moderate pain (4-6) Severe pain (7-10) Non-opioid analgesic± adjuvant drug low doses of opioid analgesics± adjuvant drug± Non- opoid more potent doses of opioids± adjuvant drug± Non- opoid WHO pain ladder

22. Non-Opioids NSAIDS Acetaminophen Topicals Lidocaine, Capsaicin Practice Points: Mild pain “ceiling” effect Start at lowest effective dose Review pt’s underlying medical illnesses

23. GUIDE TO COMMON NONOPIATE MEDICATIONS AND STARTING DOSES FOR ADULTS

24. Adjuvant Drugs  To Enhance opioid analgesia  To Provide analgesia for certain types of pain (e.g., neuropathic pain, bone pain, and visceral pain)  To Treat opioid side effects or other symptoms associated with pain  They are an integral part of the WHO three-step analgesic ladder

25. Adjuvants Antidepressants Amitriptyline Nortriptyline Desipramine SSRIs

26. Adjuvants Anticonvulsants Gabapentin Lamotrigine Carbamazepine Valproic acid BDZ

27. Adjuvants NMDA Receptor Antagonists (N-methyl-D-aspartate) Ketamine Dextromethorphan Methadone

28. Adjuvants Bone pain Bisphosphonates Calcitonin Pain from malignant bowel obstruction Steroids Octreotide Anticholinergics Practice Points: Choose adjuvant carefully (risk:benefit) Start low and titrate gradually Avoid initiating several adjuvants concurrently

29. GUIDE TO COMMON WEAK AND STRONG OPIOID MEDICATIONS AND POTENTIAL STARTING DOSES

30. Opiate Side Effects Treating a patient's pain is a balance of maximizing analgesic effects and minimizing side effects Common opioid side effects : 1.gastrointestinal (constipation, nausea, and emesis) 2. respiratory (decreased respiratory rate), 3. dermatologic (pruritus and dry mouth) 4.central nervous svstem (sedation, hallucinations, and seizures).

31. Management of side effects l. Pharmacologic treatment of the side effects (e.g., high water intake, dietary fiber, stool softeners, laxativtes, 2. Reduction of opiate dose; 3 Addition of adjuvant medications for pain management

32.  Chemotherapy o Kill cells, reduce tumor size and reduce tumor compression on nerves o Not suitable in tumors which are not chemo sensitive o It can induce pain in itself Management of Pain

33.  Hormone Therapy o Used in mostly breast and prostate cancers o useful for patients with widespread disease and metastatic pain o Anti estrogen and anti androgen drugs are used respectively Management of Pain

34.  Biphosphonates o Slows down the rate of growth of bone crystals and their dissolution o used in the management of cancer-induced bone pain(CIBP). o reduce morbidity from bone metastasis by reducing skeletal events and preventing the need for radiotherapy. Management of Pain

35.  Radiation o Relieves pain by killing cell to reduce tumor size o promotes re-mineralisation of bone. o predominantly used for primary tumours associated with osteoblastic metastases o usually delivered as external beam treatment or systemic radioisotopes Management of Pain

36. INTERVENTIONAL MANAGEMENT  Peripheral nerve blocks  Neuroablation  Neuroaxial

37. Alternative Therapies Acupuncture Cognitive/behavioral therapy Meditation/relaxation Guided imagery Herbal preparations Magnets Therapeutic massage

38. Cancer Pain Emergencies (things you can’t miss) Cord Compression Withdrawal Bone Mets/Impending Fractures Headache and brain metastases

39. Barriers to Pain Control Inadequate assessment Lack of patient education Improper dosing Side effects of analgesics Patient concerns : opioid analgesics Patient compliance

40. Management of the Tolerant Patient  Use combinations of nonopioid and opioid drugs  Use combinations of drug therapy, anesthetic, and neurosurgical procedures  Switch to an alternative opioid analgesic, starting with one-half the equianalgesic dose  Use epidural local anesthetics  Reassess the nature of the pain

41. If you can feel pain you are alive, If you feel the pain of other people, you are human