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Treatment of Cancer Pain University of Massachusetts Medical School eScholarship@UMMS Cancer Concepts: A Guidebook for the Non- Oncologist Radiation Oncology 2016-09-21 Treatment of Cancer Pain Mark Dershwitz University of Massachusetts Medical School Et al. Let us know how access to this document benefits ou.y Follow this and additional works at: https://escholarship.umassmed.edu/cancer_concepts Part of the Anesthesia and Analgesia Commons, Medical Education Commons, Neoplasms Commons, and the Oncology Commons Repository Citation Dershwitz M, Pieters RS. (2016). Treatment of Cancer Pain. Cancer Concepts: A Guidebook for the Non- Oncologist. https://doi.org/10.7191/cancer_concepts.1024. Retrieved from https://escholarship.umassmed.edu/cancer_concepts/23 Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 4.0 License. This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in Cancer Concepts: A Guidebook for the Non-Oncologist by an authorized administrator of eScholarship@UMMS. For more information, please contact [email protected]. Treatment of Cancer Pain Citation: Dershwitz M, Pieters RS. Treatment of Cancer Pain. In: Pieters RS, Liebmann J, eds. Mark Dershwitz, MD, PhD Cancer Concepts: A Guidebook for the Non-Oncologist. Worcester, MA: University of Massachusetts Richard S. Pieters, MD Medical School; 2016. doi: 10.7191/cancer_concepts.1024. This project has been funded in whole or in part with federal funds from the National Library of Medicine, National Institutes of Health, under Contract No. HHSN276201100010C with the University of Massachusetts, Worcester. Copyright: All content in Cancer Concepts: A Guidebook for the Non-Oncologist, unless otherwise noted, is licensed under a Creative Commons Attribution-Noncommercial-Share Alike License, http://creativecommons.org/licenses/by-nc-sa/4.0/ Summary and Key Points 10. Physical therapy or physical measures such as heat, cold or bracing, 1. Chronic cancer pain is usually managed with multimodal analgesia, may relieve some pain. the combination of opioids, Cyclooxygenase (COX) inhibitors, 11. Cognitive behavioral therapy may make pain more bearable. anticonvulsants, and/or antidepressants. 12. Complementary or alternative therapies have a role for some patients. 2. Opioids are excellent analgesics but are associated with significant toxicity. Ventilatory depression may be life-threatening, particularly in 13. Pain is a part of the course of the disease for greater than half of opioid-naïve subjects or those receiving concurrent benzodiazepines. cancer patients, roughly in proportion to stage of disease. But Constipation is nearly universal and warrants pre-emptive therapy uncontrolled pain is the greatest fear of most patients and their when opioids are initiated. families. 3. COX inhibitors are also excellent analgesics. Gastrointestinal (GI) 14. Epidural or intrathecal administration of opioids, local anesthetics, and ulceration, and decreased platelet function are significant adverse other agents can give relief in the setting of intractable pain or effects of the nonselective and selective COX-1 inhibitors, but not the intolerable side effects of systemic opioids. selective COX-2 inhibitors, which are associated with an increased risk of myocardial infarction. Introduction 4. Anticonvulsants and/or antidepressants may be particularly useful in Pain is one of the first concerns most cancer patients express when newly neuropathic pain. diagnosed or meeting a new physician. They are concerned about how much pain they presently have, how much pain they are likely to 5. Glucocorticoids may relieve pain, either by decreasing swelling or by experience, and their physicians’ commitment to treating cancer pain. The an adjuvant effect. reality is that many cancer patients will never experience pain during their 6. Combination therapy with two or more classes of medications may course and for those that do, the great majority can be well-managed with decrease the doses of each required to achieve adequate pain relief. the tools described in this chapter. It is incumbent on every physician to understand the mechanisms of cancer pain and the fundamentals of 7. Radiation therapy is very effective local treatment for certain types of treating it. cancer pain, particularly bone pain, compression of nerves and Glissen’s capsule pain. Cancer pain may be somatic (e.g., a pathological fracture of a long bone with a metastasis), visceral (e.g., a locally metastatic intra-abdominal 8. Blocking neural transmission by injection of local anesthetics or tumor or neuropathic (e.g., spinal nerve root compression from a vertebral neurolytics can respectively, relieve pain temporarily or long-term metastasis). It is important to attempt to identify the mechanism of cancer (months). pain because neuropathic pain responds poorly to opioids and COX 9. Transcutaneous electrical nerve stimulators (TENS) units may be inhibitors. used as local therapy. Cancer Concepts: A Guidebook for the Non-Oncologist (21 September 2016) 1 Treatment of Cancer Pain There are four primary classes of analgesics given systemically to treat analgesic effect following a dose and requires increasing the opioid dose cancer pain: as the duration of therapy increases. Along with tolerance is the • opioids development of physical dependence, defined as the occurrence of a • COX inhibitors stereotypical withdrawal syndrome when drug administration is stopped abruptly or an antagonist is administered. It is important to differentiate • anticonvulsants tolerance and physical dependence from substance use disorder (formerly • antidepressants called addiction). While it is typical for persons with substance Different medications may be injected locally to block neural transmission dependence who use opioids to develop tolerance and physical to relieve pain, either temporarily (e.g., local anesthetics) or long-term dependence, it is actually quite uncommon that persons appropriately (e.g., absolute ethanol). prescribed opioids for pain develop new substance use disorder.1 Analgesics may be administered for systemic effect by several different A recent study, based on the newly-released DSM-5 criteria for opioid-use routes. The best route depends on the clinical situation. It is important to disorder, revealed that the lifetime risk of moderate or severe opioid-use remember that time to maximal effect varies depending on the agent and disorder among patients using opioids long-term for chronic (non-cancer) on the route of administration. Most commonly, the oral route is used. If pain was only 13%.2 There is a significant genetic component to the risk the oral route is not available (due to inability to swallow, loss of of developing opioid use disorder. Persons with impulsivity and novelty- consciousness or other reasons), or if more rapid onset is desired, seeking behavior types that may be in part genetically determined are at intramuscular injection (IM), buccal or sublingual or transanal (PA) routes higher risk. Additional risk factors include those related to family, peer, and may be used. If even more rapid onset of action is required, intravenous environmental factors. administration (IV) is used. Epidural or intrathecal administration of Several screening instruments are available to assess risk of substance opioids, local anesthetics, and other agents can give relief in the setting of use disorder. These include the Opioid Risk Tool (ORT), the Diagnosis, intractable pain or intolerable side effects of systemic opioids. Finally, Intractability, Risk and Efficacy Inventory (DIRE), the Screener and Opioid fentanyl is available as a transdermal patch for long acting use. Assessment for Patients with Pain (SOAPP), and the NIH-National Opioids Institute on Drug Abuse has a chart of Evidence-Based Screening Tools for Adults & Adolescents. One small study found that a semi-structured Opioids are used for many conditions. The opioids used in cancer pain are clinical interview combined with SOAPP were most effective at predicting full agonists at the -opioid receptor. The mechanisms of analgesia risk at baseline in a group of patients who were discontinued from opioid involve modulating the transmission of pain impulses in the spinal cord medication for drug related issues.3 and altering the perception of pain in the brain. Unlike local anesthetics that may render an area numb and insensate, opioids do not prevent the Patients have often undertreated their pain with opioids because of the perception of pain but permit the patient to feel it as less noxious. severity of the associated constipation. The new peripheral opioid antagonists, methylnaltrexone and naloxegol, are opioid receptor In addition to analgesia, opioid agonists produce other characteristic dose- antagonists that do not penetrate the central nervous system. As a result, dependent effects: they do not interfere with the analgesic properties of opioids. However, by • ventilatory depression blocking the effects of opioids on the gut, they treat or prevent opioid- • sedation induced constipation. These novel agents are useful when the traditional • miosis (pupillary constriction) daily laxative regimen is ineffective. • constipation (by decreasing GI propulsive muscle activity and The primary difference between the opioids is their kinetics of onset and increasing GI sphincter activity) duration. The most common opioids are discussed below and summarized Tolerance develops when opioids are administered
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