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CANCER PAIN: • I Am Not Making a Ton of Money (Or Any Money, Actually) Through a Relationship with a Pharmaceutical Or Device PRINCIPLES and PRACTICE Company

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CANCER PAIN: • I Am Not Making a Ton of Money (Or Any Money, Actually) Through a Relationship with a Pharmaceutical Or Device PRINCIPLES and PRACTICE Company 11/6/2019 DISCLOSURE CANCER PAIN: • I am not making a ton of money (or any money, actually) through a relationship with a pharmaceutical or device PRINCIPLES AND PRACTICE company. Kerstin Lappen, MS, ACNS, ACHPN Allina Health, Abbott Northwestern Hospital November 6, 2019 OBJECTIVES Supportive Care in the Oncology Patient • List pharmacologic and nonpharmacologic interventions for pain management in patients with cancer. • Identify different types of pain commonly seen in cancer and appropriate Spiritual interventions. Journeying Maslow’s Hierarchy • Identify criteria for eligibility for medical cannabis for patients with cancer. Psychological Modified by Laurel Herbst, MD & Social Issues Information Physical symptoms Why is pain undertreated? The Meaning of Pain to the Patient Clinician Factors • Current climate—opioid epidemic, overdoses, diversion, fear of • Worsening disease being sued or board complaints • Fear—may have witnessed others in unrelieved, agonizing pain. • Decreasing functional status • Lack of training beyond the basics • Fear of loss of control and loss of independence • Lack of time it takes to do a full assessment • Punishment • Provider and patient discrepancy in judging the severity of the pain • Unrelieved pain can lead to hopelessness, depression and increased risk of • Fear of causing respiratory depression suicide in uncontrolled pain • Fear of causing addiction • Relief of pain often “cures” perceived behavioral disorders: • “It took 18 years and a terminal illness for me to finally get good pain control.” • Patients may not be fully honest about their pain because it might • --Melissa, a patient I cared for. impact the decision to keep treating the cancer. ©AllinaHealthSystems 1 11/6/2019 Causes of Cancer Pain Treatment Related Pain • INFLAMMATION! Release of chemicals by tumors •Arthralgias and myopathies due to chemo and (prostaglandins, endothelins, cytokines,TNF) sensitize hormone therapy peripheral nerves and cause painful inflammation •Mucositis/esophagitis from immunosuppression and • Ischemia and necrosis, tumor erodes in to tissues, vessels tissue damage from chemo, radiation • Rapid weight loss => cancer cachexia, immobilization, •Chemo-induced peripheral neuropathy (CIPN) increased muscle tension and spasms causing muscular pain •Surgical interventions that give rise to nerve damage • Cancer treatment…. and chronic post-op pain Types of Pain in Cancer: Nociceptive Pain Types of Pain in Cancer: Neuropathic Pain • Primary activation of somatic or visceral nerves by the tumor, typically • Pain caused by damage/injury to nerves directly from the tumor or impinging on adjacent tissues or obstructing blood vessels. Think—normal by enzymes made by the tumor, or by toxic effect of cancer body response to painful stimuli treatment on the nerves. Also, malignant involvement of the CNS • Somatic pain: Referring to skin, deep tissue, muscle. Pain is localized. such as leptomeningeal carcinomatosis. Patients can point to it. Often described as sharp, achy, intermittent, related to activity. • Described as burning, numbness, tingling, “pins and needles”, • Visceral Pain: Mechanical invasion or stretching of hollow organs or sharp, shooting, stabbing, “like a spear going through me”, distortion of the capsule of solid organs (i.e. liver). Pain is generalized (all electrical shock, throbbing, pulsating, “like walking on marbles”. over) or referred. Usually described as dull, aching, squeezing, cramping. Can cause a physical reaction of pallor, sweating, nausea and vomiting. Types of Pain in Cancer: Bone Pain Opioids as the Mainstay of Cancer Pain Management • Considered a subset of nociceptive somatic pain. Can also often • Morphine—gold standard. SR and IR oral forms cause neuropathic pain, particularly with spinal involvement. • Codeine—used rarely • The membrane covering the surfaces of bones (periosteum) has • Hydrocodone (only available in combination with ibuprofen or many nerve endings that are injured by malignant cells. acetaminophen—Norco//Vicodin) • Loss of mechanical strength of bone leading to pathological • Oxycodone: SR and IR. ONLY oral. $$$ fractures • Hydromorphone: SR ($$$) and IR. Short acting. Good in impaired • Usually described as continuous, achy with sharp renal function—no metabolites. exacerbations—incident pain typically with movement: “It doesn’t • Fentanyl: TD primarily. Good in impaired renal function and impaired hurt unless I move.” gut function. Not good in cachectic patients, patients requiring rapid escalation of pain meds, or opioid naive patients. • Bony mets can also cause painful muscle spasms • Methadone ©AllinaHealthSystems 2 11/6/2019 Adjuvant Analgesics Neuropathic Pain Treatment: • Anticonvulsants: Bind to the calcium channels on nociceptive neurons. • Adjuvants refer to drugs that are marketed for indications other • Gabapentinoids, compared to other AEDs, tend to not have as many drug than pain, but are potentially useful as analgesics when added to interactions or adverse effects. opioid therapy in patients with cancer and chronic pain syndromes. • Renal excretion so careful dosing in patients with renal dysfunction. • Gabapentin: • AEDs: Pregabalin, Gabapentin • Initiate at 100 mg BID-TID, increase q 2-3 day • Antidepressants: Duloxetine • Titrate upward to effective dose, usually 900-3600 mg per day • Main SE is drowsiness, fluid retention • Steroids • Has not been found to be effective in CIPN in studies • Anti-spasmodics: flexeril, baclofen, robaxin • Pregabalin: • Similar to gabapentin in action but typically better side effect profile and • In more recent years, some of these drugs have acquired quicker titration approved indications for pain. • Initial dose: 50-75 mg BID. Titrate up to max of 300 mg per day after one week • More expensive. Often have to demonstrate failure with gabapentin 1st Neuropathic Pain Treatment Neuropathic Pain Treatments: Antidepressants • Antidepressants: Although very few studies have included cancer patients, the • Tricyclics: old drugs, anticholinergic side effects make them difficult to use in utility of these drugs for treatment of cancer pain has been extrapolated from many patients data in other conditions. • Amitriptyline • Analgesic effects are related to inhibition of norepinephrine reuptake, but • Nortriptyline and Desipramine--better side effect profile than amitriptyline serotonergic and dopaminergic effects also may play a role, exerting their • Serotonin-norepinephrine reuptake inhibitors (SNRIs) effects particularly along the descending spinal pain pathways. • Duloxetine, venlafaxine have analgesic effects. Evidence of analgesic efficacy is best • Antidepressants have been predominantly used for neuropathic pain. described with duloxetine but the literature lacks trials in patients with cancer pain, and However, given the range of their potential analgesic efficacy, they could be there are no comparative trials within the SNRI class. considered for other types of cancer/chronic pain as well. • there is minimal evidence of analgesic efficacy with SSRIs • Analgesia from an antidepressant is not dependent on mood elevation and • Dopamine/Norepi reuptake inhibitor pain can be improved in non-depressed patients. • Bupropion: (contraindicated for current or past history of seizures or eating disorder, also may be excessively activating) Neuropathic Pain: Nonpharmacologic Treatment Adjuvant Therapy for Bone Pain • NSAIDS: ibuprofen, naproxen • COX-2 selective NSAIDs for pts on anticoagulation or have impaired clotting: •Radiation therapy: for spinal cord compression Celecoxib • Ketoralac: IV or po in limited prognosis •Surgical decompression: spinal cord compromise • Steroids, emergent 1st line treatment for spinal cord compression. Dexamethasone drug of choice due to less mineralcorticoid side effects (less salt and water retention, •Acupuncture edema, hypertension, hypokalemia). Has a long T1/2: 36-54 hours, allowing for daily administration. Adrenal suppression unlikely if an acute course is discontinued within 2 wks. Not good long term due to side effects: hyperglycemia, weight gain, immune suppression, bone density, muscle weakness, moon face. • Radiation therapy • Bisphosphonates--usually infused monthly to prevent or slow down bone destruction • Radionuclide therapy (eg. strontium-89)-indicated for longer prognosis (> 6 mo), multiple and scattered bone mets, commonly used in patients with prostate cancer. Targets areas of increased bone turnover: ©AllinaHealthSystems 3 11/6/2019 Chemo-induced Peripheral Neuropathy Why does it matter? • Many of the best agents for solid tumor treatment have • Development of CIPN can be dose-limiting, thus promoting neurotoxicity as dose-limiting side effects: evolution of drug resistance • Vinca alkaloids (vinblastine, vincristine, vinorelbine, and etoposide) • CIPN is a frequent cause of chemo dose reduction or • Platinum-complex agents (cisplatin, carboplatin, and oxaliplatin) termination of otherwise successful treatment • Proteosome-inhibitors (bortezomib and carfilzomib) • 20% of patients develop a neuropathic pain syndrome that • Less common: 5-FUPlatinum drugs like Taxanes (paclitaxel, docetaxel, and cabazitaxel is difficult to treat, can be chronic, and range from • Epothilones, such as ixabepilone annoying to debilitating in it’s effects. • Plant alkaloids, such as Thalidomide, lenalidomide and pomalidomide • Eribulin Mechanism of CIPN CIPN • Research has found atypical mitochondria (swollen) in the sensory • Typically dose-dependent and cumulative. axons—not
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