Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

3/13/2012

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Managing Cancer PainManaging Cancer PainBuilding an App for that…….Building an App for that…….

Melanie H. Simpson, Melanie H. Simpson, PhD, RNPhD, RN--BC, OCN, CHPNBC, OCN, CHPNThe University of Kansas HospitalThe University of Kansas HospitalPain Management Resource TeamPain Management Resource Team

ObjectivesObjectives

►►Participants will be able to:Participants will be able to: List four processes involved in the pain pathwayList four processes involved in the pain pathway State the components of a comprehensive pain State the components of a comprehensive pain

assessmentassessmentassessmentassessment Define “balanced analgesia”Define “balanced analgesia” Identify appropriate advanced techniques for Identify appropriate advanced techniques for

cancer paincancer pain

Prevalence of Cancer PainPrevalence of Cancer Pain

►► reported to reported to be 30% to 40% for patients with early be 30% to 40% for patients with early diseasedisease

►► estimates as high as 70% to 90% for patients with estimates as high as 70% to 90% for patients with advanced diseaseadvanced disease

►► in advanced, in advanced, incurable cases approximately incurable cases approximately 6464%%►► chronic pain after cure chronic pain after cure 3333%.%.

Deer et al. (2011) Comprehensive Consensus Based Guidelines on Intrathecal Drug Delivery Systems in the Treatment of Pain Caused by Cancer Pain, Delivery Systems in the Treatment of Pain Caused by Cancer Pain, Pain Physician, Pain Physician, 14:E283-E312 • ISSN 2150-1149.

Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

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Causes of Pain in Cancer PatientsCauses of Pain in Cancer Patients

►►DiseaseDisease

►►TreatmentTreatment

►►Invasive proceduresInvasive procedures

►►Unrelated to cancer Unrelated to cancer

Higginson, I. J. & Murtagh, F. (2010). Cancer pain epidemiology. In: Bruera, E. & Portenoy, R. K. (eds). Cancer Pain. Assessment and Management. Vol. 3. Cambridge: Cambridge University Press, 37–52.

Basic Anatomy, Physiology Basic Anatomy, Physiology and Types of Cancer Painand Types of Cancer Pain

3. Brain

4. Descending modulation

Pain Pathway 4 processes involved:

1. Transduction2. Transmission3. Perception of pain4. Modulation

1. Peripheral tissues

2. Spinal cord

modulation

Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

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OpioidsTCAs, SNRIsAnticonvulsants

Ascending pathway

Descending pathway

NSAIDS COX-2s

Nerve BlocksAnticonvulsants

Mechanism of Action of Selected Analgesics

Types of Pain Syndromes in Types of Pain Syndromes in Cancer PatientsCancer Patients

►►NoceiceptiveNoceiceptive►►SomaticSomatic -- well localized, tender, aching, well localized, tender, aching,

(arthritis, incisional, bone mets)(arthritis, incisional, bone mets)

►►VisceralVisceral -- poorly localized, cramping poorly localized, cramping

pressure, (bowel obstruction, liver mets, pressure, (bowel obstruction, liver mets,

pancreatic cancer)pancreatic cancer)

Types of PainTypes of Pain (con’t)(con’t)

►►NeuropathicNeuropathic►►involves nerve damage, burning, shooting, involves nerve damage, burning, shooting,

numbness, tingling, (postnumbness, tingling, (post--herpetic neuralgia, herpetic neuralgia, postpost mastectom pain s nd ome phantommastectom pain s nd ome phantompostpost--mastectomy pain syndrome, phantommastectomy pain syndrome, phantom--limb pain, chemolimb pain, chemo--induced neuropathies)induced neuropathies)

►►Temporal AspectsTemporal Aspects AcuteAcute Persistent/ChronicPersistent/Chronic

Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

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Comprehensive Assessment of PainComprehensive Assessment of Pain

►►Detailed historiesDetailed histories Pain/pain treatmentPain/pain treatment MedicalMedical PsychosocialPsychosocialPsychosocialPsychosocial

►► Physical examinationPhysical examination►►Diagnostic testsDiagnostic tests►►Observable physiologic signsObservable physiologic signs►►The most important tool:The most important tool:

Patients Self ReportPatients Self Report

Assessment of PainAssessment of Pain►►WILDAWILDA

WWords (ex. aching, ords (ex. aching,

burning…)burning…)

IIntensity (0ntensity (0--10)10) IIntensity (0ntensity (0 10)10)

LLocation (all sites)ocation (all sites)

DDuration (constant, episodic)uration (constant, episodic)

AAggravating and alleviating factors (what ggravating and alleviating factors (what makes the pain better or worse)makes the pain better or worse)

Fink, R. (2000). Pain assessment: the cornerstone to optimal pain management. BUMC Proceeding, 13: p 236-239

Pain Assessment in the ElderlyPain Assessment in the Elderly

►► Poor memory, depression and Poor memory, depression and sensory impairment may make sensory impairment may make getting pain information from getting pain information from g g pg g pthe patient difficultthe patient difficult

►►Use of standard toolsUse of standard tools

►► Pain assessment by proxyPain assessment by proxy

Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

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How does the pain affect?How does the pain affect?

►► Sleep Sleep

►►AppetiteAppetite

►► EnergyEnergy►► EnergyEnergy

►►ActivityActivity

►►RelationshipsRelationships

►►MoodMood

Experiencing other symptoms?Experiencing other symptoms?

►►Nausea/vomitingNausea/vomiting

►►ConstipationConstipation

►►Sleepiness Sleepiness

/confusion/confusion►►ConstipationConstipation

►►ItchingItching►►Urinary retentionUrinary retention

►►WeaknessWeakness

Related to the pain or the medications?Related to the pain or the medications?

Reassessment of PainReassessment of Pain

►►RoutinelyRoutinely q 2h, q 4h, q 8h (acute)q 2h, q 4h, q 8h (acute) Weekly, monthly (chronic)Weekly, monthly (chronic)

►►After pharmacologic After pharmacologic p gp ginterventionintervention 30 min after IV30 min after IV 60 min after PO60 min after PO 24h after Transdermal24h after Transdermal

Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

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It is impossible to treat It is impossible to treat pain appropriately if it is pain appropriately if it is

not assessed appropriately!not assessed appropriately!

Treatment of Cancer PainTreatment of Cancer PainRequired ToolsRequired Tools

PharmacologicNonpharmacologic

Should always be both

Pharmacologic Approaches to Pharmacologic Approaches to Cancer Cancer Pain ManagementPain Management

►►NonNon--opioidsopioids►►Adjuvants/Adjuvants/CoanalgesicsCoanalgesics►►OpioidsOpioids

►► Provides better Provides better pain reliefpain relief

►► Fewer side effectsFewer side effects

“Balanced Analgesia”

►►OpioidsOpioids►►Advanced TechniquesAdvanced Techniques PatientPatient--controlled analgesiacontrolled analgesia Regional analgesiaRegional analgesia Invasive methodsInvasive methods

►► Fewer side effectsFewer side effects►►OpioidOpioid--sparingsparing

Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

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NonNon--opioidsopioids

►►AcetaminophenAcetaminophen

►►AspirinAspirin

►►NSAIDs/CoxNSAIDs/Cox--22

“Unless contraindicated, any analgesic regimen should include a nonopioid drug, even if pain is severe enough to require the addition of an opioid”

Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 5th ed., American Pain Society, 2003.

First-line for mild to moderate pain

Adjuvant MedicationsAdjuvant Medications

►►Do not directly provide analgesiaDo not directly provide analgesia►►Used more extensively in chronic pain than Used more extensively in chronic pain than

acute painacute pain►►Help with sufferingHelp with suffering►►Help with sufferingHelp with suffering

Selected Adjuvant MedicationsSelected Adjuvant Medications

►►AntidepressantsAntidepressants -- Ex: TCA (Elavil, Ex: TCA (Elavil, Pamelor, Sinequan), SSRI (Paxil, Zoloft, Pamelor, Sinequan), SSRI (Paxil, Zoloft, Celexa, Lexapro), *SSNRI (Cymbalta, Celexa, Lexapro), *SSNRI (Cymbalta, Effexor Savella)Effexor Savella)Effexor, Savella) Effexor, Savella)

►►AnticonvulsantsAnticonvulsants -- Ex: Neurontin, Ex: Neurontin, Tegretol, Depakote, Klonopin, Dilantin, Tegretol, Depakote, Klonopin, Dilantin, Gabatril, Topamax, Lamictal, Trileptal, Gabatril, Topamax, Lamictal, Trileptal, Zonegran, LyricaZonegran, Lyrica

Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

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Selected Adjuvant MedicationsSelected Adjuvant Medications

►►BenzodiazepinesBenzodiazepines –– Ex: Valium, Ativan, Xanax, Ex: Valium, Ativan, Xanax, Halcion, Restoril, Klonopin, VersedHalcion, Restoril, Klonopin, Versed

►►Muscle relaxantsMuscle relaxants –– Ex: Valium, Robaxin, Ex: Valium, Robaxin, Fl il S N fl *Z fl *B l fFl il S N fl *Z fl *B l fFlexeril, Soma, Norflex, *Zanaflex, *BaclofenFlexeril, Soma, Norflex, *Zanaflex, *Baclofen

►►Misc. AgentsMisc. Agents –– Ex: Lidoderm 5% patch, Ex: Lidoderm 5% patch, Capsaicin, Emu oilCapsaicin, Emu oil

Combination OpioidsCombination Opioids

►►Used for mild to moderate painUsed for mild to moderate pain

►►Usually given in combination with nonUsually given in combination with non--opioidsopioids

►►Doses are limited due to nonDoses are limited due to non--opioid componentopioid component

►►Commonly used as rescue/ Commonly used as rescue/

breakthroughbreakthrough

Combination OpioidsCombination Opioids

►►Codeine (Tylenol #3, Codeine (Tylenol #3, FioricetFioricet))

►►Hydrocodone (Hydrocodone (LortabLortab, , VicodinVicodin))

►►Oxycodone (Percocet, Percodan)Oxycodone (Percocet, Percodan)

►►Tramadol Tramadol (Ultram, (Ultram, UltracetUltracet))

Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

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SingleSingle--Agent OpioidsAgent Opioids

►►Used for moderate to severe painUsed for moderate to severe pain

►►No maximum doseNo maximum dose

►►Can be given by many different routesCan be given by many different routes►►Can be given by many different routesCan be given by many different routes

►►LongLong--acting forms available for chronic acting forms available for chronic cancer paincancer pain

SingleSingle--Agent OpioidsAgent Opioids

►►MorphineMorphine►►HydromorphoneHydromorphone►►MethadoneMethadone►►MethadoneMethadone►►OxycodoneOxycodone►►FentanylFentanyl►►OxymorphoneOxymorphone►►TapentadolTapentadol

Benefits of LongBenefits of Long--Acting OpioidsActing Opioidsin Chronic/Persistent Painin Chronic/Persistent Pain

►►Avoids peaks and valleysAvoids peaks and valleys

►► Improves functionalityImproves functionality

►► Patients use less medicationPatients use less medication

►► Patient satisfaction/compliancePatient satisfaction/compliance

►► Easier medication surveillanceEasier medication surveillance

Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

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IV Pain medicinesIV Pain medicines

►►DripDrip►►PCAPCA►►IV BolusIV Bolus►►MedicationsMedications FentanylFentanyl HydromorphoneHydromorphone MorphineMorphine MethadoneMethadone

IV PCA AdvantagesIV PCA Advantages

►► Improved patient satisfaction Improved patient satisfaction

►► Improved pain reliefImproved pain relief

►► Less sedationLess sedation

►► Less opioid consumptionLess opioid consumption

►►PCA pump allows for PCA pump allows for monitoring pain controlmonitoring pain control

IV analgesic

IV analgesic IV analgesic

Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

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Epidural AnalgesiaEpidural Analgesia

►►Temporary is usually 2Temporary is usually 2--4 days, but tunneled can 4 days, but tunneled can go up to 6 monthsgo up to 6 months

►►DeliveryDeliveryBol sBol s (M hi )(M hi ) Bolus Bolus (Morphine)(Morphine)

Continuous infusion Continuous infusion (Fentanyl)(Fentanyl)

PatientPatient--controlled analgesia controlled analgesia (PCEA)(PCEA)

►►Opioids and local anesthetics Opioids and local anesthetics

((bupivucainebupivucaine, , ropivicaineropivicaine))

Regional Analgesia Regional Analgesia –– Patient CriteriaPatient Criteria

►►Localized painLocalized pain►►Chronic Opioid TherapyChronic Opioid Therapy►►Other Medical Problems Other Medical Problems –– CHF, COPD, etcCHF, COPD, etc

Nerve BlocksNerve Blocks

►► Many insertion sites for blocks depends Many insertion sites for blocks depends on area of intereston area of interest

►► Paravertebral Block: Paravertebral Block: Th t iTh t i th ith i l bil bi Thoracotomies, Thoracotomies, thoracoscopiesthoracoscopies, lung biopsy, lung biopsy

►► Femoral Block: Femoral Block: Total Knee Total Knee ArthroplastyArthroplasty, Lower Extremity , Lower Extremity

amputation, ACL repair, Postamputation, ACL repair, Post--op knee op knee surgeriessurgeries

Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

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Nerve BlocksNerve Blocks

►►Axillary Brachial Plexus Block: Axillary Brachial Plexus Block: Hand and elbow surgery, forearm Hand and elbow surgery, forearm fxfx

manipulationmanipulation►►Celiac Plexus Block: Celiac Plexus Block: Pancreatic cancerPancreatic cancer

►►Popliteal Block: Popliteal Block: Foot and ankle surgeries, foot amputationFoot and ankle surgeries, foot amputation

►►PerirostaticPerirostatic Block: Block: Prostate surgery, prostate biopsyProstate surgery, prostate biopsy

Peripheral Nerve Catheter PNCPeripheral Nerve Catheter PNC►► Provides continuous infusion of a Provides continuous infusion of a

local anesthetic at the surgical site. local anesthetic at the surgical site. ►► Similar devices can also be used as Similar devices can also be used as

a nerve blocka nerve block►► Soaks the site with local anestheticSoaks the site with local anesthetic►► Soaks the site with local anesthetic Soaks the site with local anesthetic

and works continuously for two to and works continuously for two to five daysfive days

►► Portable and requires little Portable and requires little management by caregiver or management by caregiver or patientpatient

►► Can be sent home with patient Can be sent home with patient upon dischargeupon discharge

Implantable Implantable IntrathecalIntrathecal PumpsPumps

►► Side effects such as nausea, vomiting, Side effects such as nausea, vomiting, constipation, and sedation are reducedconstipation, and sedation are reduced

►► Places medication directly into the cerebrospinal Places medication directly into the cerebrospinal fluidfluid

►►Much lower doses of medication is used compared Much lower doses of medication is used compared to oral medication (1/300 OME) to oral medication (1/300 OME)

►► For chronic pain, after more For chronic pain, after more conservative therapies have failedconservative therapies have failed

Managing Cancer Pain - Melanie Simpson, PhD, RN-BC, OCN, CHPN

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NeurostimulatorNeurostimulator►►Delivers low voltage electricity stimulation to the Delivers low voltage electricity stimulation to the

spinal cord or targeted peripheral nerve to block spinal cord or targeted peripheral nerve to block the sensation of painthe sensation of pain

►► Implanted in the epidural space, stimulates the Implanted in the epidural space, stimulates the painpain--inhibiting nerve fibers (Gate Control Theory), inhibiting nerve fibers (Gate Control Theory), pp g ( y),g ( y),masking the sensation of pain with a tingling masking the sensation of pain with a tingling sensation (sensation (paresthesiaparesthesia))

►► For chronic pain, after more For chronic pain, after more conservative therapies have failedconservative therapies have failed

NonNon--Pharmacologic TherapiesPharmacologic Therapies

►►AlternativeAlternative

►►ComplementaryComplementary

►►IntegrativeIntegrative

Nonpharmacologic TherapiesNonpharmacologic Therapies

Empowers patientsEmpowers patientsTakes focus away from medicationsTakes focus away from medicationsProvides relaxation and relief from painProvides relaxation and relief from painDiminishes emotional component of painDiminishes emotional component of painDecreases anxietyDecreases anxietyDecreases fatigueDecreases fatigueImprove quality of lifeImprove quality of life

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Selected ComplementarySelected ComplementaryMethods of Pain ManagementMethods of Pain Management

►► Exercises/positioning/PT, OTExercises/positioning/PT, OT►► Heat and ColdHeat and Cold►► TENSTENS►► UltrasoundUltrasound

►► Psychological methodsPsychological methods PsychotherapyPsychotherapy

►► MassageMassage►► Diet/Nutrition/HerbalsDiet/Nutrition/Herbals►► Acupuncture/AcupressureAcupuncture/Acupressure►► Music TherapyMusic Therapy►► Therapeutic TouchTherapeutic Touch►► ReflexologyReflexology►► AromatherapyAromatherapy

ImageryImagery

Relaxation/meditationRelaxation/meditation

HypnosisHypnosis

BiofeedbackBiofeedback

DistractionDistraction

HumorHumor

Cancer Pain Care SettingsCancer Pain Care Settings

Pain Pain InpatientInpatient

Primary CarePrimary Care

OncologistsOncologists

Hospice/Home Hospice/Home CareCare

ClinicsClinics

HomeHome

Ambulatory CareAmbulatory Care

CommunicationCommunication

►►PatientPatient►►Nurse Nurse ►►PhysicianPhysician►►Social workerSocial worker►►PharmacistPharmacist►►TherapistsTherapists►►FamilyFamily

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DocumentationDocumentation

►►Consent to treat with opioidsConsent to treat with opioids►►Controlled Substance AgreementsControlled Substance Agreements►► PrescriptionsPrescriptions►►One pharmacyOne pharmacy►►One pharmacyOne pharmacy►► Physical exam and diagnostic findingsPhysical exam and diagnostic findings►► FunctionalityFunctionality

Make use of all the tools in your Make use of all the tools in your toolbox when building an App for toolbox when building an App for

treating cancer paintreating cancer pain

Helpful Web SitesHelpful Web Sites►► http://www.painhttp://www.pain--topics.org/topics.org/►► http://www.aspmn.org/http://www.aspmn.org/►► http://www.ampainsoc.org/http://www.ampainsoc.org/►► http://cis.nci.nih.gov/http://cis.nci.nih.gov/►► http://www.cancer.org/docroot/home/index.asphttp://www.cancer.org/docroot/home/index.asp►► http://www.pain.com/http://www.pain.com/►► http://www.postoppain.org/frameset.htmhttp://www.postoppain.org/frameset.htm►► http://aspi.wisc.edu/http://aspi.wisc.edu/►► http://www.stoppain.org/for_professionals/compehttp://www.stoppain.org/for_professionals/compe

ndium/ndium/

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BibliographyBibliography►► American Pain Society (2008). Principles of AnalgesicAmerican Pain Society (2008). Principles of Analgesic Use in the Use in the

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►► Deer, T.R., SmithDeer, T.R., Smith, , H. S., BurtonH. S., Burton, , A.W., PopeA.W., Pope, , J. E., J. E., DoleysDoleys, , D. M., LevyD. M., Levy, , R. M. R. M. StaatsStaats, , P. S., WallaceP. S., Wallace, , M., WebsterM., Webster, , L. R., L. R., RauckRauck, , R., R., and and CousinsCousins, , M. (2011). Comprehensive M. (2011). Comprehensive Consensus Based Consensus Based Guidelines on Guidelines on IntrathecalIntrathecalDrugDrug Delivery Systems inDelivery Systems in the Treatmentthe Treatment of Pain Caused by Cancerof Pain Caused by Cancer PainPainDrug Drug Delivery Systems in Delivery Systems in the Treatment the Treatment of Pain Caused by Cancer of Pain Caused by Cancer Pain, Pain, Pain Physician, Pain Physician, 14:E28314:E283--E312 E312 • ISSN • ISSN 21502150--1149.1149.

►► Fink, R. (2000). Pain assessment: the cornerstone to optimal pain Fink, R. (2000). Pain assessment: the cornerstone to optimal pain management. management. BUMC Proceeding, BUMC Proceeding, 13: p 23613: p 236--239239

►► Higginson, I. J. & Higginson, I. J. & MurtaghMurtagh, , F. F. (2010). Cancer (2010). Cancer pain epidemiology. In: pain epidemiology. In: BrueraBruera, E. & , E. & PortenoyPortenoy, R. K. (, R. K. (edseds). Cancer Pain. Assessment and ). Cancer Pain. Assessment and Management. Vol. 3. CambridgeManagement. Vol. 3. Cambridge: Cambridge : Cambridge University University Press, 37Press, 37––5252..

►► JacoxJacox A, Carr, DB, Payne R, et al. (1994). Management of Cancer Pain. A, Carr, DB, Payne R, et al. (1994). Management of Cancer Pain. Clinical Practice Guideline No. 9 AHCPR Publication No. 94Clinical Practice Guideline No. 9 AHCPR Publication No. 94--0592. 0592. Rockville, MD. Agency for Health Care Policy and Research, U.S. Rockville, MD. Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service.Department of Health and Human Services, Public Health Service.

BibliographyBibliography►► McNicolMcNicol, E., , E., StrasselsStrassels, S., , S., GoudsGouds, L., Lau, J., and Carr, D. (2009). , L., Lau, J., and Carr, D. (2009).

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►► National Comprehensive Cancer Network. (NCCN) (2011). Clinical National Comprehensive Cancer Network. (NCCN) (2011). Clinical Practice Guideline in Oncology. Adult Cancer Pain Version 2.2011. Practice Guideline in Oncology. Adult Cancer Pain Version 2.2011. NCCN.orgNCCN.org

►► Ripamonti, C. I. & Bandieri, E. (2009). Cancer pain. Critical Review Ripamonti, C. I. & Bandieri, E. (2009). Cancer pain. Critical Review Oncology Hematology; 70:Oncology Hematology; 70:145145––149.149.

►► Ripamonti, C. I., Bandieri, E., & Roila, F. Ripamonti, C. I., Bandieri, E., & Roila, F. ESMO ESMO Guidelines Working Guidelines Working Group (2011). Group (2011). Management of cancer pain: ESMO Clinical Management of cancer pain: ESMO Clinical Practice Practice Guidelines. Guidelines. Annals Annals of of OncologyOncology, 22 , 22 (Supplement 6): (Supplement 6): vi69vi69––vi77.vi77.