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Pain Management

Pain in management in cancer patients

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Pain Management

  1. 1. Pain Management in Cancer Patients By Dr.Ayush Garg
  2. 2. Types Nociceptive : pain signals from nerve endings Neuropathic : damage to nerve fibres.
  3. 3. •What Pain Rating Scales Do We Know??
  4. 4. Descripatientive pain rating scales
  5. 5. Numeric pain rating scale
  6. 6. Wong-Baker faces pain rating scale
  7. 7. Verbal Pain Scale
  8. 8. Cancer Pain Nociceptive Somatic: intermittent to constant sharp, knife-like, localized e.g. soft tissue infiltration
  9. 9. Cancer Pain Nociceptive Visceral: constant/intermittent crampy/squeezing poorly localized, referred e.g. intra-abdominal mets
  10. 10. Cancer Pain Nociceptive Bony: constant, dull ache localized, may have neuropathic features e.g. vertebral metastasis pathologic fractures
  11. 11. Cancer Pain Neuropathic Destruction/infiltration of nerves a) dysesthetic: burning/tingling constant, radiates e.g. post-herpetic neuralgia
  12. 12. Cancer Pain Neuropathic Destruction/infiltration of nerves b) neuralgic: shooting/stabbing shock-like/lancinating paroxysmal e.g. trigeminal neuralgia
  13. 13. Neuropathc pain  Chemotherapy induced Neuropathies • Cisplatin,Oxaliplatin • Paclitaxel,Thalidomide • Vincristine,Vinblastine  Surgical Neuropathies • Phantom Limb pain • Post mastectomy syndrome • Post thoracotomy syndrome
  14. 14. Cancer Pain Breakthrough “Incidental” pain Severe transitory increase in pain on baseline of moderate intensity or less Caused by movement, positioning, cough, wound dressing, etc Often associated with bony metastasis
  15. 15. Adapted WHO pain ladder.
  16. 16. Opioid receptors Classically, opioids active on CNS receptors mu (µ) kappa (κ) delta (δ) receptors Now found on: Peripheral Neurons Immune Cells Inflammed Tissue Respiratory Tissue GI Tract
  17. 17. Opioid Side Effects Common Uncommon Constipation Bad Dreams / Hallucinations Dry Mouth Dysphoria / Delirium Nausea / Vomiting Myoclonus / Seizures Sedation Pruritus / Urticaria Sweats Respiratory Depression Urinary Retention
  18. 18. Opioid-Induced Neurotoxicity (OIN)  Neuropsychiatric syndrome • Cognitive dysfunction • Delirium • Hallucinations • Myoclonus/seizures • Hyperalgesia/allodynia
  19. 19. Pain Management Nociceptive Soft Tissue Visceral Agent Opioids Opioids Steroids Surgery Radiation Treatment
  20. 20. Bone Pain Pharmacologic treatment • Opioids • NSAIDs/steroids/Cox-2 inhibitors • Bisphosphonates  Pamidronate  Clodronate  Zoledronate
  21. 21. Bone Pain Radiation treatment 1. Single treatment (800 cGy) 2. Multiple fraction (200 cGy x 3-5) 3. Effective immediately 4. Maximal effect 4 - 6 weeks 5. 60-80% patients get relief
  22. 22. Bone Pain Surgical opatientions 1. Pathologic # (splint, cast, ORIF) 2. Intramedullary support 3. Spinal cord decompression 4. Vertebral reconstruction
  23. 23. Adjuvants NSAIDs Anti-inflammatory, anti-PEG S/E: gastritis/ulcer, renal failure ↑ K+ , platelet dysfunction Ibuprofen, naproxen Don’t use both steroids & NSAIDs!
  24. 24. Adjuvants Cox-2 Inhibitors Celecoxib Rofecoxib Meloxicam Valdecoxib Anti-inflammatory Anti-prostaglandin S/E: less gastritis no platelet dysf’n renal failure still a problem OD dosing expensive
  25. 25. Adjuvants Steroids ↓ inflammation ↓ edema ↓ spontaneous nerve depolarization Multipurpose
  26. 26. Adjuvants Anticonvulsants Gabapentin Lamotrigine Carbamazepine Valproic acid
  27. 27. Adjuvants Antidepressants Amitriptyline Nortriptyline Desipramine SSRIs: results disappointing
  28. 28. Adjuvants NMDA Receptor Antagonists (N-methyl-D-aspartate) Ketamine Dextromethorphan Methadone
  29. 29. Neuropathic Pain Non-pharmacologic  Radiation treatment  Anaesthetic treatment • Nerve Block • Epidural Block
  30. 30. Neuropathic Pain Pharmacologic treatment • Opioids • Steroids • Anticonvulsants • TCAs (dysesthetic) • NMDA receptor antagonists • Anaesthetics
  31. 31. Step 4
  32. 32. Interventions
  33. 33. Alternative Therapies Acupuncture Cognitive/behavioral therapy Meditation/relaxation Guided imagery Herbal preparations Magnets Therapeutic massage
  34. 34. Key Points • Current, accurate information • Use available resources • Involve family & caregivers • Know patient knowledge base • Address patient priorities first • Small doses of useful info (e.g., S/E) • Individualize to patient (social, education level)
  35. 35. Conclusion  Cancer pain can be from the cancer itself, or from cancer-related treatments  Can be somatic, visceral, or neuropathic  Negative effects of cancer-related pain can effect QOL, mortality  Ask the patient about pain and REASSESS!
  36. 36.  Choose non-opioid / adjuvants carefully paying close attention to side effect profile  Use WHO ladder guidelines when titrating pain medications  Use long-acting opioids for chronic cancer pain  Recognize “4th step” in WHO ladder and utilize your multidisciplinary resources
  37. 37. Can we offer this ?

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