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CANCER PAIN MANAGEMENT

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CANCER PAIN MANAGEMENT Medtronic system Medtronic system * Pain control should encompass total pain Pain management specialists should not work in isolation ... – PowerPoint PPT presentation

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Title: CANCER PAIN MANAGEMENT


1
CANCER PAIN MANAGEMENT
2
Cancer pain management
Pain control should encompass total pain
  Pain management specialists should not work in
isolation   Education is fundamental to good pain
management
3
Education in cancer pain management
A survey of physicians actively involved in
cancer care 1/3 wait until prognosis lt6 months
before giving maximal analgesia (Von Roenn et al.
1993)   A study of 81 doctors only 5 could
convert a parenteral dose of morphine to an
equivalent of MST they were unfamiliar with
palliative use of radiation (Mortimer and
Bartlett 1997).  
4
Cancer pain has increased worldwide an ageing
population   WHO - 4 million people in the world
have cancer pain Site of primary tumour important
Pain not usually significant in early disease
1/3 with metastatic disease have significant
pain Most patients with end stage disease have
pain gt50 patients report lt70 pain relief with
analgesics
5
Breakthrough pain   Transitory exacerbation of
severe pain on a background of otherwise stable
chronic pain in a patient on regular opioids
Incidence about 63 Median number 4 severe
breakthroughs per day Median duration 30
minutes Incident pain is breakthrough pain
related to movement (Portenoy Hagen, 1990)
6
Basic pain management principles  Decrease pain
and improve quality of life Do no further
harm Allow patient and carers choices Use
resources as effectively as possible
7
Disease modification Surgery Radiation Chemothera
py Biological therapy
8
Basic pain management Oral opioid
analgesics Adjuvant analgesics WHO principles
Neuropathic pain Individual variation Opioid
switching
9
Clinical bottom line   Paracetamol remains 1st
line   Topical NSAIDs do work (NNT 3) - no GI
side effects   NSAID Ibuprofen (lt2400 mg/day)
probably 1st choice GI protection for those
at risk   COXIBs offer advantages in terms of GI
safety short prognosis
10
Adjuvant analgesics   Tricyclic antidepressants
NNT 3.0 30 patients gt50 pain relief 30
minor adverse reactions 4 have to stop
treatment SSRIs less effective (50 reduction
side effects) No difference in efficacy across
different pain conditions  
11
Adjuvant analgesics anticonvulsants NNT 2.6
in trigeminal neuralgia Evidence of efficacy in
diabetic neuropathy Evidence of efficacy in
migraine prophylaxis Relatively high risk for
minor adverse effects
12
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13
Difficult cancer pain may need specialist pain
management   The WHO guidelines fail in 10-15
patients   This may be due to - opioid
resistance intolerable drug side
effects inability to deliver drugs effectively
e.g. GI problems
14
Alternatives   local anaesthetic/steroid
somatic/sympathetic nerve blocks neurolytic
blocks spinal ITDD neuro-destructive surgical
procedures Combined approach aimed at several
different levels within the nervous system
provides optimum relief with least adverse
effects
15
Simple nerve blocks
16
Complex Nerve Blocks
17
Autonomic Nerve Blocks
18
Spinal drug delivery   Much smaller drug doses
are needed 2 patients with cancer pain When
simpler and more economic methods have
failed   Indications failure of systemic
treatment intolerable drug side effects
19
Epidural or intrathecal drug delivery
20
External internal systems
21
Choice of patient for spinal drugs   Contraindicat
ions Local or systemic infection Non-correctable
co-aggulopathy Patient refusal
  Indications Segmental pain or spasticity Not
head pain ? Neuropathic pain, ? Visceral pain,
incident and cutaneous pain
22
Investigations Cord compression ? Good CSF
flow Life expectancy External or internal
systems Life expectancy gt 3 months ?
23
Intrathecal or epidural drug delivery? Intrathecal
drugs need not pass dura Used in lower doses
(10-20 epidural dose). Large volume epidurally
- spinal cord compression Change in epidural fat
influences drug delivery. Epidural catheters
blocked by fibrosis
24
Intrathecal or epidural drug delivery?   Complicat
ions within 20 days after implant Intrathecal 25
Epidural 8 CSF leak was the main intrathecal
complication   Complications after 20 days after
implant Intrathecal 5 Epidural 55 Epidurals
frequently obstruct or dislodge
25
  • Implantable or external system?
  • Pain problem
  • Patients condition
  • Experience of the team

26
Spinal drugs infection   Infection rates vary
1 per 168 - 1 per 2446 catheter days   20
cultures from cassettes, syringes and
filters colonised without clinical   Infection
associated with prolonged catheter placement
time gt 100 min
27
Medtronic system
28
Spinal drug delivery   Pain may change as patient
approaches the end of life Small pump reservoir
may mean alternative method of analgesia needed
29
Clinical bottom line   Pain relief better with
intrathecal than epidural systems Treatment
failures more common with external epidural
catheters compared with internal IT catheters
  Treatment failures less common with
internalised IT catheters than with internalised
epidural catheters   Higher rates of system
removal with internalised epidural catheters
than with internalised IT catheters   Higher
rates of catheter complications with epidural
than with IT catheters
30
Spinal drugs   Opioids Clonidine Ketamine Octreoti
de Midazolam Neostigmine Baclofen Local
anaesthetics Ziconatide
31
Spinal drugs adverse effects   Dose escalation
- Spinal opioid rotation   Sedation or itching
with opioids Hypotension with clonidine Motor
block with local anaesthetics   Subtle
personality change with ketamine Hormonal and
immune suppression with opioids
32
Conclusions   A multi-disciplinary approach
Lessons now being applied to Non-cancer pain
gt25,000 patients have been treated world-wide
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