Pain Management For The Terminally Ill Patient

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Pain Management For TheTerminally Ill Patient

• Raymond Gaeta, M.D.Associate Professor of
  Anesthesiology
• Pain Management Service
• Stanford University Medical CenterMay 6, 2006

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Outline of Todays Talk

• Spectrum of Terminal Illness
• General Treatment Considerations
• Medical Management
• Neural Blockade
• Implantable Therapies

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Spectrum of Terminal Illness

• Malignancy
• Acquired Immune Deficiency
• Congestive Heart Failure
• Chronic Obstructive Pulmonary Disease
• Severe Malabsorption Syndromes
• Intractable Angina

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Advanced Directives

• Makes patients wishes known
• Provides for empowered decision makers
• Avoids initiation of unwanted therapy
• Allows for withdrawal of support

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Withdrawal of Support

• By-laws definition of futile care
• Ethics committees
• Family education
• Consensus building
• Appropriate Sedation and Analgesia

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Types of Pain

• Nociceptive tissue injury
• Generally opioid responsive
• Inflammatory - prostaglandin mediated
• Steroids and NSAIDS
• Neuropathic - nervous system injury
• Anticonvulsants, antiarrythmics, antidepressants
• Less opioid responsive

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Cancer Pain

• Pain due to tumor
• Direct invasion or compression
• Metastasis
• Pain due to tumor treatment
• Post surgical
• Post chemotherapy or radiotherapy
• Pain due to pre-existing conditions
• Low back pain or headache

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Cancer Pain

• Acute treatment phase
• Curative intent
• Prolonged remission
• Risk / benefit issues
• Palliative care
• Relief of pain and suffering
• Quality end of life
• Altered risk / benefit ratio

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Traditional Approach
Pain Management
Cancer Specific Treatments
Symptom Management
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New Paradigm
Cancer Specific Treatments
Pain and Symptom Management
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WHO Step Ladder Approach
Parenteral Administration Strong
Opioids Weak Opioids NSAIDs, Adjuvants
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Pain Medication

• Steroids and NSAIDs
• Antidepressants
• Anticonvulsants
• Antiarrhythmics
• Local Anesthetics
• Opioids

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Opioids - Routes of Administration

• Oral
• Sublingual
• Inhaled
• Transdermal
• Rectal

• IM
• IV
• SQ
• Epidural
• Subarachnoid

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Opioids Why use them?

• Effective in treating nociceptive pain
• Mechanism of action at spinal cord, brain, and
  periphery
• Useful in treating rest pain and incident pain
• Multiple delivery systems
• Tolerance to most side-effects occurs
• Variable efficacy with neuropathic pain

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Weak Opioids

• Propoxyphene
• Codeine
• Hydrocodone
• Tramadol

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Potent Opioids

• Long Acting
• Morphine SR
• Methadone
• Fentanyl patch
• Levorphanol
• Oxycodone SR

• Short Acting
• Morphine soluble tabs
• Morphine elixir
• Fentanyl oralet
• Hydromorphone
• Oxycodone

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Continuous narcotic infusion with
patient-controlled analgesia for chronic cancer
pain in outpatients.

• 18 patients - poorly controlled pain or side
  effects
• Education about use of ambulatory pump
• Improved pain relief in all patients - 7 to 225
  days
• Acceptable side effects and safety profile
• Maximum doses (in mg/hr)
• morphine 80 hydromorphone 60 meperidine
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Kerr IG, etal. Ann Intern Med 1988
Apr108(4)554-7
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Treating Persistent PainTheory
Over Medication
Therapeutic Window
Around-the-Clock(ATC) Medication
Pain ReliefThreshold
Persistent Pain
Time
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Breakthrough Pain

• Rapid onset and offset
• Occurs sporadically through the day
• Normal event up to 3 - 4 times per day
• Does not reflect poor management when it occurs

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Treating Acute Pain Ideal
Over Medication
Ideal Breakthrough Medication
Around-the-Clock Medication
Persistent Pain
Time
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What is Patient Controlled Analgesia?
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Patient Controlled Analgesia

• Pain relief
• Locus of control
• Lower total dose
• Fewer side effects
• Patient satisfaction

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Patient Controlled Analgesia - Parameters

• Choice of medication
• Bolus dosage and frequency
• Continuous infusion rate
• Lockout time and total dosage

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Oral patient-controlled analgesia

• Patient education
• Appropriate short and long duration meds
• Safe and effective

Coluzzi PH. Semin Oncol 1997 Oct24(5 Suppl
16)S16-35-42
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Conversion to Oral Therapywith same medication

• Obtain 24 hour total iv medication use
• Convert to oral dosing utilizing bioavailability
  chart
• Give approximately 75 as long acting agent
• Give remainder as short acting prn
• NB reduce dose in elderly or higher acuity
  patients

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Conversion to Oral Therapy

• MSO4 60 mg iv per 24 hours
• Oral bioavailability 20-30 180 300 mg
• 25 bioavailability gives a dose of 240 mg
• 75 long acting agent is 180 mg per day
• TID dosing is 60 mg TID
• Prescribe SR MSO4 60 mg
• Prescribe IR MSO4 20mg q3-4h prn
• NB reduce dose in elderly or higher acuity
  patients

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Conversion to Oral TherapyDifferent Opioid

• Must deal with issues of equianalgesic dosing
• MSO4 5 mg
• Methadone 5mg
• Fentanyl 50 mcg
• Dilaudid 1mg
• Oxycodone 12.5mg
• Must deal with incomplete cross tolerance
• With chronic use may see extreme conversion
  ratios
• Acute MSO4 to Methadone 21
• Chronic MSO4 to Methadone 81 or higher!

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Neurolytic Blocks Chest Wall

• Intrathecal alcohol at level of rootlets
• Phenol ablation of intercostal nerves
• Radiofrequency lesioning of intercostal nerves

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Neurolytic Intrathecal Injection
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Neurolytic Spinal Nerve Injection
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Neurolytic Blocks Abdomen/Pelvis

• Celiac Plexus
• Superior Hypogastric Plexus
• Ganglion of Impar
• Intrathecal Saddle Block

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THE SPLANCHNIC NERVES
Innervates distal esophogus to mid transeverse
colon Liver Pancreas Kidneys Adrenals Ureters Blo
od vessels
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NEEDLE PLACEMENT FOR CLASSIC CELIAC PLEXUS
BLOCK

• Spinal injection
• Nerve Injury
• IV injection
• Hemorrhage
• Visceral injury
• Infection
• Hypotension

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Effect of Neurolytic Celiac Plexus Block on Pain
Relief, Quality of Life, and Survival in Patients
with Unresectable Pancreatic Cancer A
Randomized Controlled Trial
Wong, GY, etal. Jama Vol 291 No. 9 March 3, 2004
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TECHNIQUE OF SUPERIOR HYPOGASTRIC PLEXUS BLOCK
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Neurolytic Saddle Block

• Subarachnoid puncture at L5-S1
• Deliberate slow injection of agent
• Sequential sensory checks at L5 and S1
• Stop injection at first signs of L5 changes

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GANGLION OF WALTHER (IMPAR) BLOCK
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Intrathecal Pumps

• Delivery of extremely potent and selective
  analgesics directly to site of action - the
  spinal cord
• Avoids side effects related to higher CNS
  centers, and may provide profound pain relief

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Pain processing
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Equianalgesic Opioid Conversion
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Spinal Medications

• Opioids
• morphine, hydromorphone
• Local Anesthetics
• bupivacaine
• Alpha Adrenergic
• clonidine
• Gaba agonist
• baclofen
• Calcium channel antagonist
• ziconotide (SNX-111)

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Randomized Clinical Trial of an Implantable Drug
Delivery System Compared With Comprehensive
Medical Management for Refractory Cancer Pain
Impact on Pain, Drug-Related Toxicity, and
Survival
Smith TJ, etal Implantable Drug Delivery Systems
Study Group
Journal of Clinical Oncology, Vol 20, Issue 19
(October), 2002 4040-4049
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Comfort Measures
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Psychosocial Support

• Communication about goals
• Patient
• Family
• Nursing
• Physicians
• Social Work
• Chaplaincy Service

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Cancer Pain Management - Summary

• It is better to prevent than treat
• Individualize treatment and route
• Reassess pain and side effects on regular basis
• Manage other non-pain symptoms
• Pain management should be integrated into initial
  care plan of the patient

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Step Ladder Approach
Spinal Medications Neurolytic Blockade Strong
Opioids Weak Opioids, NSAIDs, Adjuvants