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MANAGING INCIDENT PAIN Dr Ong Eng Eng
MBBS(MelbUni)MRCP(UK)ClinDipPallMed(RACP)
Palliative Medicine Physician
Hospital Pulau Pinang
Johor Bahru June 2012
OVERVIEW
Incident pain as part of breakthrough pain
Challenges in managing incident pain
Strategies
Practical considerations for procedure related pain
CASE 1
Mr UHK is a 50 year old gentleman
Diagnosed with NSCLC in 2011
At time of diagnosis, had lung nodule on left hilar
region, contralateral lung metastases and
mediastinal lymphadenopathy
Also had bone metastases in pelvis and
lumbosacral spine
CASE 1
He had 3 cycles of chemotherapy
Post 3 cycles of chemotherapy, he felt that he was
getting weaker with increasing pain symptoms
CT scans revealed that stable disease in his lungs
but progressively worsening disease in his bones
He made a decision to have no more chemotherapy
and was referred to the palliative team for pain
control
CASE 1
Issues of severe pain in his back and pelvis.
Beginning to limit his mobility
Was on SR Morphine 30 mg bd at that stage and
reluctant to have his medication increased further
Had adjuvants added with some benefit and was
later referred back to the oncology team for
radiotherapy to the pelvis.
CASE 1
However, he continued to deteriorate and had
further admissions for pain
Had severe pain in the back and pelvis area that
did not improve much. Had severe pain especially
on movement and was bed bound by that stage.
He had background opioids increased further but
that resulted in increased somnolence and
constipation and he was distressed by it.
Definition
BREAKTHROUGH PAIN-1
Breakthrough pain is defined as a transient
exacerbation of pain that occurs either
spontaneously or in relation to a specific trigger
(predictable or unpredictable) despite relatively
stable & adequately controlled background pain.
9
BREAKTHROUGH CANCER PAIN (CONT)
Classification BTCP
Spontaneous
Incident
– Volitional
– Nonvolitional
– Procedural
1. Davies AN et al. Eur J Pain. 2009;13:331-338.
Davies AN et al. Eur J Pain.
2009;13:331-338.
INCIDENT PAIN
Incident pain is considered a subtype of pain
induced by innocuous stimuli which presumably
activates hyperexcitable spinal cord neurons and
therefore resembles a form of severe mechanical
allodynia
INCIDENT PAIN- HOW COMMON IS THIS?
Bone pain reported as predominant source of incident pain
Significantly associated with pain syndromes involving vertebral lesions, pelvis and long bones. Caraceni et al. 2004. Palliative medicine ,18,177-183
86% of patients in home care settings had breakthrough pain and half of them had activity associated incident pain Fine et al. 1998. J Pain and Symp Management, 16, 179-83
93% of patients in inpatient palliative care unit had breakthrough pain and out of these 53% had incident pain related to movement Swanwick et al. 2001. Pall Med, 15, 9-18
Mean number of 7 episodes per day in hospice inpatients Zepetella et al. 2000. J Pain and Symp Management, 20,87-92
INCIDENT PAIN- IMPACT
Have a mean VAS of 7/10 compared with 3/10 at
rest
83% of patients with cancer induced bone pain
have pain that is significantly worse on movement
Patients with breakthrough pain including incident
pain had more intense background pain and more
functional impairment
Portenoy et al. 1999. Pain, 81,129-34
Caraceni et al. 2004. Pall Med, 18,177-85
Challenges in
Management
CHALLENGE IN MANAGING INCIDENT PAIN
Mismatch between temporal onset of pain and
temporal onset of analgesia from opioids
Mean interval between onset and peak of pain is 3 mins
and mean duration is 30 mins
Resolution of pain in relation to duration of opioid
analgesia
Evidence of poor opioid responsiveness in some
aspects of underlying neurophysiology of incident
pain
CHALLENGE IN MANAGING INCIDENT PAIN
Freedom from pain with movement is particularly
difficult to achieve in patients with bone metastases Banning et al, 1991. Pain, 47,129-34
Continuous pain may be absent at rest but severe
pain occurs on movement or different positions Mercadante et al, 1997. Pain, 69,1-18
Pain assessment is difficult as patients maintain
their pain control by avoiding particular movements
that may trigger pain Mercadante et al, 2002.Cancer,94,832-59
CHALLENGE OF MANAGING INCIDENT PAIN
Opioid side effects more likely to
dominate than analgesia and
patients can become opioid toxic
Strategies
STRATEGIES- FOR BREAKTHROUGH PAIN
Recommendations from Association of Palliative
Medicine task force 2009
Patients with pain should be assessed for presence
of breakthrough pain (Grade D)
Differentiate between patients with uncontrolled
background pain experiencing transient exacerbations
of that similar pain cw patients with controlled
background pain experiencing episodes of breakthrough
pain
BREAKTHROUGH PAIN - DIAGNOSTIC
ALGORITHM
BREAKTHROUGH PAIN - DIAGNOSTIC
ALGORITHM
Exacerbation pain ≠ breakthrough pain
Opioid titration pain ≠ breakthrough pain
End of dose pain ≠ breakthrough pain
Patients with breakthrough pain should have this
pain specifically assessed ( Grade D)
BREAKTHROUGH PAIN – MANAGEMENT
3. The management of breakthrough pain should be
individualised (D)
• Aetiology of pain
• Pathophysiology of pain
• Clinical features of pain
• Stage of disease
• Performance status of patients
• Personal preferences of patient
BREAKTHROUGH PAIN – MANAGEMENT
4. Consideration should be given to treatment of the
underlying cause of the pain (D)
• Conventional radiotherapy
• Bisphosphonates
• Radio-isotope • Ripamonti et al. 2007, Support Care Cancer. 15,339-42, 1177-84
5. Consideration should be given to avoidance /
treatment of the precipitating factors of the pain (D)
• Provision of simple adaptations and practical support with
ADL
BREAKTHROUGH PAIN – MANAGEMENT
6. Consideration should be given to modification of
the background analgesic regimen / “around the
clock” medication (D)
MODIFICATION OF BACKGROUND ANALGESIC
REGIME
Titration of opioid analgesics Mercadante et al 2004. J Pain and Symp Management, 28, 505-10
Switching of opioid analgesics Kalso et al, 1996. Pain, 67,443-9
Enting et al, 2002. Cancer 94,3049-56
Addition of adjuvant analgesics Gannon et al, 2006. 2006. Oxford Uni Press,p83-96
Addition of other drugs to provide relief from
adverse effects of analgesia Bruera et al,1992.Pain, 50,75-7
Other strategies
BREAKTHROUGH PAIN – MANAGEMENT
7. Opioids are the “rescue medication” of choice
in the management of breakthrough pain
episodes (D)
Rescue medications- when to use it
-Type and route of medication
30
BREAKTHROUGH PAIN – MANAGEMENT
Management of BTCP
“Rescue medication” is mainstay of treatment
Oral immediate-release morphine is standard of care worldwide
PK/PD profile of oral immediate-release morphine does not fit temporal characteristics of BTCP
APM RECOMMENDATIONS
“...oral opioids are not the optimal rescue medication for
most breakthrough pain episodes”.
BREAKTHROUGH PAIN – MANAGEMENT
0 30 60 90 120 150 180 210 240 270 300
Time (min)
Duration of
breakthrough pain
Onset effect oral
morphine
Peak effect oral
morphine
Duration effect oral
morphine
BREAKTHROUGH PAIN – MANAGEMENT
Ideal rescue medication:
Good efficacy
Rapid onset of action
Short duration of effect
Good tolerability
Easy to use
Acceptable to the patient
Available / affordable
[Low risk addiction / diversion]
34
BREAKTHROUGH CANCER PAIN BTCP is “a transient exacerbation of pain that occurs
either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background (baseline) pain”1
1. Davies AN et al. Eur J Pain. 2009;13:331-338.
Ideal
Breakthrough
Medication
Typical
Breakthrough
Medication
(eg, IRMS)
Background
(around-the-clock)
Medication
Background,
Baseline Pain
Time
Pain
In
ten
sit
y
BTCP, breakthrough cancer pain. BTCP, breakthrough cancer pain. V
BREAKTHROUGH PAIN – MANAGEMENT
ORAL TRANSMUCOSAL OPIOIDS
Buccal preparations:
Actiq™ (Cephalon)
Effentora™ (Cephalon)
Farrar et al,1998.J Nat Cancer Ins 90,611-6
Portenoy et al,1999.Pain,79,303-12
ORAL TRANSMUCOSAL OPIOIDS
Sublingual preparations:
Abstral™ (Prostrakan)
Effentora™ (Cephalon)
BREAKTHROUGH PAIN - INTRANASAL OPIOIDS
Instanyl™ (Nycomed)
PecFent™ (Archimedes)
1. Watts P et al. Expert Opin Drug Deliv. 2009;6:543-552.
2. Portenoy RK et al. Pain. In press.
BREAKTHROUGH PAIN - OTHER ROUTES
ADMINISTRATION
Intrapulmonary
Subcutaneous
BREAKTHROUGH PAIN – MANAGEMENT
8. The dose of opioid “rescue medication” should be
determined by individual titration (B)
Thou shalt give 1/6th daily dose
of oral morphine for
breakthrough cancer pain
DOSE OF RESCUE MEDICATIONS
Oral transmucosal Fentanyl- no relationship between most effective dose and the effective background dose of opioid medications Christie et al. 1998.J of Clin Onc, 16,3238-45
Portenoy et al,1999. Pain, 79,303-12
Colluzi et al,2001. Pain,91,123-130
Portenoy et al,2006. Clin J Pain,22,805-11
Slatkin et al,2007. J Support Oncol,5,327-34
Data from 1 study showing that there is no relationship between most effective dose of oral morphine for breakthrough pain and the effective dose of background opioid. Colluzi et al,2001. Pain,91,123-130
TITRATION OF RESCUE MEDICATIONS
BREAKTHROUGH PAIN – MANAGEMENT
9. Non-opioid analgesics may be useful in the management of breakthrough pain episodes (D)
• Paracetamol
• Non steroidal anti-inflammatory drugs
Gomez et al,2002. J Pain and Symp Management. 24,45-52
Davies et al,2008. J Pain and Symp Management. 35,406-11
• Ketamine
Carr et al. 2004. Pain,108,17-27
• Midazolam
del Rosario et al,2001. J Pain and Symp Management. 21,439-442
• Nitrous oxide
Parlow et al,2005. Pall Med,19,3-8
BREAKTHROUGH PAIN – MANAGEMENT
10. Non-pharmacological methods may be useful in the management of breakthrough pain episodes (D)
11. Interventional techniques may be useful in the management of breakthrough pain (D)
• Neuraxial drug infusion, neural blockade, neuroablation
Christelis et al,2006. Oxford University Press, 97-110
Mercadante et al, 1995. Reg Anes,20,343-6
• Interventional radiological procedures- vertebroplasty, direct tumour ablation, balloon kyphoplasty
• Farquhar et al,2007. Oxford Uni Press,85-97
• Burton et al, 2005.J Pain and Symp Management,30,87-95
BREAKTHROUGH PAIN – MANAGEMENT
12. Patients with breakthrough pain should have this
pain specifically re-assessed (D)
Procedural
related pain
TYPES OF PROCEDURAL RELATED PAIN
Goal
Adequate pain relief without undesirable side effects
Considerations:
Anticipated pain severity
Procedure duration
Current opioid use
Patient’s past experiences
NON PHARMACOLOGICAL APPROACHES
Discuss past experience of procedure related pain
Explain procedure before starting
Stop if requested to by patients
Choose most comfortable position for the patient
Distract and relax Katz et al,1987.J Paed Psy,12(3),379-90
Zeltzer et al,1990. Paed,86(5),826-31
Pfaff et al, 1989. Child Healthcare, 18(4), 232-6
Ross DM 1984. Issues Compr Paed Nurs,7, 83-89
Jay et al,1985. Behav Res Ther,23,513-20
PHARMACOLOGICAL APPROACHES
o Local anaesthetic agents
o EMLA cream, lidocaine gel
o Nitrous oxide o Miser et al,1998.Pain,4,5-10
o Step wise analgesic ladder
ANALGESIC LADDER FOR PROCEDURE
RELATED PAIN (PCF GUIDELINES)
Step 1
Step 2
Step 3 PO Analgesia
+/- sedatives
60 mins before
procedure
SL/SC
analgesia +/-
sedatives 30
min before
procedure
IV analgesia +/-
sedative 5 min
before procedure
STEP 1
If anticipating mild to moderate pain
Administer 60 mins before procedure
PO Morphine ( the usual rescue dose for
breakthrough pain)
If necessary, combine with
PO Diazepam 5 mg
SL Lorazepam 0.5- 1 mg
An alternative sedative
ANALGESIC LADDER FOR PROCEDURE
RELATED PAIN (PCF GUIDELINES)
Step 1
Step 2
Step 3 PO Analgesia
+/- sedatives
60 mins before
procedure
SL/SC
analgesia +/-
sedatives 30
min before
procedure
IV analgesia +/-
sedative 5 min
before procedure
STEP 2
If anticipating moderate to severe pain
Administer 30 mins before procedure
SC Morphine (50% of patient’s usual PO morphine
rescue dose)
If necessary combine with
SL/SC Midazolam 2.5-5mg or
SL Lorazepam 0.5-1mg or
An alternative sedative
ANALGESIC LADDER FOR PROCEDURE
RELATED PAIN (PCF GUIDELINES)
Step 1
Step 2
Step 3 PO Analgesia
+/- sedatives
60 mins before
procedure
SL/SC
analgesia +/-
sedatives 30
min before
procedure
IV analgesia +/-
sedative 5 min
before procedure
STEP 3
If anticipating severe to excruciating pain
Administer 5 mins before procedure
IV Morphine (50% of the usual PO Morphine rescue dose) or
IV Ketamine 0.5-1 mg/ kg ( typically 25-50 mg)
Combine with
IV Midazolam 2.5-5 mg or
An alternative sedative
NB: Marked sedation and airway compromise if combined ketamine and midazolam- use if competent in airway management
ALTERNATIVE OPIOID
Alternative to SC/IV Morphine
Fentanyl Citrate (OTFC) 200 mcg or more
Alfentanil 250-500 mcg SL/ SC/IV
Fentanyl 50-100 mcg SL/SC/IV
Sufentanil 12.5-25 mcg SL/SC/IV
IF PAIN RELIEF INADEQUATE
Administer repeat dose and wait
If still inadequate, move to next step of the ladder
USING SEDATION
Practitioners must be competent in airway management
Patients should not eat or drink before procedures that involve conscious sedation
Monitoring includes assessment of heart rate, respiratory rate and effort, pulse oxymetry, blood pressure and level of consciousness
Monitoring should continue after the procedure until the patient is fully awake.
Amaerican Academy of Paeds, 1985,1992
USING SEDATION
Opioid antagonist ( Naloxone) and Benzodiazepine
antagonist should be available if required
Naloxone 20-100 mcg IV repeated every 2 mins
until respiratory rate or cyanosis improved
Thank You