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.

BREAKTHROUGH CANCER PAIN (CONT)

Classification BTCP

Spontaneous Incident

Volitional
Nonvolitional Procedural
Davies AN et al. Eur J Pain. 2009;13:331-338.
1. Davies AN et al. Eur J Pain. 2009;13:331-338.
9

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

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

30

APM RECOMMENDATIONS
...oral opioids are not the optimal rescue medication for most breakthrough pain episodes.

BREAKTHROUGH PAIN MANAGEMENT

Duration effect oral morphine

Peak effect oral morphine

Onset effect oral morphine

Duration of breakthrough pain 0 30 60 90 120 150 180 210 240 270 300

Time (min)

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]

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) pain1
Background (around-the-clock) Medication Typical Breakthrough Medication (eg, IRMS)

Pain Intensity

Ideal Breakthrough Medication

Background, Baseline Pain

Time

BTCP, breakthrough cancer VBTCP, breakthrough cancer pain. pain.

1. Davies AN et al. Eur J Pain. 2009;13:331-338.
34

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 management of breakthrough pain episodes (D)

the

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) Interventional techniques may be useful in the management of breakthrough pain (D)

11.

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 Patients 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

Nitrous oxide
o

Miser et al,1998.Pain,4,5-10

Step wise analgesic ladder

ANALGESIC LADDER FOR PROCEDURE RELATED PAIN (PCF GUIDELINES)

SL/SC analgesia +/sedatives 30 min before procedure IV analgesia +/sedative 5 min before procedure

PO Analgesia +/- sedatives 60 mins before procedure

Step 3

Step 2

Step 1

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)

SL/SC analgesia +/sedatives 30 min before procedure IV analgesia +/sedative 5 min before procedure

PO Analgesia +/- sedatives 60 mins before procedure

Step 3

Step 2

Step 1

STEP 2

If anticipating moderate to severe pain Administer 30 mins before procedure

SC Morphine (50% of patients 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)

SL/SC analgesia +/sedatives 30 min before procedure IV analgesia +/sedative 5 min before procedure

PO Analgesia +/- sedatives 60 mins before procedure

Step 3

Step 2

Step 1

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