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Pain and Symptom Management in Pancreatic CancerPresented byPancreatic Cancer Action Networkwww.pancan.orgMarch 5, 2014If you experience technical difficulty during the presentation: Contact WebEx Technical Support directly at: US Toll Free: 1-866-229-3239Toll Only: 1-408-435 -7088orSubmit a question to the Event Producer via the Q&A PanelFor international support numbers rs.htPain and Symptom Managementin Pancreatic CancerAndrew Tyler Putnam, MDPalliative Care ProgramSmilow Cancer Hospital at Yale New HavenMarch 5, 20141

ObjectivesDiscuss Common Symptoms and ConcernsDiscuss Supportive Care ApproachesSome Barriers to Symptom ReliefPalliative Care2

Palliative CarePalliative care is specialized medical care for people withserious illnesses. This type of care is focused on providingpatients with relief from the symptoms, pain, and stress ofa serious illness, whatever the diagnosis.The goal is to improve quality of life for both the patientand the family. Palliative care is provided by a team ofdoctors, nurses, and other specialists who work with apatient's other doctors to provide an extra layer of support.Palliative care is appropriate at any age and at any stagein a serious illness, and can be provided together withcurative treatment.Center to Advance Palliative Care 2011The Continuum of Palliative CareDISEASEDISTRESSDISCOMFORTDYSFUNCTIONDisease Specific RxComfort, Supportive RxBereavementSupport(Palliative Care)(Palliative Care)PersonFamilyCaregivers and Service providersILLNESS TRAJECTORYSYMPTOMSDXDYINGDEATHBEREAVEMENT3

PAINPainPhysical pain is affected by emotionsThere are no objective tests for painThe most accurate assessment of pain is basedon what the patient says4

Effects of Pain on Quality of LifePhysical:Poor SleepDecreased strength and enduranceNausea and poor Difficulty concentratingReduced social relationshipsClassification of Pain5

Nociceptive PainFeeling of pain transmitted along healthy nervesSomatic: Fractures, bone cancer, arthritis, skin infections etc.Typically well-localized (One finger test)Visceral: Pancreatitis, peptic ulcer, heart attack etc.Hard to localizeFrom compression, stretching or injury to internal organsOften described as “deep”, “squeezing,” “aching,”“pressure.”May be associated with nausea and sweating.Neuropathic PainFrom injury to the nervous system– Post surgical pain, shingles, diabetic neuropathy,phantom limb pain etc.Constant and burning– Antidepressants or anticonvulsants can be helpfulShooting pain– Typically sharp or shock-like– Lasts seconds to minutes– Anticonvulsant medications may be very helpful.6

Treating Pain with OpioidsWhat’s so Great about Opioids?They relieve most types of painNo maximum doseDo not damage liver, kidneys or stomachNo increased risk of bleeding.7

WHO 3-step AnalgesicLadder3 SevereMorphine2 Moderate1 CodeineFentanylA/HydrocodoneOxycodoneA/Oxycodone AdjuvantsTramadol Adjuvants AdjuvantsAdapted from the EPEC ProjectOpioid EffectivenessMost common reason an opioid is ineffective isreluctance to increase dose till pain is relievedNo upper limit to doses of opioidsIncrease dose until– Pain is relieved– There are bad side effects8

Difficult PainIf increasing dose bad side effects– Try a differentroute of administrationOpioidType of pain medicine– Nonmedical approach– Therapy to treat adverse effectsOther Routes for Pain ReliefIV PCA (Patient Controlled Analgesia)– The ButtonNerve Blocks– Celiac Plexus BlockSpinal Opioids– Intrathecal or epidural9

Six Opioids for Chronic PainMorphine: Most Commonly UsedOxycodone: Oral onlyOxymorphoneHydromorphone: Dilaudid– Short-acting & long-acting pillsFentanyl– Patch or oral fentanyl products– 100x stronger than morphineMethadone: inexpensive, long acting– Bad reputationFentanyl PatchFentanyl patch is useful for chronic, stable painDifficult to adjust for rapidly increasing pain– Takes 18 hours to reach full strengthListed for 3 days but many change every 2 daysVery Strong, should be used with care!Do not cut the patch and ensure it sticks to skinMultiple patches should not touch each other10

Long- & Short-actingOpioidsOpioid Dosing & Breakthrough PainPatients who use opioids for severe chronic cancerpain need scheduled dosing using a long acting opioid– MS Contin, OxyContin, fentanyl Patch, Opana ER,– Exalgo, methadoneThese patients also use “as needed” doses of shortacting opioids for breakthrough pain (BTP)– Morphine, oxycodone, hydromorphone, Opana– Actiq, Fentora, Abstral, Onsolis, Lazanda (Oral fentanyl)11

Long-acting OpioidsSame drug as the short-acting but in a timedrelease formGoal is to prevent as much pain as possible with astable blood level of the opioidBreakthrough medication about 0 – 2 times a day isexpected.Never works as fast as we wantOpioid Side EffectsCommonUncommonConstipationBad dreams / hallucinationsDry mouthDysphoria / deliriumNausea / vomitingMyoclonus / seizuresSedationPruritus / urticariaSweatsRespiratory depressionUrinary retention12

Opioid AllergyAdverse effects, not allergic reactions– Nausea / vomiting, constipation, drowsiness,confusionTrue allergies– Bronchospasm (Closing throat)– RashDependence not Addiction13

Physical DependenceThe body misses the drug if stopped too quicklyAbrupt withdrawal may abstinence syndrome– “Cold Turkey”Sweats, Abdominal pain, back pain, runny nose, diarrhea– Take an extra as-needed dose– If improved CALL YOUR DOCTOR!AddictionPsychological dependenceCompulsive use in spite of harmLoss of control over drugsLoss of interest in pleasurable activitiesAn uncommon outcome of pain management– particularly, if no history of substance abuse14

Adjuvant Pain MedicationsMedications that work with opioids to help treatpain– may themselves be normally used for painand so used aloneAdjuvant (Non-opioid)Pain MedicationsAcetaminophenNon-steroidal anti-inflammatory drugsCorticosteroidsAntispasmodicsTricyclic antidepressantsAnticonvulsantsNMDA antagonists (ketamine)Anesthetics15

Nonsteroidal Anti-inflammatory Drugs(NSAIDs)All have analgesic ceilingEffective for bone, inflammatory painHighest incidence of adverse events– Stomach problems– Kidney problems– Bleeding problemsAdapted from EPECSteroidsMany uses– Bone & Inflammatory pain– Improved appetite– Improved energy– Feeling of well-being etc.Many Side Effects16

Constant Neuropathic PainUsually Burning, TinglingAntidepressants– Amitriptyline: limited usefulness in frail, elderly– Desipramine: tricyclic of choice in seriously ill– Duloxetine (Cymbalta)Anticonvulsants– Pregabalin (Lyrica)– Gabapentin (Neurontin)minimal adverse effectsdrowsiness, tolerance develops within daysShooting, Stabbing, Neuropathic Pain– AnticonvulsantsPregabalinGabapentin– Monitor blood levels of drug for risk of toxicityOxcarbazepineCarbamazepineValproic Acid17

Barriers to Pain ManagementBarriers exist within and among threedifferent groups:Health care systemsHealth care professionalsPatients and families/caregiversBarriers to Good Pain Management:Patients/Families/CaregiversFears of:Looking weakDistracting physiciansMeans disease is worseBeing seen as a bad patientDoses get “too high”AddictionSide effects of opioids18

Non-Pain SymptomsConstipationMedications– opioids– calcium-channelblockers– anticholinergicDecreased litiesSpinal gnancy19

ConstipationCommon to all opioids– Opioid effects on gut– Tolerance usually does not developMuch easier to prevent than treatAsk when get opioid what to do if constipatedConstipationDiet usually not enoughNo over-the-counter bulk forming agentsStool softeners– Sodium docusate (Colace, etc)Stimulant laxative– senna, bisacodyl, casanthranol– Combine with a stool softenersenna docusate sodiumcasanthranol docusate sodium20

ConstipationOsmotic laxative– Lactulose or Sorbitol 15-30 ml QD to Q4h– Bisacodyl 5-15 mg PO/PR QD-BID– Polyethylene glycol (MiraLax, GlycoLax)Prokinetic agent– MetoclopramideOther measures– Mineral oil, magnesium hydroxide,magnesium citrate, suppositories, enemas– Methylnaltrexone (Relistor) (Injection)Nausea / VomitingNausea– Subjective sensationVomiting– Visible action21

Causes of Nausea / VomitingMetastasesMeningeal irritationMovementMental anxietyMedicationsMucosal crobesMyocardialManagementof Nausea / nergicsSerotonin antagonistsProkinetic agentsAntacidsCytoprotective agentsOther medications22

Dopamine AntagonistsHaloperidol (Haldol)Prochlorperazine (Compazine)Promethazine (Phenergan)Metoclopramide (Reglan)Treatment of Nausea/ VomitingSeratonin antagonists– Ondansetron, granisetron, dolasetronAntihistamines– Diphenhydramine, Meclizine, HydroxyzineAnticholinergics– Scopolamine patchH2 receptor blockers– Cimetidine, famotidine, ranitidine, etc.Proton Pump Inhibitors– Omeprazole, lansoprazole23

Other MedicationsDexamethasone (and other steroids)DronabinolLorazepamMisoprostolOctreotide (Last ditch of drying out the gut)Dyspnea (Breathlessness)May be described as– shortness of breath– Suffocating feeling– inability to get enough air24

Dyspnea (Breathlessness)The only reliable measure is patient self-reportNothing to do with– Respiratory rate,– Pulse-Oximetry– Blood gas determinationsCauses of DyspneaAnxietyAirway obstructionBronchospasmHypoxemiaPleural effusionPneumoniaPulmonary edemaPulmonary embolismThick secretionsAnemiaMetabolicFamily / financial /legal / spiritual /practical issues25

Management of DyspneaTreat the underlying causeSymptomatic management– Oxygen: potent symbol of medical carePulse oximetry not helpful– Opioids– Anxiolytics– Nonpharmacologic interventionsFanAnorexia / CachexiaAnorexia– Loss of appetiteCachexia– Loss of weight and energy, fatigue26

Management of Anorexia/ CachexiaAssess, manage related conditionsEducate, support patient and familyFavorite foods / nutritional supplementsManagement of Anorexia /CachexiaCorticosteroids (short term)Progestational agents (megestrol acetate)DronabinolTrials of many medications27

Management of Fatigue /WeaknessEducation, supportClarify role of underlying illnessPromote energy conservationPermission to restEvaluate medicationsImprove fluid & electrolyte intakeManagement of Fatigue /WeaknessDexamethasone– feeling of well-being, increased energy– effect may wane after 4-6 weeks– continue until deathMethylphenidate (Ritalin)28

Poor Fluid Balance / EdemaOften associated with advanced illnessLow blood protein (albumin)– Decreased ability to hold liquid in bloodBlockage of veins or lymph system– May contributeFluid Balance / EdemaUrine output will often be lowLimit or avoid IV fluidsDrink some fluids with saltSkin care29

Psychiatric SymptomsDepression & AnxietyVery CommonUnder-diagnosedEffective management is possible30

Depression¼ up to ¾ of patientsIntense sufferingNot inevitableTreatable in most cases– Especially if caught earlyWatch for suicidal patientRisk FactorsPancreatic CancerProgressive physical weaknessUncontrolled Pain– Spiritual painPreexisting risk factors– prior history, family history, social stress– suicide attempts, substance use31

Diagnosing Depression inAdvanced IllnessPhysical symptoms always present– Poor appetite, poor sleep, low energyLook for psychological symptoms– pain not responding as expected– sad mood / flat affect, anxious, irritable– worthlessness, hopelessness, guilt– Lack of enjoyment, lost self-esteemManagement of DepressionPsychotherapeutic interventions– cognitive approaches– behavioral interventionsMedicationsCombination of psychotherapy, medication32

Medical ManagementStimulants– Rapid effect– Methylphenidate, 5 or 10 mg q am,Also Modafinil or dextroamphetamine– Alone or with antidepressent– May continue indefinitelySSRIs & atypical antidepressants– 2–4 weeks to kick in– Highly effective (70%)– Well toleratedAnxietyFear, uncertainty about futurePhysical, psychological, social, spiritual,practical issuesPresentation– agitation, insomnia, restlessness,– sweating, fast heart rate, fast breathing– panic disorder, worry, tension33

Management of AnxietyCounseling, supportive therapyAtypical antidepressantsBenzodiazepines– short vs long half-lifediazepamClonazepamlorazepamalprazolam, oxazepamSummaryMany symptoms can make patients miserableTreat them– Maximize effects of disease-specific treatments– Care for patients after disease-specifictreatments stoppedPalliative care teams can be effective intreating difficult symptoms at all stages ofdisease34

Questions?Thank you for your participation!Pancreatic Cancer Action Networkwww.pancan.orgIf you have questions, please contact our Patientand Liaison Services (PALS) program at(877) 272-6226 or e-mail [email protected]