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