Pain and Symptom Management in the Pancreatic Cancer Patient. Objectives:

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1 Pain and Symptom Management in the Pancreatic Cancer Patient Michael D. Harrington, M.D. Division of Geriatrics and Palliative Care MetroHealth Medical Center April 25, 2012 Objectives: Understand palliative care definition and how palliative care services can improve your quality of life Review pain management definitions, myths and facts Learn some basic pain management concepts Discuss common pancreatic cancer symptoms including nausea, vomiting, decreased appetite, weight loss and fatigue 1

2 What is Palliative Care? Palliative care is: Medical specialty focused on relieving the symptoms, pain, and stress of a serious illness whatever the diagnosis Cancer, heart failure, stroke, dementia, emphysema The goal is to improve quality of life for both the patient and the family Appropriate at any stage of illness Can help coordinate and share information with all of your other doctors and health providers The Nature of Suffering and the Goals of Medicine - Eric J. Cassell The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself. 2

3 Palliative Care in Cancer Patients? Today's Medical System Challenges Acute care model in age of chronic illness Cure driven care with death as enemy Widespread suffering, disability and loss of independence Decreasing access and continuity Diseases drive the care Specialty hospitals Little training in the natural history of illness High patient symptom scores (pain, sob, anxiety) Little formal training in treating symptoms Time is increasing precious and rare resource Palliative Care in Cancer Patients? How Palliative Care Can Assist Patient and family focused Expertise in symptom management of illness/treatments Pain, fatigue, nausea, constipation, depression, delirium, weight loss, shortness of breath, etc Fill in gaps that oncologist may not be able to at each visit Symptoms, objective opinion, supports, continuity Setting goals of care that can help drive care Assist in prognostication Comfortable with all types of advance directives Some data showing longer life expectancy with PC Familiar with home care services Hope for the best, prepare for the worse 3

4 Palliative Care vs. Hospice What is hospice care? Medicare program/entitlement Hospice care is for a patient with a terminal diagnosis and is usually no longer seeking curative treatment. Medicare benefit intended for 6 months or less It focuses on relieving symptoms and supporting patients who are expected to live for months, not years. Hospice care can be provided in home, residential setting, or hospital. Is palliative care the same as hospice care? Palliative care is appropriate for anyone at any point of a serious illness Diagnosis, symptom flares, continuity, end-of-life It can be provided at the same time as treatment that is meant to prolong your life or curative therapy Palliative care is philosophy and medical specialty Hospice is a model of care Hospice Palliative Care 4

5 Therapies to Modify disease Hospice Benefit Palliative Care Presentation Therapies to relieve suffering and improve quality of life 6m Death Bereavement Care MD is 57 year old man presenting to our palliative care clinic after recent diagnosis of locally advanced, unresectable pancreatic cancer with treatment plan to start chemotherapy next week. His pain is just above belly button and described as sharp, penetrating pain that moves into both sides and his back His has been using some as needed Vicodin with minimal relief. Unable to tolerate work as bus driver due to pain worse with potholes. His pain is starting to effect his relationship and willingness to continue seeing the doctors. His family believes him but are not sure how much he is really hurting. 5

6 What could be concerns about his pain management Is he really in pain Should my pain be controlled? Can it be controlled? What medication? Will I become addicted? Are there barriers to getting pain controlled? If start pain medications now will they work later if pain worsens? Will I get side effects? Is He Really In Pain? Cannot rely on changes in vital signs Not that useful deciding he does not look in pain or act like in pain **pain paradox** Hard to know how much a procedure or disease should hurt (medicine vs. surgery) Don t assume that if sleeping then is pain free Don t assume a patient will say when in pain Pain occurs in the context of a person s life Past experiences, impact on others, spiritual context, emotional context 6

7 Should My Pain Be Controlled? There are consequences to untreated pain Longer hospital stays Increased risk of depression Fatigue Irritability Increased disability Decreased quality of life. Potentially less cancer treatments Decreased performance status ECOG 0-5 scale Can My Pain Be Controlled? YES -- need provider comfortable treating May need aggressive titration 90% of all pain can be controlled with oral medications Need source of pain and pain type identified May need combination of therapies Adjuvants Non-steroidal, epilepsy drugs, antidepressants, steroids Interventional therapies available Surgery Chemotherapy Radiation therapy Nerve blocks Epidural catheters Spinal cord stimulator 7

8 What medication --Depends? Each person is unique and certain medications work better than others Past pain medication usage is helpful Pain pattern and description Type of pain may dictate choice of meds Somatic Visceral Neuropathic Degree of impact on your life and function Will I become addicted? Understanding the Definitions Addiction Psychological Manifest in Behaviors Compulsive Use Loss of Control Continued Use Despite Harm to Self and Others Dependence Physiologic Marked by a withdrawal phenomenon Universal for regular use greater than a week 8

9 Tolerance Will I become addicted? Understanding the Definitions Need more drug to get the same effect. Tolerance is our friend allows increased dosing Pseudoaddiction Behaviors that are reminiscent of addiction, but are driven by pain and disappear with better pain relief Iatrogenic condition (medical system caused) due to under treated or improperly treated pain Example is hospital wards Call button syndrome Diagnose by increasing dose and/or frequency of pain medications and observing resultant behavior Barriers to Good Pain Management Patient Barriers Save for when it s really bad Fear of addiction Stigma of morphine Side effects Obtaining meds Reluctant to report pain Physician Barriers Fear of addiction Knowledge deficits Regulatory oversight Analgesia low priority compared to disease and cure Medical culture 9

10 If I start pain medications now will they work later if pain worsens? Dosed with gradual escalation until development of adequate pain relief or intolerable and unmanageable side effects. No therapeutic ceiling effect = no maximum dose Around the clock dosing or scheduled dosing for continuous or frequently recurring pain. As needed ( prn ) dosing for dose finding and for rescue doses or breakthrough Dose frequency based on ½ life Opioids T1/2 is 3-4 hours (less for fentanyl) Peak Effect of Opioid Administration IV Route 10 min E f f e c t T ½ = 4 hours T ½ = clinical effectiveness Oral Route 60 min Time - hours 10

11 Will I Get Side Effects. Most if not all of side effects can be anticipated and treated No Tolerance develops Constipation near 100% and no tolerance softener and stimulant laxative at start of therapy Tolerance in 4-7 days Nausea Metoclopramide, prochlorperazine, ondansetron, Confusion/Sedation give it time or change meds Itching -- Not an allergy if no rash Diphenhydramine or doxepin Pain Management Pearls For Docs Pharmacology must match pain etiology Dosing Interval is based on ½ life (3-4 hours) or peak effect (IV 10 minutes, Oral 60 minutes) Breakthrough/Rescue dose is 10-20% of 24 hr dose Stimulant bowel regimen is a must Use equianalgesic tables when converting Dose escalation: Severe pain 100%, Mod 50%, Mild 25% Anticipate and treat side effects aggressively Frequent assessment, put on problem list Questions or pain not controlled : Ask for help 11

12 Nausea and Vomiting Gastrointestinal Causes Obstruction Stomach inflammation Slow motility from cancer produced hormones Squashed stomach syndrome Constipation Abdominal carcinomatosis or spread of cancer to attach to intestines Acute effect of abdominal radiation or chemotherapy Brain Causes Nausea and Vomiting *** Drug induced nausea *** Opioids, chemotherapy, antibiotics Brain issues with elevated pressure Tumors or bleeding or meningitis Vestibular dysfunction Balance Centers Metabolic Elevated calcium, liver failure, renal failure, infection Psychological anxiety, pain, learned response (anticipatory n/v) 12

13 Loss of Appetite and Weight Loss in Cancer (Anorexia and Cachexia) Secondary to body inflammation Cytokines Interleukin (IL) 1, 6 and Tumor Necrosis Factor (TNF) alpha Tumor associated cachexin breaks down muscle, protein, and fat ***Caloric intake plays a minor role in the pathogenesis of cachexia Anorexia and Cachexia Common in advanced disease Assess and treat underlying cause Nausea and vomiting Medications Constipation Weakness Depression Pain Gastritis or stomach irritation Dry mouth, thrush or teeth issues 13

14 Anorexia and Cachexia: Supportive Therapy Odor management Pain management Alcohol prior to meals Small, frequent meals Bring meals to patient Make meals a social event Emphasize companionship Patient plans menu Anorexia and Cachexia: Pharmacologic Management Megestrol acetate (Megace) 400mg twice a day Corticosteroids Dexamethasone 2-4 mg bid Dronabinol (Marinol THC derivative) mg 2-3 times a day Metoclopramide (Reglan) 10-20mg 30 minutes prior to meals Cyproheptadine (Periactin) 4-8mg three times a day Mirtazepine (Remeron), Omega 3, Thalidomide 14

15 Fatigue in Pancreatic Cancer The Most common symptom Many Causes / Multi-factorial Usually 4-5/patient Untreated pain Medication side effects Dehydration Infection Hormonal abnormalities or metabolic causes Anemia (low blood count); Depression or anxiety Weight loss Inadequate rest Disease itself helps determine performance status Fatigue in Pancreatic Cancer The Most common symptom The first step is to tell your doctor about it. Not always trained to ask specifically about this The treatment of fatigue involves three things: Lifestyle Adjust job or other responsibilities Behavioral changes Adjusting daily activities (e.g. reducing housework) Asking for help Spend more time in bed or alternating exercise with rest Medications Medications Steroids like dexamethasone megestrol acetate (Megace) stimulant medications methylphenidate (ritalin) or modafanil (Provigil) 15

16 Summary You and your loved ones deserve best care possible Palliative care services are one of the resources to help support patient, family and health providers View yourself as part of the health care team and advocate for your symptom control Aggressive symptom control is available regardless of disease and prognosis 16