Pain Management for Patients with Cancer

Educational Objectives

The goal of this program is to improve management of pain in patients with cancer. After hearing and assimilating this program, the clinician will be better able to:

1. Choose pain management treatments appropriate for patients in the terminal stages of cancer.
2. Distinguish treatments for nociceptive pain from treatments for neuropathic pain in patients with cancer.

Summary

Pain management: interventional procedures for cancer-related pain and non-cancer pain include sympathetic blocks, neurolysis, intrathecal pumps, externalized epidurals, spinal cord stimulators, nerve stimulators for tibial augmentation (eg, vertebroplasty, kyphoplasty), and vertebral body radiofrequency ablation; non-specific treatments include steroid injections into joints or epidural spaces and botulinum toxin injections

Sympathetic nerve block: useful for nociceptive pain and visceral related pain; targets include the celiac plexus, hypogastric plexus, and ganglion impair plexus, which relay pain signals through visceral afferent fibers; sympathetic nerve blocks interrupt visceral pain signaling and may be used for cancers of the gastrointestinal tract, liver, adrenal gland, vagina, bladder, and prostate

Presentation: patients typically report nondescript, achy pain which is unrelated to food consumption or a particular time of day; the pain may be described as gnawing; pain related to pancreatic cancer typically occurs in the epigastric region but may be felt in other areas

Neurolysis: not recommended for patients without terminal illness with metastasis because it causes destruction of the nervous system which may result in deafferentation pain; regrowth of the damaged nerves produces pain signals of greater intensity; patients with a life expectancy prognosis of 6 mo to 1 yr are candidates for neurolysis; repeated neurolysis is not advised; patients with widely metastatic disease (carcinomatosis) are not candidates for neurolysis because nerves other than visceral afferent fibers may be sending pain signals; McGreevy et al (2013) found reduced efficacy with repetition of sympathetic chain neurolysis because of involvement of other nerves as the cancer spreads

Contraindications: neurolysis is contraindicated in patients with bowel obstruction; a flush in the form of diarrhea occurs after neurolysis; patients with bowel obstruction may develop perforation following flush against a fixed space; patients with intra-abdominal infection and coagulopathy or thrombocytopenia that cannot be corrected are not recommended for neurolysis; neurolysis may cause a sudden drop in blood pressure and reflex tachycardia, which may be fatal in patients with existing poorly controlled coronary artery disease or congestive heart failure; other contraindications include patients on disulfiram and clinically unstable individuals

Intrathecal pumps: useful for management of nociceptive or neuropathic pain in patients with response to opioids who are dose limited by adverse effects (eg, constipation, dizziness, lethargy); opioids are delivered to a specific area of the spinal cord; the tip of the catheter is placed at the site where pain signals are processed; systemic absorption is avoided to prevent adverse effects (as with oral opioids); adjuncts, eg, local anesthetic, are added to opioids as part of the multimodal approach to pain; patients are admitted for intrathecal trials to identify the correct location for injection; the primary goal is to transition the patient from oral or systemic opioids to intrathecal injections, and obtain complete pain control; the intrathecal pump may be programmed for acute pain or as a continuous infusion of small amounts of opioids (long acting); patients with generalized pain or pain at multiple distant locations are not ideal for intrathecal pump therapy; patients are taken for implantation of the pump after the trial is successful; the pump is refilled every 3 mo; one fill is given before hospice care begins

Medications: morphine, ziconotide, and baclofen are approved by the Food and Drug Administration for intrathecal pumps; use of other opioids is considered off-label use

Risks: include bleeding, infection, nerve damage, increased pain, and medication reaction; increased concentration of opioid in the intrathecal pump may result in the development of an inflammatory mass (granuloma) at the catheter tip which compresses the underlying spinal cord; patients present with loss of efficacy of the intrathecal pumps, and neurologic signs; patients with neutropenia and thrombocytopenia are at increased risk for developing complications from intrathecal pumps; the internal system of the intrathecal pump is battery operated; reports exist of device failure when it is placed directly in the field of radiation; epidural and spinal metastases increase the risk for bleeding and other complications; conditional parameters have to be followed if the patient is slated to undergo magnetic resonance imaging (MRI)

Externalized epidural catheters: indicated in patients with a life expectancy prognosis of <3 mo; the spinal cord is numbed; reliance on opioids is reduced and patients may gain more quality time with family at end of life; the epidural catheter is placed before hospice care begins; the port of the catheter is connected to an infusion pump; nurses change the infusion bags regularly for epidural infusion; patients may remain lucid in their final moments; the concentration of medications used is similar to that in an intrathecal pump

Spinal cord stimulation: recommended for patients with neuropathic (nerve related) pain; tumors may invade nerves and cause pain; useful for chemotherapy-induced peripheral neuropathy and extremity pain after surgery; evidence is limited for the use of spinal cord stimulation in cancer patients; patients may undergo MRI but 30 min breaks in between the imaging processes are required; spinal cord stimulation has similar neuraxial considerations as intrathecal pumps

Peripheral nerve stimulation: useful for neuropathic pain; peripheral nerve stimulation targets a single superficial nerve; less invasive than spinal cord stimulation; useful for patients with nerve damage-related pain because of direct tumor invasion or postsurgical injury; the catheter is placed with ultrasonography guidance; systems are available with catheters that may be left in place indefinitely, or must be removed after 60 days

Structural rebuilding: patients with pathologic compression fractures from tumor metastases or multiple myeloma may present with axial back pain; vertebral body height is re-established with surgery; structural rebuilding produces immediate relief

Radiofrequency ablation: useful for management of nociceptive pain, eg, in patients with vertebral body metastasis presenting with axial back pain; trocars are inserted which are identical to kyphoplasty trocars; the metastatic lesion is ablated; signaling from periosteal nociceptors is prevented

Pain unrelated to cancer: patients with cancer may have trigger points which are palpable, discrete knots in, eg, the trapezius muscle; trigger point injections are beneficial; patients may have an exacerbation of their fibromyalgia central sensitization, which results a lower threshold for feeling pain from other causes; facet arthropathy refers to wear on the spine related to ageing; patients with cancer may have osteoarthritis, migraines (pre-existing or related to cancer treatment); approaches — medial branch block, radiofrequency ablation, epidural steroid injections, botulinum toxin injections, and steroid injections to the joints; palliative care — includes symptom management with medications for pain, nausea, and other symptoms related to cancer

Readings

Abd-Elsayed A, Hughes M, Narel E, Loebertman MD. The efficacy of radiofrequency ablation for pain management in patients with pre-existing hardware at the site of ablation. Pain Ther. 2020;9(2):709-716. doi:10.1007/s40122-020-00201-4; Caylor J, Reddy R, Yin S, et al. Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action. Bioelectron Med. 2019;5:12. doi:10.1186/s42234-019-0023-1; Cornman-Homonoff J, Holzwanger DJ, Lee KS, Madoff DC, Li D. Celiac plexus block and neurolysis in the management of chronic upper abdominal pain. Semin Intervent Radiol. 2017;34(4):376-386. doi:10.1055/s-0037-1608861; Helm S, Shirsat N, Calodney A, et al. Peripheral nerve stimulation for chronic pain: a systematic review of effectiveness and safety. Pain Ther. 2021;10(2):985-1002. doi:10.1007/s40122-021-00306-4; Matsumoto T, Yoshimatsu R, Osaki M, et al. Percutaneous splanchnic nerve neurolysis analgesic efficacy and safety for cancer-related pain: a systematic review and meta-analysis. Support Care Cancer. 2023;31(6):324. Published 2023 May 6. doi:10.1007/s00520-023-07746-y; McGreevy K, Hurley RW, Erdek MA, et al. The effectiveness of repeat celiac plexus neurolysis for pancreatic cancer: a pilot study. Pain Pract. 2013;13(2):89-95. doi:10.1111/j.1533-2500.2012.00557.x; Padalia RB, Reeves CJ, Shah N, Patel AA, Padalia DM. Case report: bilateral tunneled epidural catheters to prevent unilateral analgesia for cancer-related pain. Local Reg Anesth. 2017;10:79-82. Published 2017 Jul 20. doi:10.2147/LRA.S135809; Perruchoud C, Dupoiron D, Papi B, et al. Management of cancer-related pain with intrathecal drug delivery: a systematic review and meta-analysis of clinical studies. Neuromodulation. 2023;26(6):1142-1152. doi:10.1016/j.neurom.2021.12.004; Pusceddu C, Faiella E, Derudas D, et al. Re-expansion of vertebral compression fractures in patients with multiple myeloma with percutaneous vertebroplasty using spinejack implants: a preliminary and retrospective study. Front Surg. 2023;10:1121981. Published 2023 May 23. doi:10.3389/fsurg.2023.1121981; Scarborough BM, Smith CB. Optimal pain management for patients with cancer in the modern era. CA Cancer J Clin. 2018;68(3):182-196. doi:10.3322/caac.21453; Wilkes D. Programmable intrathecal pumps for the management of chronic pain: recommendations for improved efficiency. J Pain Res. 2014;7:571-577. Published 2014 Oct 3. doi:10.2147/JPR.S46929.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Christiansen has received an institutional research grant from Avanos. Dr. Christiansen's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Christiansen was recorded at the 5th Annual Targeted Pain Treatment Conference, held March 31, 2023, in Alcoa, TN, and presented by the University of Tennessee College of Medicine. For information about upcoming CME activities from this presenter, please uthsc.edu/ continuing-medical-education. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

AN654302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.