We were pleased to have Ishwaria Subbiah MD, MS (@IshwariaMD), a palliative care and medical oncology physician from MD Anderson, join #gyncsm for tonight's Managing Cancer Pain chat.
Eighteen patients/survivors and physicians participated in the chat. Below is a sample of the responses to the questions we asked during the chat. You may find a complete transcript here. Resources may be found at the end of this post.
T1: What are some of the causes of pain in cancer patients? How is cancer-related pain diagnosed?
- We tend to think of cancer pain as acute (new or rapidly worsening pain) or chronic (not new). Acute is often bc of cancer itself (organ involvement eg liver; fracture; bowel perforation) or treatment (mouth sores, esophagitis, enteritis...). Chronic is neuropathy...
- Approximately 25% to 50% of people w/ cancer complain of pain at time of dx, and up to 75% of people with cancer complain of pain as the cancer progresses. It can be caused by stage of Ca, even the tx type
- Cancer-related pain is complex. Causes can include direct involvement of nerves, blockage of the bowels or constipation.
- Cancer pain can come from various sources. It can come from the tumor pressing on bone, nerves or organs and sometimes pain comes from the treatment.
- treatments cause pain too - surgery, radiation therapy, chemo,hormone therapy
T2: What pain medications are available for cancer patients? What is recommended?
- Pain control can be achieved with narcotic meds, anti-inflammatory meds, anti-spasm meds, anti-seizure meds (for neuropathy)
- After surgery, doctors are trying out pain management strategies using varying combinations of acetaminophen, ketorolac, gabapentin and other opioid alternatives.
- NSAIDS, short acting opioids long acting Opiods and Methadone as per reading
- Pain meds are opioids or non-opioids, which are muscle relaxants, NSAIDS, steroids, as well as antidepressants (SSRI/SNRIs/TCAs) and anticonvulsants both which help w nerve pain.
- Combining pain medications can be synergistic - lower doses of multiple different types of drugs so that there are fewer side effects but improved pain control. Alternating NSAIDS with opioids for example.
T3: In addition to medications, what are some other ways to manage pain?
- acupuncture, cognitive behavioral therapy, exercise
- acupuncture, mindfulness based stress reduction, and spiritual
- I've been writing about C.A.T.S. for years; complimentary & alternative treatment strategies for pain management. We don't always have to throw drugs at a problem as the only strategy
- Yes! Cognitive-behavioral therapy has strong data to support its use in cancer pain management. Here are 2 of the important papers: https://t.co/Ot6OkmJelc CBT in breast ca #bcsm https://t.co/B9kCJcM5y4 in all cancers.
- @CancerdotNet has a very helpful booklet. https://t.co/A5uadf2FVh
T4: How has the legislation regarding opioid use impacted the care of patients with cancer? What alternatives and guidelines are in place?
- Article | New Strategy Almost Halves Opioid Use in Surgical Cancer Patients https://t.co/mWlewpd52j
- For Opioids prescribers for adults, it’s7 days for children it’s 5 days
- as a soon to be RN I’m concerned that regulations are making it too hard for cancer patients to get pain meds.
- An inadvertent consequence though is that we may try to use opioid alternatives in addition to or instead of narcotics to improve pain control and also involve supportive care with pain control early - these are both good things!
- Many states have exceptions to opioid prescribing guideline for cancer patients.
- The CDC has this fact sheet on opiods https://t.co/sVCD63IvcN
- The #opioid shortage was a very real issue earlier this year (& still is to a lesser extent). @AP picked up on this & spoke w many of us around the US who care for people w severe pain. #gyncsm US hospitals grapple w prolonged injected opioid shortage https://t.co/nM1IKlyApG
- Patients are so worried about becoming addicted - we try to hammer the fact that if you are taking #opiods appropriately for control of your pain- you will not become addicted! We don't want you to suffer
Bonus Topic:
- grimacing
- because we need more words and descriptions for pain levels. lol
- The current one is OK for intensity but really doesn't describe the pain. #gyncsm is it Dull ache, stabbing, pins and needles etc
- Absolutely - it is just one measure of a part of the pain and inadequate for all those additional details
And a closing thought from @ShereesePubHlth:
Effective pain management requires a comprehensive approach; no one size fits all. Have the conversation w/ your care team and let that team listen w/ E.A.R.S (empathy, attentiveness, respect, & support).
You may continue the discussion on Smart Patients at https://buff.ly/2yzFai6.
See you next month on Wednesday Nov 14, 2018 for our chat on Cancer and Careers.
Dee #gyncsm co-founder
RESOURCES
Meta-analysis of psychosocial interventions to reduce pain in patients with cancer https://www.ncbi.nlm.nih.gov/pubmed?holding=mdacclib&term=22253460
Efficacy of Mindfulness-based Cognitive Therapy on Late Post Treatment Pain in Women Treated for Primary Breast Cancer : A Randomized Controlled Trial https://www.ncbi.nlm.nih.gov/pubmed?holding=mdacclib&term=27325850
@CancerDotNet ASCO Answers Managing Cancer-related Pain https://www.cancer.net/sites/cancer.net/files/managing_pain_booklet.pdf
New Strategy Almost Halves Opioid Use in Surgical Cancer Patients
https://www.medscape.com/viewarticle/902402?src=rss
CDC Fact Sheet on Opiods https://www.cdc.gov/drugoverdose/pdf/AHA-Patient-Opioid-Factsheet-a.pdf
US Hospitals Grapple with Prolonged Injected Opiod Shortage https://apnews.com/6af21607e6ba4d03937c4d67f3c8b1b7
FDA’s Opioid Analgesic REMS Education Blueprint for Health Care Providers Involved in the Treatment and Monitoring of Patients with Pain
https://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM620249.pdf
MD Anderson Supportive Care Clinic visit assessment
PCORI Video What are opiods?
ACS managing cancer pain at
home
Cancer pain relief is possible - Mayo Clinic
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