Gulf Coast Pain Management
Cancer Pain
 
 

Cancer Pain Management: Lynne Carr Columbus, D.O.'s Continuum Approach

Just as the sensation of pain can manifest itself in a variety of ways, there is a broad range of options for managing pain. Treatment with analgesic is the basis of pain management for cancer patients. However, every patient is unique and responds to medication differently, so a variety of doses and drug combinations may be tested to determine the most effective pain relief methods. Patient education and knowledge about chronic pain treatment options also can make a significant difference in helping them navigate the pain management continuum.

The World Health Organization (WHO) summarizes the basic pharmacologic principles of cancer pain management in the form of an "analgesic ladder", whereby increasingly severe pain is treated with increasingly potent analgesics. The  three rungs of this ladder include: nonpioids (including acetaminophen and non-steroidal anti-inflammatory drugs  [NSAIDSs] for mild main; weak opioids (such as codeine and propoxyphene) for moderate pain; and potent opioids (including morphine and methadone) for treating severe pain. As treatment progresses, adjuvant drugs and  interventional therapies may also be added as needed to alleviate pain.

This basic approach to pain management can also be represented as a continuum that includes interventional techniques - which may be appropriate as pain intensity progresses or when a patient is unable to take medicine by  mouth. In general, however, according to Lynne Carr Columbus, D.O., "the key steps to ensure adequate pain control  are: an accurate pain diagnosis; appropriate use of surgical, medical and radiation interventions; proper application of noninvasive and invasive pain relief techniques; and adequate and ongoing follow-up to adjust the treatment  approach to the patient's changing clinical condition.

Interventional Pain Therapy

Most cancer-related pain can be managed by taking oral analgesics, or with transdermal skin patches of rectal suppositories. However, some patients have little pain relief or experience intolerable side effects with traditional  systemic therapy. Common drug-related side effects such as constipation, nausea and vomiting, drowsiness and slowed  breathing - even if they are transitory or episodic - can often discourage use of what is otherwise a viable pain
management option. This is when interventional techniques are necessary for providing adequate pain control.

Some of the most significant developments in pain management have been in more advanced delivery systems for  established drugs. These interventional ways of administering drugs are intended to minimize side effects and more  precisely target their use. Interventional therapies include:

• Intrathecal pain therapy - administering opioids or local anesthetics to the intrathecal space of the spin, where the spinal fluid flows. (Opioids or local anesthetics also can be delivered to the epidural space.) Injection techniques - such as nonneurolytic and neurolytic nerve blocks in which targeted nerves are inject with agents such as phenol or anesthetics that destroy or numb them.

• Neurosurgical treatment - the most invasive and irreversible form of pain management through neurosurgical procedures, such as ablation that sever the nerves responsible for pain transmission.

Intrathecal delivery - A safe, effective treatment option

Intrathecal pain therapy delivers opioids directly to the fluid that surrounds the spinal cord using a small pump that is  surgically placed just under the skin of the abdomen. The therapy can offer dramatic pain control for long-term pain  management. Intrathecal pain therapy provides analgesia directly to the site of the action at the spine, with substantially smaller doses than are required for oral analgesia (one study approximates that the equivalent daily dose of
morphine via intrathecal administration is as little as 1/300th of an oral dose).

With the direct, intrathecal delivery of medication to the spine, side effects such as sedation, lethargy, mental clouding, constipation, nausea and vomiting can be reduced - affording patients a significant improvement in their activities of daily living and overall quality of life. According to one nursing study, "the use of intraspinal narcotics can yield fewer side effects and complications, as well as a reduction in the number of hospitalization days required for pain control that can traditional therapy.

Studies also have found that in appropriately selected cancer patients, 70 percent to 80 percent experience good to excellent pain relief with intraspinal drug infusion. Before incurring the cost of implanting such a drug delivery system, a trial with intraspinal morphine should be conducted to determine the potential therapy response. Patients whose pain relief is 50 percent greater are recommended to receive the therapy. In particular, implantable intrathecal drug infusion systems have been show to be more cost-effective than external pumps for patients treated beyond three months in ambulatory settings.

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