COMPREHENSIVE PAIN  MANAGEMENT Disclosure‐ No commercial interests Some of the slides used are from Medtronics , no other affiliation

GOPI KASTURI, MD Physiatrist‐interventional Pain Specialist Asst. Clinical Professor,  UCSF‐FRESNO

Sources of Pain in Cancer Patients Cancer pain comprises:

▪ Acute pain ▪ Chronic pain ▪ Tumor-specific pain ▪ Treatment-related pain

Carr D, Goudas L, Lawrence D, et al. Management of cancer symptoms: pain, depression, and fatigue. Evidence report/technology assessment No. 61 (prepared by the New England Medical  Center Evidence based Practice Center under contract No. 290‐97‐0019). AHRQ Publication No. 02‐E032. Rockville, MD: Agency for Healthcare Research and Quality. July 2002. Downloaded at http://www.ahrq.gov/clinic/epcsums/csympsum.htm on 4/22/2009. http://www.ahrq.gov/clinic/epcsums/cansympsum.pdf. Accessed 03/23/2009

Potential Causes of Cancer‐Related Pain  Tumor / Mass effect  Post‐chemotherapy  Post‐radiation  Post‐surgical

Mechanisms

▪ Destruction Of Bone ▪ Microfractures And Periosteal Involvement ▪ Infiltration Of Nerves ▪ Activation Of Nociceptors By Tumor‐derived Mediators ▪ Nociceptor Sensitization ▪ Opioid induced hyperalgesia

Pain is a subjective experience

TREATMENT OPTIONS ▪ PHARMACOLOGICAL ▪ INTERVENTIONAL ▪ INTEGRATIVE MEDICINE ▪ OTHERS

WHAT IS THE BEST TREATMENT FOR CANCER  PAIN??

PHARMACOLOGICAL ▪ ADVANTAGES ▪ DISADVANTAGES ▪ PRINCIPLES OF PAIN MANAGEMENT

WHO Ladder

WHEN SHOULD YOU CONSULT A PAIN  SPECIALIST

Facility requirements ▪ Procedure Suite (OR) ▪ Recovery Setting ▪ Imaging (Fluoro, CT)

Interventional procedures for pain management

PARAVERTEBRAL BLOCK

VERTEBRAL METASTASES‐FRACTURE

VERTEBROPLASTY Injection of poly methyl methacrylate (PMMA) into a fractured  vertebra for pain relief.

KYPHOPLASTY Similar to Vertebroplasty except for introduction of a balloon tamp  into the vertebral body to create a void. 

INDICATIONS

 Painful acute‐sub acute VCF  Metastatic lesions  Prior to other orthopedic surgery  Painful hemangioma

MECHANISM OF ACTION ▪ ??? ▪ Immobilization of microfracture ▪ Increased tensile strength ▪ Destruction of nerve endings 

CONTRAINDICATIONS ABSOLUTE ▪ Infection ▪ Medically unstable ▪ Unstable fracture (posterior element involvement) ▪ Bleeding diatheses ▪ Lack of a definable level of vertebral collapse

RELATIVE Inability to lie prone, lack of surgical back‐up, neurological signs and  symptoms 

DIAGNOSIS ‐ MRI T2 WEIGHTED IMAGE

MRI WITH STIR 

L4 L4

RETROPULSION

VERTEBROPLASTY ‐TECHNIQUE

VERTEBROPLASTY

KYPHOPLASTY

KYPHOPLASTY

KYPHOPLASTY

RISKS AND ADVERSE EVENTS ▪ Pneumothorax ▪ Extravasation of cement ▪ Embolization ▪ Incident fractures

Mudano AS, Bian J, Cope JU, Curtis JR, Gross TP, Allison JJ, Kim Y, Briggs D, Melton ME, Xi J, Saag KG. Vertebroplasty and kyphoplasty are associated with an increased risk of  secondary vertebral compression fractures: a population‐based cohort study. Osteoporos Int. 2008 Sep 17.[Epub ahead of print]

CEMENT LEAKAGE

CEMENT LEAKAGE

Avoid cement in the poster aspect of the vertebral body

Intrathecal Drug Delivery:Patient Selection Criteria I. Symptoms of pain due to advanced stage cancer at presentation, with a minimum life expectancy of >3 months1-4 II. Refractory to conventional pain management because of drug toxicity or unsatisfactory analgesia1-4 III. Visual analog scale (VAS) of ≥ 5, despite 200 mg/day of oral morphine or the analgesic equivalent1,3,4

1. Smith TJ, Staats PS, Deer T, Stearns LJ, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refactory cancer  pain: Impact on pain, drug‐related toxicity, and survival. J Clin Oncol. 2002;20(19):4040‐4049. 2. Stearns L, Boortz‐Marx R, Du Pen S, Friehs G, et al. Intrathecal Drug Delivery for the Management of Cancer Pain: A Multidisciplinary Consensus of Best Clinical Practices. J Support  Oncol. 2005;3(6):399‐408. 3. Smith TJ, Coyne PJ. Implantable Drug Delivery Systems (IDDS) After Failure of Comprehensive Medical Management (CMM) Can Palliate Symptoms in the Most Refractory Cancer Pain  Patients. J Pall Med. 2005;8(4):736‐742. 4. Brogan, SE. Intrathecal Therapy for the Management of Cancer Pain. Curr Pain Head Rep. 2006;10:253‐259.

Trial for Intrathecal Drug Delivery To evaluate patient’s response Assess pain relief Evaluate side effects 50% pain reduction considered a positive result

Hassenbusch SJ, Stanton‐Hicks M, Covington EC. Long‐term intraspinal infusions of opioids in the treatment of neuropathic pain. J Pain Symptom Manage. 1995;10(5):527‐543.

Intrathecal Drug Delivery (IDD) Therapy ▪ IDD therapy involves the delivery of

pain medicine in the intrathecal space

▪ The pump is connected to a thin,

flexible catheter; both are implanted under the skin

▪ Smaller doses of medication are

needed for effective pain relief because drug is delivered directly to the pain receptors

Intrathecal Drug Delivery: SynchroMed® II Infusion System

Adverse Events with Intrathecal Drug Delivery Therapy ▪ Infection ▪ Spinal fluid leak ▪ Pump inversion ▪ Skin erosion ▪ Drug side effects ▪ Loss of therapy effect

• Inflammatory mass (a mass near the tip of the catheter) • Spinal cord damage • Meningitis • Complications due to use of unapproved drugs or not using drugs in accordance with drug labeling • Life-threatening programming or patient monitoring errors or device malfunction

myPTM®* for Management of Intermittent, Variable Pain myPTM with SynchroMed® II infusion system that gives patients the control and ability to respond to symptoms of episodic pain at onset.

*maybe a self-pay device

CONCLUSION ▪ No single treatment option is efficacious in all patients ▪ Consider  ‐non cancer etiologies of pain ‐ non pharmacological options for management of pain ‐ Depression, anxiety and other comorbidities ‐ Consultations as appropriate

THANK YOU