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Cancer
Pain Management: Dr. Columbus'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 Dr. Lynne Carr Columbus, "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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