El Tratamiento del Dolor Para Sobrevivientes de Cáncer de Seno Ana Maria López MD Centro de Cáncer de Arizona alopez@azcc.arizona.edu 520-626-2271 1

Metas Educativas 1-Explicar el origen del dolor neuropático que sufren las sobrevivientes de cáncer de seno 2-Describir las técnicas multi- disciplinarias para aliviar y tratar el dolor 3-Enlistar el uso apropiado de los métodos de evaluación del dolor

Físico Emocional Espiritual

Noticias no muy buenas: Buenas noticias: Having cancer does not equal having pain Pain can affect every aspect of your life—how you sleep, how you interact with your loved ones, your appetite, your mood, etc. Vast majority of pain (>90%) can be managed with simple medications and interventions

Principios Básicos “Una experiencia emocional, sensorial y desagradable, relacionada con una lesión de tejido actual o potencial” (Merskey, 1986) El dolor SIEMPRE es subjetivo El dolor es una experiencia muy individual Important not to forget EMOTIONAL pain This lecture will focus on PHYSICAL pain There is no neurophysiological or chemical test to measure someone’s pain You must trust and respect the patient’s report of pain Pain is a highly individualized experience and influenced by many factors such as past experiences with pain, brain’s processing of pain stimulus Cancer-related pain afflicts approx. 9 million people worldwide annually (1996) Despite published guidelines by the WHO for pain management many cancer pts. Experience suboptimal pain and inadequate anlagesia.

La Evaluación del Dolor El dolor agudo El dolor crónico Acute Pain Follows injury to the body and generally disappears when the injury heals Usually associated with objective physical signs of distress Finding the source of the pain is a priority, treat the underlying cause of the pain and pain should resolve Pain comes quickly, and leaves quickly. Signs of distress (autonomic nervous system activity): tachycardia, hypertension, diaphoresis, pallor, restlessness, grimacing Comes quickly, leaves quickly Chronic Pain: Etiology of pain is priority Pain is present for greater than three-six months Nervous system has adapted Typically no “traditional” objective signs of distress

Tipos de Dolor: La Duración Nociceptivo Dolor Somático: cutáneo o profundo Dolor Visceral: infiltración/compresión de los órganos internos Dolor Neuropático: lesión de los nervios Central (espina dorsal y el cerebro) Periférica (espina externa y el cerebro) Classified by cause: etiology These often overlap!! Somatic pain: results from stimulation of nociceptors (pain receptors) in cutaneous or deep tissue, ex. Bone pain, “aching” or “throbbing” usually well localized Visceral pain: pain caused by activation of nociceptors from infiltration, compression or stretching of the viscera, often vague, difficult to localize, described as a “pressure or squeezing” “gnawing” “aching” not well localized, can be referred pain---liver capsule pain can manifest as shoulder pain Neuropathic pain: pain that results from direct injury to nerves in the periphery or CNS, ex. Phantom limb pain, postherpetic neuralgia, chemotherapy induced neuropathies; abnormal processing of sensory input

La Evaluación del Dolor Síntoma Re-evaluar Escuchar/Creer Evaluar Mejorar la Calidad de Vida Symptom could be related to the cancer itself, an oncologic emergency, a side effect of treatment, disease progression, or unrelated to the cancer at all. Chemotherapy doesn’t prevent someone from getting appendicitis! Each symptom must be assessed independently, while remaining aware of the side effects of the oncologic therapy Cycle of symptom management Find and fix underlying problem** Keep them comfortable while you’re figuring it out Goals of care** Cost, adherence, caregiver burden Resources (including ID team), algorithms*, consensus guidelines, etc. Prevention is the goal One change at a time Constant symptoms = consistent intervention Involucrar Establecer el Alivio 8

Constant pain = constant medication

¿ Cómo Se Evalua el Dolor? Las Preguntas: ¿ A dónde le duele? ¿ Le duele en un sólo lugar? ¿ Cómo es su dolor? ¿ Qué le alivia/empeora? ¿ Es constante o se va y viene? ¿ Ha tenido éste dolor anteriormente? ¿ Cuándo le comenzó el dolor? ¿ Cómo le afecta el dolor a su vida cotidiana? Scales help give us an idea of how we are doing in treating the pain…one person’s 5 may be another person’s 10; important to have pt rate their pain prior to intervention and then post-intervention. Pain that is rated 8/10 or higher needs IMMEDIATE intervention, does not have to be analgesia. Pain must be assessed _______________ . Effectiveness of pain relief interventions MUST be documented. JCAHO requirement.

La Evaluación del Dolor Many scales used to assess and monitor pain Describe the importance of the pain scale Pain as the 5th vital sign

Barreras a la Terapia Efectiva Para Aliviar el Dolor Temores/Conceptos erróneos Pacientes Proveedores de salud Consideraciones para el paciente Cultura/lenguaje Edad No-verbal o confundido El historial con medicamentos para alivian el dolor Fortunately, we have access to these medications, not like in Nepal/India, etc. Many patients, for their part, are reluctant to mention pain. Some may not want to distract physicians from treating the cancer, or they may view talking about pain as complaining - as not being a "good" patient. Most important, many assume that pain and cancer go hand-in-hand - that pain is inevitable, something to "tough out." In fact, cancer pain can be effectively controlled in most cases, and experts have been fighting these misconceptions for years. Pain as the 5th vital sign Patients fear of reporting pain or using pain medications Reluctance to view severe, intractable pain as a medical emergency, whether it’s on the unit, the clinic or home. Intractable pain is a justifiable reason for admission to the hospital!

Mitos Comunes “Me voy ha hacer adicta a los medicamentos que alivian el dolor” “Mejor no voy a tomar mucho ahora, porque después no me va a funcionar” “Si le digo a mi médico que tengo dolor, me parará el tratamiento”

El Dolor de los Sobrevívenos de Cáncer de Seno ¿ De dónde origina el dolor? Del cáncer De las intervenciones médicas/ de los estudios Del tratamiento o de los efectos secundarios producidos por el tratamiento No tiene relación con el cáncer Cancer itself – tumor pressing on bone, nerves or other organs Oncology emergencies, like spinal cord compression, bone pain Treatment – chemotherapy, surgery Side effects – neuropathy pain, mouth sores, etc . Cancer patients can still get appendicitis! A big increase of pain does not necessarily mean a big increase in the cancer!

Metas del Tratamiento para Aliviar el Dolor Identificar la causa del dolor y dar el tratamiento Escoger los medicamentos apropiados/ las intervenciones Reducir el dolor a un nivel tolerable que le permita mantener un nivel de vida óptima Enfrentar factores psicosociales Educar al paciente y a los que proveen cuidados Come at pain from 2 angles, w/u underlying cause and control pain Anxiety, fear, depression, confusion/delirium all can exacerbate one’s perception of pain; likewise, living with pain can precipitate depression and anxiety—creates a vicious cycle and should be appropriately treated. Address pt’s/caregiver’s concerns re: opioid therapy, specifically questions re: addiction/side effects

Terapias Para Aliviar el Dolor Farmacológicas medicamentos No-farmacológicas meditación, acu-presión, masaje, hipnosis Intervenciones Médicas “intervenciones usando agujas” bloqueo de los nervios, etc. May need to combine all modalities

Medicamentos para el Dolor: Categoría Básica “Analgésicos simples” Tylenol, Motrin Opioides Drogas parecidas a la morfina Adyuvantes Esteroides, antidepresivos y anticonvulsivantes “Weak” opioids versus “strong” opioids Adjuvants: in addition to; meds that were created for another primary purpose, but also work to relieve pain

Opiodes Se une a receptores opioides en el cuerpo Impiden el paso de los “mensajes de dolor” al cerebro Se necesitan ambos medicamentos: de acción larga y medicamentos para el dolor intermitente No tiene efecto “límite” According to the WHO, opioids are the mainstay of therapy for cancer-related pain Inhibit ascending sensory information from reaching the brain and being perceived as pain. Mixed agonist-antagonist developed to decrease SE from opioids and supposedly decrease potential for addiction. Inhibit ascending sensory information from reaching the brain and being interpreted as pain. We don’t use them often because escalating doses becomes problematic and messy.

Opiodes Comunes Morfina MS Contin/MSIR Hidromorfona Oxicodona Oxicontina/oxicodona Percocet (Tylenol + oxicodona) Fentanilo Metadona MORPHINE: --oldest analgesic known to humankind. --gold standard for cancer pain --MSIR vs. MS Contin/Oromorph, 12 hr dosing --Kadian/Avinza, 24 hr dosing --active morphine metabolites, M6G/M3G and normorphine may contribute to both analgesia and adverse side effects OXYCODONE: --only available in the US in oral forms --oxycodone vs. Oxycontin --Percocet (oxycodone + tylenol): beware the hepatic toxicity of Tylenol DILAUDID: --PO and IV routes --no sustained release preparation to date --few, if any, known active metabolites, less complex metabolism --can be good choice for patients w/ renal failure or o/w metabolically challenged patients FENTANYL: --not a great choice if drug needs to be titrated rapidly --IV, transdermal, buccal, usually every 72 hours, sometimes 48hrs --very lipidphilic—jumps into fatty tissue --patch is convenient but expensive --can take 12-18 hrs to reach peak effect --if patches are well stuck they aren’t working --may increase release in pts w/ fever --waterproof --rotate to avoid skin irritation --Actiq, fast acting, short ½ life --some data to suggest less constipation and hypotension w/ Fentanyl vs other opioids METHADONE: --tricky and pharmacologically complex drug --long and unpredictable ½ life; 5-150 hours, can take weeks to reach steady state --cheap effective --consider when needing impractical doses of other opioids --some research suggest may be more effective in neuropathic pain, hits at two receptors, opioid agonist and NMDA receptor antagonist

Parche Fentanilo IV, transdermal, buccal Patches Convenience vs. expense Not for opioid naïve patients Cumbersome to titrate, can take 16-18 hrs to reach peak effect If not stuck, not working Fever Body mass Skin irritation Systemic, not localized like lidocaine patch

Efectos Secundarios Comunes Estreñimiento Sequedad de la boca Nausea (el cuerpo se adapta) Sedación (el cuerpo se adapta) Review how we treat these side effects.

Dolor Neuropático Causas en los pacientes con cáncer Quimioterapia (CIPN) Compresión del tumor Infecciones (Herpes zoster) Intervenciones médicas/ Cirugías ¿ Cuál es la diferencia? La calidad del dolor La duración y ubicación Chemotherapy drugs, such as vincristine, cisplatin and paclitaxel, may cause nerve damage in some people. This nerve damage may cause numbness or a burning or shooting pain, usually in the fingers or toes. These side effects usually go away after chemotherapy treatment ends, but in rare cases, the numbness or pain can persist. It is important to tell your health care provider if you have this type of pain or numbness as he/she may want to change your chemotherapy treatment plan to ease these symptoms. Your health care provider may also prescribe mild pain relievers or recommend other types of treatment to ease the pain or numbness. Thoracotomy/Mastectomy Burning, stabbing Hyperalgesia, allodynia Only partially opioid responsive

Dolor Neuropático ¿ Se puede aliviar el dolor al nervio? Educación Medicamentos Opioides Anticonvulsivantes (Neurontin, etc) Antidepresivos tricíclicos (Amitriptilina, etc) Tópicos (crema apsaicina, parches de lidocaína) Pain should gradually improve after therapy ends Important for you to let us know about nerve pain

Dolor Neuropático ¿ Cómo se alivia el dolor neuropático? Sigue bajo investigación Vitamina B/Vitamina E Calcio/suplementos de magnesio No- farmacológicos Estimulación Transcutanea Eléctrica de los Nervios (TENS) Técnicas de relajación, acu-presión y masaje Ejercicios Intervención con anestésicos Bloqueo de los nervios, etc.

Maneras Como Usted Puede Ayudar Llevar un diario de su dolor Historial de sus alergias Tomar los medicamentos de acuerdo a la receta y avísenos si no le alivian Monitoree cualquier efecto secundario ocasionado por la terapia contra el dolor

En Resumen La gran mayoría (>90%) de dolor del cáncer, puede ser controlado con medicamentos simples y con intervenciones La clave para ayudarle, es que usted le comunique a su proveedor de salud, si usted siente dolor Especialistas del dolor/cuidado paliativo están dispuestos a ayudarle aún si su dolor es intenso

Recursos Sociedad Americana del Cáncer www.cancer.org, busque “dolor” Instituto Nacional del Cáncer: dolor http://www.cancer.gov/search/results.aspx?lang=s panish www.chemocare.com, escoja Español y busque “Entumecimiento, hormigueo y dolor periférico” National Coalition for Cancer Survivorship www.canceradvocacy.org, “es Español “neuropatia” o use éste enlace: http://www.canceradvocacy.org/espanol/resources /neuropathy.html