Holistic Managementof Cancer Pain:Beyond Opioids

Christian Sinclair, MD, FAAHPMKansas City Hospice & Palliative Care

April 8th, 2010

Objectives

• Clarify the broad umbrella of holistic health• Discuss the major elements of a holistic

assessment of cancer pain• Apply proven holistic therapies for cancer pain

The Impact of Pain

• Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

Endocrine

• Increased– ACTH– Cortisol– ADH– Epinephrine– Norepinephrine– GH– Catecholamines– Renin

– Angiotensisin II– Aldosterone– Glucagon– IL-1

• Decreased– Insulin– Testoterone

Metabolic

• Gluconeogenesis• Hyperglycemia• Glucose intolerance• Insulin resistance• Muscle protein catabolism• Increased lipolyis

Cardiovascular

• Increased – HR– Cardiac output– Myocardial oxygen consumption

• Hypertension• Hypercoagulation• DVT

Pulmonary

• Decreased– Airflow– Volumes– Atalectasis– Shunting

– Hypoxemia– Cough– Sputum retention– Infection

GU/GI

• Decreased– Urinary output– Retention,– Hypokalemia

MSK

• Fatigue• Immobility• Muscle spasm

Developmental/Psych

• Reduced cognitive function

• Altered mood• Increased anxiety• Depression• Addictive behaviors• Future pain disorders• Insomnia

• Suicidal ideation• Fear• Hopelessness

Holistic?

• Taking into account all the needs of a patient– Physical– Social– Psychological– Spiritual

• Essential element of palliative medicine

Holistic Can Also Mean• ‘New Age’• Complimentary and Alternative Medicine• Herbal medicines or botanical supplements• Exotic rituals• A natural approach• Art and music therapy• Hypnosis• Imagery• Meditation• Psychotherapy• Spirituality and prayer• Yoga

Cancer Pain Assessment

• Biomedical model– Pain scale• VAS

– Are you hurting? Do you have pain?– Location, intensity, quality– Onset, duration, variations– Therapeutic effectiveness– Physiologic signs

Cancer Pain Assessment

• Holistic Model– How are you feeling today?– Do you have any pain?– Include elements of biomedical model– Observe patient at rest and with

function/movement– Cultural considerations– Family input– Temporal/Contextual considerations

Who is the expert on pain?

• No objective measures exist• Patient report is the gold standard– But open to many alterations– Interpretation bias from staff/family

• Important distinction between accepting and believing a patient

Cancer Pain Treatment

• Education of patient and family– Administration– Indications– Addiction concerns– Diversion concerns– Tolerance concerns– Cultural concerns

Attitudes

• Patient/Family/Staff exaggerated fears about ‘narcotics’ and addiction

• Skeptical of health care professionals to relieve pain

• Lack of access to effective pain control

Non-Drug Approaches to Pain

• Method can be direct pain reduction• Or indirect– Making pain more bearable (changing pain

threshold)– Improved mood– Reduced distress and fatigue– Increasing control– Increasing sleep effectiveness

Non-Drug Therapies

• Usually inexpensive• Low risk• Easy to do• Readily available• Not uniformly effective (intra or interpersonal

differences)• Usually in addition not substitution of

medications• Lack strong scientific evidence

Cutaneous Stimulation

• Heat, cold and vibration have been shown to be effective in various pain types– Increase pain tolerance – Reduce pain

• Doesn’t always have to be at site of pain– Direct– Proximal (between the pain and the brain)– Distal (beyond the pain)– Contralateral (consensual response v. distraction)

Cold v. Heat

• Thought to be related to increase or decrease of blood flow– Underlying mechanism not clear

• Both cause decreased sensitivity to pain, decrease muscle spasm

• Cold – numbness/anesthesia• Limited in hospital by physician’s order

Heat

• Typically 104 to 113F• Warms only superficial skin (restinsulated by

subcut fat) • Can be applied indefinately• Avoid immersion• Avoid burns– Layer between heat source and skin

• Avoid in irradiated skin – possible increased tissue damage

Cooling

• Usually around 60F• Can cool the muscles in sites with decreased

subcut fat– 10 minutes in slender people– 30 minutes in obese people

• Can be applied indefinitely at low level• Cold usually relieves pain better longer and faster

than heat• Alternating probably more effective than either

Vibration

• Can cause numbness, paresthesia/anesthesia• Can change quality of pain (sharp ->dull)• Avoid in – Patients with easy bruising– Thrombophlebitis/clots– Injured skin

Distraction

• A type of sensory shielding– Focused attention on other areas decreases pain– Can be internal or external

• Increase pain tolerance and self-control• Decrease in intensity• Changes in quality of pain• Limitations– May increase pain– More useful in acute pain than chronic pain

Successful Distraction Techniques

• Interesting to the patient• Consistent with patient’s energy level• Ability to concentrate• Rhythm is emphasized (keeping time)• Stimulate all senses– Hearing, vision, touch, movement

Visual Distraction Techniques

• Picture– Look at pictures and describe them– Hide picture and recall– Count or name items or colors– Tell a story– Mix known vs. new photos– Photographs versus art/paintings

Musical Distraction Techniques

• Pick a song you know the lyrics to• Sing (out loud or just mouth the words)• Mark time to the song (tap finger/toes)• Sing faster/louder if the pain increases

Music Therapy

• Controlled trials demonstrate– Reduced anxiety, stress, depression and pain– Decreased HR, RR– Trials have demonstrated decreased pain med

needs• Trials have often been small and exact cause

of responses unclear– From music or relaxation?

Humor

• Of questionable impact• Studies conflicting• But if it helps your patient then use it

Relaxation

• Alternating tensing and relaxation• Progressive relaxation• May be combined with imagery/music• Tend to have a narrow focus• May require practice and motivation• Deep breathing• Time involved may be a limiting factor• Rarely selected non-drug approach

Art Therapy

• Behavioral modality• Enhances coping skills• Well studied in children– And can be effective outlet for adults

• Limited evidence, limited availability• Often seen in self-motivated individuals

Acupuncture

• Availability limited by provider availability• Evidence is mixed• Current Cochrane Collaboration is underway• More evidence with nausea/vomiting

associated with chemo

Therapeutic Touch/Reiki

• Often has ties to ‘ancient healing methods’• AKA distance healing / energy field

manipulation• Not connected with faith healing• Debunked in JAMA 1998 by an 11 year old• Cochrane Review– Lack of sufficient data means results are

inconclusive, the evidence that does exist supports the use of touch therapies

TENS for Cancer Pain

• Electrical stimulation via battery• Limited use in chronic back pain per Neurology review

• Not widely used secondary to lack of availability

• See your local PMR doc• Cochrane Collaboration Review– ‘Insufficient Evidence’

Opioids and Cancer Growth

• Highlighted in the media end of 2009• Based on speculative connections with

methylnatlrexone and opioids given at time of surgery

• In very early stages of research• See www.geripal.org for review of the

evidence

Summary

• Medical analgesia should be the main therapy• Consider physical, social, psychological,

spiritual aspects of patient and family in assessment

• Get access to experts in these holistic modalities – amateur efforts of minimal help

• May need to try multiple approaches to non-drug management of cancer pain

Contact Info

• Christian Sinclair, MD, FAAHPM• Kansas City Hospice & Palliative Care• Cell: 816-786-8895• Email: csinclair@gmail.com• Twitter: @ctsinclair• Blog: www.pallimed.org

References

• Oxford Textbook of Palliative Medicine 4th ed• Pain Clinical Manual 2nd ed –McCaffery &

Pasero• Malone MD, Strube MJ, Scogin FR. Meta-

analysis of non-medical treatments for chronic pain. Pain. 1988 Sep;34(3):231-44.\

• The Cochrane Review – Pain, Palliative and Supportive Care Group

References

• Cold and Heat studies: Bini 1984,Shere 1986, Collins 1985, Creamer 1996, Lehman 1985, Melzack 1965, Yarnitsky 1997

• Dubinsky, Miyaski. Assessment: efficacy of TENS in treatment of pain in neurologic disorders. Neurology 74(2) 173-176

• Rosa, Rosa, Sarner, Barrett. A Close Look at Therapeutic Touc. JAMA 1998; 1005-10.

• Ward SE et al. Patient-related barriers to management of cancer pain. Pain. 1993 Mar;52(3):319-24.