Welcome to our session on the basics of pain management for cancer patients from the time of diagnosis through palliative care. We will focus today on lung cancer. Your faculty for this session include myself. I'm a professor of medicine at the University of Wisconsin. I am a thoracic oncologist and I also trained in palliative care actually here in Chicago at Northwestern and I continue to practice both palliative care and then thoracic oncology. Dr. Kavitha Ramachandran is a professor of medicine at Stanford where she directs a number of programs including a clinician education mentorship program and medical director for cancer services at Stanford. Also a dual trained palliative care medical oncology physician who continues to practice both. Next we have Becca Jones a palliative care very experienced palliative care clinician who currently focuses on cancer clinic palliative care where she's routinely seeing patients. She's at the University of Nebraska in Omaha. Next Dr. Lauren Cech who's an assistant professor of medicine also dual trained in palliative care and oncology also thoracic oncologist. She's at University Hospital Seidman Cancer Center in Cleveland. We are fortunate to have two patient advocates today. Dave Bork is the founder and host of the Research Evangelist podcast. He is also very curious and engaging person who is someone I feel like you want to hear from. Dave himself is a lung cancer survivor had a lobectomy after a thoracotomy over 20 years ago and has a great story not great has a terrible story really to tell about pain but great in the sense that it can make a lot of points for us today as we're learning about pain. And finally Chris Conneran is a representative from the KRAS kickers. Chris is a care partner for his wife who has KRAS positive non-small cell lung cancer but is herself a seven-year survivor and doing lots of work. In fact she's speaking somewhere else so she sent Chris and her to represent and talk about caregiving and lung cancer. So there is our panel as we open here are our disclosures. Briefly our learning objectives are to illustrate how to effectively assess and screen cancer patients who require pain management. So we want to help you identify which patients in your panel are those for whom we should be embarking on a path of managing their pain whether that be acute pain or for the purposes of today we will focus more on the chronic pain patient someone who's going to need pain management for a longer period of time. We'll talk about the pharmacologic options for treating cancer pain the non-pharmacologic options for treating cancer pain. We will talk throughout about communication strategies as they apply to the management of this patient population and those are going to be our major objectives. Without further ado may I introduce my colleague and friend Dr. Ramachandran. So I just wanted to see how many of you here take care of people who have a cancer diagnosis. Can I get a show of hands and how many of you work in industries that support cancer patients and how many of you have had an experience with cancer either for yourself or a loved one. Really nice is this really is a space for us to learn together and to use this information to make the quality of our lives of the patients that we care for and the family members that we bear witness to better. So we hope this helps and this conversation moves this forward. So I have a case and it's modeled on a few different folks that I've taken care of so it's not just one person. We were really trying to evoke different kind of flavors of what cancer medicine looks like today and also the different experiences people may go through over the course of their therapy. So this is a 66 year old carpenter an active grandparent who has a prior smoking history 40 pack years and has a new diagnosis of non small cell lung cancer with squamous cell histology. Unfortunately found to be on diagnosis metastatic to the bones. He had a CT scan which revealed a large five by five centimeter left sided mass associated bulky lymphadenopathy as well as bone metastasis to the vertebral spine. He had a bone biopsy done which showed that he had squamous cell histology. He had no actionable markers and we'll spend a lot of time in this meeting talking about all of these different actionable but markers but he did have a PDL one of 100 percent and he presented to our clinic with significant pain in his back radiating down his leg. So there are many different methods to assess and look at the cause for pain and I would say that you should pick one method and use the same method for your patients ongoing. One of the polling questions asked you which method you would use and I think many of them would work and we'll talk about that throughout the course of this but I chose to use the visual analog scale and one of the things that I usually do for people I care for is I just ask them what their normal day looked like before they had symptoms from their cancer and I learned this actually from one of my colleagues at Northwestern 15 years ago when I was training here when she just said can you describe a day to me what does a normal day look like for you and that actually told me so much more than asking 15 questions in a review of systems because I just got to know who they were, what was important to them, why they really wanted to do things in a certain way, what toxicities would really impact their quality of life. I also got to understand how quickly things had changed for them and what their function now look like today as a result of their disease. I also learned that it was really really important to not only talk to the patient but their loved ones or caregivers in the home because patients often want to present a certain type of face to you and caregivers and loved ones can often provide really integral information about how the patient is doing and then I also spent a lot of time normalizing pain and normalizing palliative care because a lot of folks feel like it's weird that they're struggling or they're suffering that if they're not perfectly well they may not get chemotherapy or targeted therapy or immunotherapy so just saying it's normal to have pain and you know a good percentage of patients who have a cancer diagnosis have pain and we really want to treat this so that you have the best quality of life. The other fear that a lot of folks have is that palliative medicine means that you're taking care of someone who's coming close to end of life and so I also normalize palliative care and its role. So just quickly we're going to talk about this more later so I won't talk about this too much but pain comes from a variety of different areas, the cancer itself, the treatment as well as procedures and you're going to hear a little bit more from our advocates. And so as we noted here you're going to screen for pain at each visit, you're going to do a comprehensive pain assessment and then we're going to talk a little bit about when you're going to call for help. Cancer is a team sport. Call for help. It's okay to get help and support for your patients and families and also it's really important to assess for the impact of and disease on the psychosocial care of your patients. So what are our goals? Our goals are really to make people's lives better. Everyone should feel better and that's when we know we're hitting the golf ball in the right direction. If we're not making people feel better we're probably not doing the right thing and most of the time when I talk to my patients about either the treatments I give them to treat their disease or the treatments that I give them to treat their symptoms I say you need to tell me how you're feeling and how you're doing because if it's not quite right we can make it better but you need to actually talk to me about it. So in very normal fashion the patient notes that his pain is a six out of ten but his wife actually says no doc it's a ten out of ten and he's very stoic. He notes that his pain is in his lower back but also has associated numbness and tingling that radiates down his legs. He has no associated weakness or bowel or bladder symptoms but he does say that he used to be able to work a full day and really enjoyed working in his shop and now is down to four to five hours and his goal is really to kind of go back to his normal activities. So as I mentioned before I think physical pain affects mood and so it's really important not only to screen for physical pain but also to screen for emotional needs and mental health needs and so using a validated depression screen such as a PHQ-2 or a distress screening instrument such as the NCCN distress thermometer is really important. The caregiver is also really important. If the caregiver is not well I can guarantee you the patient is not well. So it's really really important to not only screen the patient but also the screen the caregiver with a standardized screening tool for how they're doing and also make sure that they're plugged into care and taking good care of themselves. And then also note that a lot of people feel like they want their pain to go to a zero and to just normalize that we may not be able to do that but we'll do our best to get their pain to a number where they feel like they can function. And then also that pain is again not only do you need a team of people to take care of pain but also that pain can be treated in a variety of different ways including non-pharmacologic approaches. So for this patient we have options. He's got pain in his back radiating down his leg. I thought about the fact that I could refer him to radiation oncology. I thought about the fact that I could refer him to palliative medicine or to pain clinic. There are different reasons for all of these and you're going to hear about the different ways that people can support. So this patient was referred to radiation oncology and I said do you want to go see palliative medicine and he said no I just don't have enough time for that. But his wife actually reveals that he's very fearful that I had referred him to palliative medicine and is actually worried that maybe I might be saying that he has a very limited prognosis. So in the honor of not overwhelming, so basically I started him with this patient was started on oxycodone five milligrams q4 hours but his pain is poorly controlled and his wife tells you that he's taking the pain medicine every three hours and still not feeling great. So what do you do now? Do you switch to a short-acting morphine like MSIR? Do you start a long-acting oxycodone based on his 24-hour intake? Do you do a modified opioid risk assessment tool or do you assess for adjuvant analgesic needs? So we actually did a couple different things. He was using a short-acting medication quite frequently so based on that you could safely start him on a long-acting and my colleagues will talk a little bit about how to do this. You also start him on adjuvant because you recognize that he has a component of neuropathic pain. You expedite his referral to radiation oncology and you decide that you don't need to do a risk tool for opioid risk and because of his wife's worry you defer palliative medicine. So your patient completes his radiation to his spine and still using a little bit of oxycontin but is using less oxycodone. He goes back to working full-time and playing with his grandkids. He started on chemo and immunotherapy and yay this does happen. We were just chatting about this. Two years later he comes to you for a routine surveillance check. You look at his scans. He actually has no residual disease. The rules at that point are to stop the pembrolizumab so you do and then the nurse says, oh doc, as you're leaving the room, which also happens, can you refill his oxycontin prescription? You're like, huh he has no disease. Why am I still refilling the oxycontin prescription? What do you do now? So do you do a pain assessment? Do you do a modified opioid risk tool? Do you consider a palliative medicine consult? Do you consider a consult to addiction medicine? Do you rotate his opioids to a partial opioid agonist? Start at the beginning. So you did do a pain assessment and you also realize that he has a family history of alcohol dependency as well as occasional usage of his oxycodone for trouble sleeping. So we started this for him thinking about his back pain radiating down his leg. It's gone now but he is now starting to use his oxycodone for uses that we would ideally not recommend. So what do you do now? Openly discuss your concerns about opioid dependence. Develop a dosing plan which includes the caregiver. Consider referral to pain clinic or palliative medicine. Consider titration off of opioids or consider a partial agonist as a bridge. So I'm learning this as I get older and probably not wiser I'll be honest. But I'm learning that a lot of people even with cancer have family histories, personal histories that we need to take into account when we start to put people on opioids long-term. So it's a relatively new practice of mine is that I do I have been starting to think about doing a modified opioid risk tool for most of my patients just because opioids are important drugs for everyone to be educated on and we do need to use them and we need to use them for cancer patients but we also just need to be a thoughtful educators on the risks of being on them long-term and for those folks who have higher risk for opioid dependency at least counseling them on it so that they are also eyes wide open coming into it. So I do recommend starting to standardize a modified opioid risk tool and then also start to educate patients that we do need opioids and it's a really important bread-and-butter part of medicine but you don't necessarily need to take it forever and as people are living longer we do need to start thinking about when we need to taper it off and we should be very active participants in our patients care about when to start to taper off these medicines. They should not become routine use where two years later the nurse is still asking me to do refills and then a lot of these patients do benefit from a referral to palliative medicine or a pain clinic just to have a second eye on how things are going and as we all know palliative medicine is not about the end of life it's about quality of life and they can be wonderful partners in managing patients. Thank you. Thank you so much. Dave could I turn to you first and I'm just curious if you wouldn't mind sharing some of your story about living with pain and needing to find a way to get access to the medications that helped you feel better helped you live better. Yeah sure. Yeah okay. Yeah so I'm a lung cancer survivor and I was diagnosed over 20 years ago and had a lobectomy as you said and you know the really invasive kind that's how I describe it because it was broken ribs and chest tube and a week in the hospital at Mass General on a morphine trip and then sent home and well I couldn't even it took months and months and finally my doctor didn't even recommend the pain clinic I didn't even know they had a pain clinic and they but they did and so I finally ended up going to the pain clinic and got put on Neurontin and it helped it was but it took I don't remember how many months it was but it took several months for them to direct me to where I should have gone in the first place because it was this nerve pain that was you know it was the bone pain too but it was I think it was mostly the nerve pain that was really just uncomfortable and it's still 20 years still I still have remnants of the pain you know where I have to yeah just it's just still there but it's manageable. Yeah and I would reflect on Dr. Ramchandran what you said about phone a friend right asking for help it's a team sport and sometimes when you recognize that someone is having difficulty past what you're feeling comfortable with to ask for assistance you know it's a great strategy and allows you to live 20 years run a podcast run all kinds of different things but you can't do it can't do it when you can't even drive a car. Exactly yeah. Chris could I turn to you as a as a we've been using the term caregiver I know you prefer a different term you could introduce that but just what's it like to see the person that you're caring for in pain? Well first of all I'd like I really like to think is like for the opportunity to have a care partner we're calling care partners at a caregiver because a lot of times we're a partner in this it takes a community and I think somebody already said that about takes a community to beat this cancer and and to take care of someone with cancer it's a very major thing I can just tell you when my wife was diagnosed seven years ago, we went through the chemo. She went through a resection. When she was on chemo, she's very active. And all of a sudden, she can't hardly get out of the sofa. She's in so much pain. Going through that, it's heartbreaking. And what do you do? What's the next steps? We don't know. I mean, I'm in IT. I'm a mathematician. I'm not a doctor like you guys out here. I've never seen this before. So it's really scary. And we started looking and looking and looking for information about her until we found out she was KRAS. We couldn't find any. And anything I found, we got recommendations to get dog dewormer. That'll help you. All sorts of crazy things about pain meds online that made no sense at all. So what we did is, and what my wife is doing great now, she formed a KRAS Kickers. And basically what that is, it's a power, we call it an empowerment group. And what I'd love to do is, real quick, is I'd love to give you guys each a pair of socks. And I want to invite you guys to come see us because we are a community. We try to bring the patients, the caregivers, we try to bring the scientists, we try to bring the doctors, everyone together to beat this and help with pain. And it's really stressful. When my wife was going through pain, I'm going to tell you something, this is a true story. She was going through so much pain, I didn't know what to do. As a guy, we fixed things. Couldn't fix it. So you know what I did? I heard that dust was bad in the house. I ripped all the carpets out of our house and took all the curtains down and put in hardwoods. Ask her what she thought about that later on. It's powerful to hear what it's like and how scary it must be to see someone that you love struggling not even able to get off the couch. Well, we want to continue to try to help with that. We're going to turn our attention to non-pharmacologic strategies. And my friend and colleague, Dr. Cech. And I know we've talked a lot about managing cancer and pain and how it's a team sport. So I really want to focus the next few minutes on some non-pharmacologic strategies and some interventions for the management of cancer pain. I think it's important, and we've heard a little bit about this already, to remember that cancer pain is not just a physical symptom, but it really impacts the psychological, the spiritual well-being of patients, their social interactions, their cognition. So when we think about strategies to manage pain, I think we also need to think about those approaches, which can really have a big impact. I'm going to focus mostly on radiation therapy and some interventional strategies. But we'll briefly also touch on some psychological, functional, and integrative approaches. So as we heard a little bit in the first case, palliative radiation is really one of the most commonly used strategies for non-pharmacologic management of pain. Usually, this is for bony metastases, but can also be used for other areas of focused pain. Historically, this was with external beam radiation therapy. And we often tell patients, it's going to take a couple of weeks before your pain starts to get better. And even up to six weeks later, you still may see improvements in your pain, so really educating patients about how to expect improvements in their pain. I think it's also important to remember some patients may have flares of their pain during radiation, so preparing them for that, and potentially even using something like a corticosteroid to prevent that. For other patients who have bony metastases that are causing a pathologic fracture, or maybe an impending fracture, potentially in the femur, for example, it's also important to make sure that we're referring to our orthopedic teams and considering prophylactic pinning or other strategies prior to radiation therapy. Now, I'm a medical oncologist, so I won't go into the true details about the dosing for radiation. But I think it's just really important to remember that the dosing needs to be individualized for the patient in front of you. So the patient's location of pain, their disease burden, their prognosis, what are the systemic therapy options that are available, how quickly do we need to get them to radiation, all of these things can really impact the dosing and the strategies. And that's where really working as a team with our radiation team is important. Historically, there were fractionations looking at things like 30 gray and 10 fractions. And since then, I think we've really seen a lot of data come out that a single fraction of radiation, 8 gray, can be very effective and almost equally effective for pain management for these patients. The main caveat being that sometimes when you're using a single fraction, there may be a higher rate of requiring retreatment down the line. But this can be a really important strategy when you need to get somebody to pain management pretty quickly. And for patients who have a poor performance status or a shorter prognosis, that can be a really great option. The radiotherapy, which is being utilized a lot more commonly now, there's quite a bit of data about the safety for this for patients with palliation of pain, specifically for patients who have things like spinal cord compression, oligometastatic disease. This can be a really great approach. We also have a lot of data now really showing that SBRT is at least as effective as conventional radiation, if not more, for some patients. Although there's also a caveat that we have some data that doesn't show it's as effective. So I think, again, really personalizing for the patient in front of you is important. A lot of these studies have differences in the patients and the strategies for radiation. So again, really kind of looking at the patient and deciding with the radiation team what's most appropriate can be helpful. Moving on now to kind of some interventional strategies that I want everybody to be aware of. This can be surgical strategies or anesthesia strategies with our anesthesia pain teams. These are really limited to sites where you have access to a specialist with expertise in these procedures. So that can be a limiting factor. But I'm going to focus a little bit on the management of pathologic compression fractures, as well as some neural anesthesia options and neural blocks. Pathologic compression fractures are really common. We see these a lot for patients who have bony metastases. And often, these are able to be managed conservatively with the pharmacologic strategies we're going to talk about. But for some patients who have refractory pain, procedures may actually be really helpful, or for patients who have side effects from some of the medications we're going to talk about. Two of the most commonly used procedures are vertebroplasty, where we're actually injecting bone cement into the collapsed vertebral body, or kyphoplasty, where there's insertion of an inflatable bone tamp. And then subsequently, cement can be injected into that. These have not really been looked at as far as which one's superior. So it really relies on the expertise you have available. But really, studies have shown that this shows improvements in pain control, decreased need for opioids, and improvement in disabilities or functional status for patients. I think for some patients who really are not able to respond to the standard treatments, this can be a great option. There are some contraindications for this. So for patients who have unstable or neurologic side effects, or have any impingement on the spinal cord, this would not be recommended. Now jumping to neural blockade, I think neural blocks are something that we are starting to utilize a lot more commonly. This can be a non-neuralytic peripheral nerve block, which just involves injection of an anesthetic. And it can also be a neurolytic block, which is truly causing damage to the nerve to improve the patient's pain experience. This is sometimes with alcohol or phenol, can be a cryosurgery, true surgery, radiofrequency ablation. There's a lot of different strategies for this, again, depending on the expertise that you have available. This can be directed at somatic nerves. And it can also be directed at sympathetic nerves, which can be a really great approach for patients who have visceral-type pains. And there's a lot of different approaches for this. It really depends on where patients have pain. I think the most common one that we see, especially for patients with pancreatic cancer, for example, is the celiac plexus block. This actually targets patients who have pain from their pancreatic cancer, upper abdominal, visceral-type pain, and can really be effective in minimizing their requirements for opioids and improving quality of life. I think that's probably the one that's been most studied. But for patients with lung cancer and maybe chest wall pain, paravertebral intercostal blocks are something that we can consider as well. It really is crucial here to work as a team with your interventionalist, because the type of pain, where the pain's coming from, is really important when they're trying to plan out what strategies may work for a patient. The blocks that are not actually neurolytic can be helpful in trying to help determine if a true neurolytic block will be successful for patients. So sometimes, they will do a non-neurolytic block as kind of a test. And some patients actually can get lung pain management just with that strategy. Some other neuraxial techniques, I think, just to be mindful of. Spinal cord stimulation is something patients have asked about, and I think that's because it's used a lot more in the chronic pain space. Hasn't been studied a lot in patients with cancer, but I think there are select patients where this is a strategy to consider, especially those who have neuropathic pain or a significant neuropathy potentially. And then neuraxial infusion, this is where we're actually infusing pharmacologic agents into either the epidural or intrathecal space. This is really helpful, because it allows us to target the opioid receptors in the dorsal horn of the spinal cord, which helps to address the pain by minimizing also some of the systemic side effects from pain medications. This can be really effective. It is an implantable, usually, device. So we usually kind of recommend this for patients who have a prognosis of at least three to six months. And usually for patients, again, it is a procedure. So usually for patients who have kind of had intractable pain despite some of the other strategies that we try. Some of these actually have patient-controlled analgesia aspects, PCAs, so patients can actually control a component of their pain management that they're getting. And these can be really successful for some of our patients as well. And then I think this area could really be a whole talk all in itself, but just kind of remembering that there's a lot of other strategies when we're thinking about managing the various domains of patients' cancer pain. Psychological aspects of care, so cognitive behavioral training, guided imagery, mindfulness techniques, those can always be really helpful to not only helping patients with the experience of pain, but also with their coping strategies. Physical and functional aspects, so thinking about rehab or cancer rehab, physical and occupational therapy, which can help with pain but can also help with function and therefore the experience of pain. Integrative approaches, things like acupuncture are becoming more widely used and I think are a really great option for patients too. Being mindful of the spiritual aspect of pain. Spiritual distress can certainly cause patients to have a higher frequency or a worsened experience of pain, so addressing spiritual distress is really important in helping to manage pain. And I think also just being culturally aware as we provide this care that patients really are experiencing pain and they're experiencing their diagnosis not in a vacuum, really with their whole family and their whole culture and a lot of different things that they bring to the table, so being mindful and communicating about that with patients is really important. And with that, I will kind of pass it over, I think, to a little bit more discussion. Thank you so much. Chris and Dave, I'm interested, of course, in your perspective on this, but perhaps just to frame your thinking, was it, Dave, and for you in particular, was it difficult to convince your physicians that you were in pain? What, did you, do you think that access to programs like this would have been helpful? That definitely would have been helpful. I feel like, you know, I wasn't working with my surgeons, I was working with my, it was back to my primary care doctor and, you know, he's busy, he's running all these different programs and it's like he only sees patients once a week and just literally access to getting him to pay attention to me was very challenging and so I think there was an assumption made that, you know, just be a big boy and get over it, you know, it's like, you know, it's not supposed to be fun. By the way, I was in, when I came out of my surgery, I was confused, I was, my lips were all chapped, I was, I was, the bright lights and loud noises and this nurse said to me, well, you just had a lung surgery, it's not supposed to be, you know, it's not supposed to be, you're supposed to hurt or something. It was just so insensitive and I remember that to this day but I think just the communication part, you know, team sport, I love that idea because why not, you know, send me to someone who can help me? Don't just say, well, you're gonna have to take a codeine or whatever. It's like, he wasn't listening, I think, you know? To that point, Chris or Dave, have you learned any strategies over the years as a patient that engages the doctor in a way that then you find that they listen better? I mean, of course, we want to listen, right? And I wish that that story that you have wasn't the story that happened to you but I'm just curious if you've learned any things or cues that doctors should be listening for to sort of help them hear. Yeah. I would say in our community, one of the things that's been really enlightening to us is the integrative oncologist. And we've been encouraging that with our survivors to go out there and meet with them and get a whole body experience of what the treatment types are. And that's been one way, it's actually opened a lot of eyes. I think also going to some of these meetings like this and telling folks, hey, you know what? My loved one is in a lot of pain and I know you hear it every day, this is pain, this is pain, but understand it's our loved one. We're gonna be the biggest advocate for ourselves. I think learning, like we just heard what you just got here. I never knew any of this stuff. I was been going through this a long time. So getting that information out to the survivors is critical because when they're in pain, all you want to do is fix the pain. And I guess one of the questions I wanted to ask is with these different types of treatments, are there any of these treatments can prevent them going forward like if they want to get on a clinical trial down the line? These are questions that we're gonna have as our caregivers are gonna say, well, these treatment you're giving them, what are the impacts long range? Some of the treatments that my wife was given and other folks we know were given, it impacts their sex life. It impacts when you get chemo, some of these things really impact them and we don't know it until after the fact. So when you do get this pain treatments out, let us know what some of the side effects are and some of the implications longterm. Is this a short term implication? Is this a longterm implication? Because that really does feed into the decision whether we even want to take a treatment like that. Yeah, that's a great point. And one of the things that I'm taking away, Chris, from your words and from Dr. Ramchandran's words, which is your statement was so poignant, Kavitha, when you said, if the caregiver's not doing well, I guarantee you the patient's not doing well. And so I think I could turn up my assessment of the caregiver as a clinician in the clinic and detect some of the things that Chris is talking about if I give you the space to voice those concerns. Well, thank you all for that. We now want to turn our attention to pharmacologic approaches for the management of pain. And for that, we will welcome our colleague and friend, Becca Jones. Thank you guys for having me today. I'm going to try to quickly talk through some of the pharmacologic options for pain. This is just a repeat slide that you saw before, but I just want it as a reminder that more than likely, at some point in their cancer journey, your patient will have pain. And keep in mind that it's also likely multifactorial. And so our approach to pain management should also be multifaceted. So without further ado, when we're talking about pain, earlier it was mentioned getting a good assessment regarding what their life was like before cancer diagnosis, and then after cancer diagnosis, and how that pain has impacted them. It's highly unlikely that we're going to be able to get their pain down to a level of zero. So I think open communication about pain goals, and the hope that we could approach their pain and get it to a tolerable level where they're still able to do some of those activities or those things that they typically enjoy. So NSAIDs, I think these are often forgotten about, but very important for mild pain. Biggest thing to keep in mind is the increased risk of bleeding, particularly with certain chemotherapy regimens, and then keeping in mind those with a chronic kidney disease. But don't forget the use of NSAIDs for mild pain. Acetaminophen also can be useful for mild pain. One of the things that I often do for patients is I schedule some acetaminophen just for baseline pain relief. However, you do need to keep in mind if there's liver impairment, then generally that max dose of three to four grams a day, we would reduce down to two grams a day with liver impairment. And then also you need to watch the use of acetaminophen if your patient is also on a combination product of an opioid with acetaminophen. But this can also be a great option for mild pain. So then moving on to opioids. So when we talk about pain, we talk about nociceptive or neuropathic pain. Opioids can be useful for moderate to severe nociceptive pain. And then certain types of opioids, particularly methadone, tramadol, and then tepentadol, can be more useful for neuropathic pain. So they work on the mu, kappa, and delta opioid receptors and basically alter the perception and response to pain. When starting an opioid, it's important to always start low and go slow. So I think we all learned that in Pharmacology 101, start low and go slow. When dosing, I often start off with a Q4 hour PRN starting dose, and you'll see why when we get to the pharmacokinetics. And then it's important to keep in mind, is your patient opioid tolerant or not? And I'll talk about opioid tolerance on another slide. Other things to keep in mind, do they have kidney dysfunction or liver dysfunction? What's their age? Is cost gonna be a factor of formulation? and then is there concern for abuse. I always recommend referring to your state's prescription drug monitoring websites and reviewing that before prescribing opioids and then we'll talk on the next slide or on a future slide about when to start a long-acting opioid. Some other pearls to consider when prescribing opioids, if somebody is on an opioid and it doesn't seem to be effective, then it just may not be a strong enough dose or maybe they've been on it a while and they just need an opioid rotation. Always try to avoid multiple opioid types if possible. So I saw patients, inpatient all the time, who were on oral morphine or IV morphine, oral oxycodone, and fentanyl patch and the reason why is for when you're going to do transitions to a different opioid type or if you're worried about opioid toxicity or also just for the patient, for being able to manage that at home and not get confused with the dosing. Never start an opioid naive patient on a long-acting opioid. In terms of dose escalation, so if you have a patient on an opioid and their pain is still not well controlled, if you make a dose escalation of less than 25%, they're probably not going to notice a difference. So if they're still reporting moderate to severe pain and they're otherwise tolerating their opioid well, then I would do a dose increase of 50 to 100%. If they're reporting mild to moderate pain and otherwise tolerating the opioid well, then I would do a dose increase of 25 to 50%. So some of the opioid adverse effects and risk and not all of them are on this slide, but an important one to keep in mind is constipation and that is one that unfortunately does not go away the longer that someone is on an opioid. So anytime you are prescribing somebody an opioid, you should also be recommending a bowel regimen and so usually first line we would recommend a stimulant or an osmotic laxative. In terms of respiratory depression, I think it's most important to identify those high-risk populations, so those who have underlying lung disease, those who may also be on like a benzodiazepine, those with diabetes, a female population. So those are just things to keep in mind, but it's not necessarily a contra indication to prescribing opioids. Opioid-induced neurotoxicity, so I've been practicing in palliative care about nine years and I've only seen this about a handful of times, but when I have seen it, typically those patients have muscle jerking. Another thing to keep in mind would be if they're reporting 10 out of 10 pain and you're escalating their opioids as we talked about before and their pain level is not going down, then maybe they are actually opioid toxic and the treatment would be to actually reduce the opioid and titrate to a different opioid type and then sometimes you treat the muscle jerking with some benzodiazepines. And then keep in mind for chronic use of opioids, how it can impact hormones and also cause immune suppression. So this is talking about the pharmacokinetics of opioids. I won't spend a lot of time on this slide, but keep in mind one of the things I see oftentimes for like immediate-release opioids, such as immediate-release morphine, is they'll see it dose maybe Q8 hours or Q12 hours PRN. Well, the duration of action is 3 to 5 hours, so it's likely not going to be lasting the 8 to 12 hours that's prescribed. So just keep that in mind when you are going to prescribe the opioids. The different things to keep in mind is does your patient have liver impairment or do they have kidney impairment? If you're starting them on a short-acting opioid and they have liver impairment, then you may want to consider a hydromorphone or morphine. If they have renal impairment and you're starting them on a short-acting medication, then I would consider oxycodone or hydromorphone. If you're looking at more of a long-acting medication in renal impairment, then that's where methadone or fentanyl or even buprenorphine would be beneficial. So here is just a equinalgic dosing table. So I would refer back to this when converting from one opioid type to another. And then I also have here the methadone conversion table as well. So when you are doing a dose adjustment from one opioid type to another, the first step is figuring out how much of that opioid that they've taken in the past 24 hours. And then using that prior table, you'll calculate the equinalgic dose of the new opioid. I think one of the important things that we don't always remember to do, however, is that when you're switching to new opioid, you need to adjust for incomplete cross-tolerance. So one opioid is not equivalent to another. So generally we recommend reducing that calculated dose by 25 to 50 percent. However, for instance in the hospital, I often would see patients in acute pain crises. If they were tolerating their opioid well and having acute pain crises, 10 out of 10 pain, and we were transitioning to another opioid type, then we may actually do 100% of the equinalgic dose. Again, with immediate release morphine, I would recommend dosing on a Q4 hour schedule based on the fact that it's going to last three to five hours. Extended release morphine would be dosed on a Q12 hour schedule. And then when you're calculating breakthrough dosing, so if you have a patient on a long-acting opioid and you want them to be able to have something as needed for breakthrough pain, generally that breakthrough dose is going to be 10 to 20 percent of what that long-acting dose would be. In terms of the opioid and risk evaluation and mitigation strategies, so drug poisoning still remains the number one cause of injury-related deaths. And most opioids from overdose have come from prescription opioids that were given to family or friends. So I think I can't stress enough the education on risks and benefits of opioids, misuse, diversion, safe storage, and disposal. Always reevaluate, like in that case earlier, in terms of therapeutic response and risk factors for opioid misuse and diversion. Review your state's prescription drug monitoring database. Consider an opioid controlled substance agreement as appropriate. You can always consider routine urine drug testing. Also consider the use of naloxone, but make sure you also educate on the appropriate use of that medication. And then if concerned about substance use disorder, don't forget to phone a friend and refer to a substance use disorder specialist and or pain specialist as appropriate. We were talking earlier about defining whether or not somebody is opioid tolerant or naive. So opioid tolerance is described as somebody who has been on morphine 60 milligrams a day or oxycodone 30 milligrams a day or hydromorphone 8 milligrams a day or a fentanyl patch of 25 micrograms an hour. And they've been on that for a week or more. Once they have been on that equivalent for a week or more, then you could say that they are opioid tolerant and would be okay to start a long-acting opioid in that case if needed. So summary on the opioids. If somebody is having continuous pain, then make sure to schedule an opioid. If they're having breakthrough pain, then their breakthrough dose should be 10 to 20 percent of their total daily opioid dose. Make sure when you're titrating, you're timing to peak effect. So refer back to the pharmacokinetics slide for that. If you're doing dose adjustments for mild to moderate pain, then you may need to increase 25 to 50 percent. If it's more severe, then you may need to increase 50 to 100 percent. Just a few more slides on pharmacotherapies. One would be methadone, which can be useful for nociceptive and neuropathic pain. When you're converting from a different opioid type to methadone, don't forget about incomplete cross-tolerance. So we recommend reducing the dose to about 50 to 75 percent of the equinalgic dose. Big thing with methadone is watching for QT prolongation. So if somebody has a QTC interval of 500 or greater, then they would not be a candidate to start methadone. The other thing to keep in mind with methadone is the long half-life. So generally we're not going to make dose adjustments with methadone more frequently than every five to seven days. And I think that's important when educating patients as well in terms of timing for response to the medication. Buprenorphine can be useful for pain. It's a partial opioid agonist. It is indicated in opioid use disorder, but also in pain management. It does have an analgesic sealing effect. Also keep in mind to avoid combination products with naloxone, as it has little to no effect on analgesia unless it's being misused. Contrary to other long acting opioids, buprenorphine transdermal patch can be initiated in opioid naive patients at the five microgram an hour patch. SNRIs, so duloxetine and venlafaxine, so thinking about the earlier case and you know they didn't have response with the initial opioid, always consider adjunct medications. And also think, do they have other associated symptoms? Anxiety, depression, trouble sleeping. I always want to try to get like the most bang for my buck when I'm going to start a medication for a patient. The biggest things to keep in mind with the SNRIs are the adverse effects, the nausea, abdominal pain, potential sexual side effects, and then also caution in hepatic and renal dysfunction. Tricyclic antidepressants can be useful for neuropathic pain. Keep in mind they're anticholinergic side effects, so basically they're going to dry people up. I would say decipramine and nortriptyline tend to have fewer anticholinergic effects, so I tend to use those more so than the others. But this can be useful if you have a patient with a lot of neuropathic pain who's also having a hard time sleeping. Gabapentanoids are useful for neuropathic pain. You can see the initial dosing on the slide here. The biggest adverse effects, the sedation. So sometimes I might start people on just a once a day dose in the evening and then titrate up as appropriate. A big thing also is if you're tapering down on these medications, do just that. Taper down. I've had patients who have stopped them suddenly and then they had rebound effects of these adverse effects and it wasn't wasn't great for them. Do use caution in renal insufficiency with these medications. Other medications are useful. Anticonvulsants. The big thing with these medications, they can be helpful for neuropathic pain, but just be aware of the drug interactions. Muscle relaxants. I'll be honest, I don't use these a ton just because of the high risk of sedation, but they can be useful particularly in the evening when patients don't need to be as awake as they want to be during the day. But their use is intended more for short-term use. Corticosteroids can be useful for inflammatory as well as bone pain. Dexamethasone is generally preferred because of fewer mineralocorticoid effects, but do use caution. I know if patients are on immunotherapy, then generally the steroids are not recommended. And then of course there's long-term adverse effects. So I've seen patients who have been on steroids for several months and they're having proximal weakness. They're at higher risk for infections and then now they have new onset diabetes from their long-term steroids. Topicals. Important not to forget these. So lidocaine. I'll often recommend this. And the 4% over-the-counter patch is clinically equivalent in terms of efficacy to the 5% patch. So oftentimes I just recommend that they pick it up over the counter. They can use up to three patches at a time and they can be cut as they need to. Diclofenac is another one I'll often recommend for joint pain. It is a topical NSAID with minimal systemic absorption. So I'll use it oftentimes in patients with, you know, stage 4 chronic kidney disease who might not be able to tolerate the oral NSAIDs. And then compounded neuropathic creams oftentimes have a lidocaine base and then you would add in additional ingredients as you need, such as ketamine or gabapentin or amitriptyline. There's actually limited evidence for the use of these compounded pain creams but there's also low risk for adverse effects. However, high cost because they're needing to be compounded and insurance oftentimes doesn't like to cover these. Cannabinoids. This may depend state to state on your legislation regarding if this could be used but if it is an option in your state then it's something to consider. Could help cut back on their opioid requirements. A ketamine can be useful and it is used in topical combination compounded creams but that is considered an off-label use. It's not approved for chronic pain use but I have used it in acute pain crises and the inpatient setting. Be aware of the side effects of the hallucinations in particular. Thank you so much. Well, you know as a palliative care fellowship program director, now just a faculty member, stepped down from that role a few years ago. Almost every one of these slides y'all is like an hour of content during the fellowship and we asked you all to do it in 12 minutes. And I think that was a tall challenge but I think you handled it really well. Great session today. Thank you to all of the faculty members. Could I just check in with you Dave and Chris. I'm curious as we talked about opioids in the house and as we talked about naloxone for example and there's the certainly the language of the opioid epidemic and concern about opioid over overuse, misuse, deaths related to opioid use. I'm curious you know as a caregiver and as a patient what is it like to go to the pharmacy and pick up an opioid? You know what what do you would you like the doctors to know about what your perspective is about for example opioids? Well that's interesting that's interesting. It just sparked when I remember when I was going to the pharmacy and picking up Percocet. It was kind of it felt kind of weird you know and and I didn't want people to judge me or whatever. That's kind of what what you said kind of stuck with me. So I think what I love about that my takeaway from listening to you amazing people is that the personalized approach is really important in the team sport aspect of it. But the personalizing of the personalizing it because everyone's different. Thinking back to the question you asked me earlier about my story. I think my doctor he just is making assumptions like you can't just make an assumption. Everybody's gonna tolerate pain differently and just because I was a younger person didn't mean that I that I couldn't have this just as much pain as an older person because I was really an active person. So and I think empathy is one of the one of the things that I I know Chris you talk about this a lot too I'm sure because I think empathy is I lead with empathy now because I've learned so much from people like you and and the story about my doctor was a long time ago but I share the story because I because I I feel like I would have used I could have used a lot more empathy there. So whether it's you know getting opioids or the Percocet or Vicodin that I was taking just having that conversation and really being personal and and seeing the patient as a whole person. Thank you for that. Chris I'll give you the floor. From the caregiver point of view to help us understand more what's palliative care versus hospice is great. The other thing I really want everybody in this room to hear is is what is when I go in there and I hear we're gonna give them opioid is that forever? What is the three to six month plan? What is is there like a two-year plan because we're our survivor they're living longer we've got better drugs. What is like a four-year plan? What's a five-year plan for a stage 3 stage 4 patient? I keep I've been looking at some of the my texts going back and forth and they're saying we don't know even nobody even knows what to do for a stage 4 patient that's been living five years. What is the plan for their long-term pain management? That's a great point and I think for all of us in the room who are managing patients to remember to plant a seed because we can't at that early juncture identify which of our patients are going to be alive five years later and which which patients the disease is going to progress quickly but planting a seed that opioids are necessary when they're necessary and then when they aren't necessary we want to revisit that that this may or may not be a long-term strategy. Well again thank you everyone.

pain management

cancer patients

lung cancer

team approach

communication

pharmacological options

non-pharmacological approaches

individualized care

opioid epidemic