Talk given at Topeka Cancer Pain Conference April 8th 2010

1. Holistic Managementof Cancer Pain:Beyond Opioids Christian Sinclair, MD, FAAHPM Kansas City Hospice & Palliative Care April 8th, 2010

2. 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

3. 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

4. Endocrine Increased ACTH Cortisol ADH Epinephrine Norepinephrine GH Catecholamines Renin Angiotensisin II Aldosterone Glucagon IL-1 Decreased Insulin Testoterone

5. Metabolic Gluconeogenesis Hyperglycemia Glucose intolerance Insulin resistance Muscle protein catabolism Increased lipolyis

6. Cardiovascular Increased HR Cardiac output Myocardial oxygen consumption Hypertension Hypercoagulation DVT

7. Pulmonary Decreased Airflow Volumes Atalectasis Shunting Hypoxemia Cough Sputum retention Infection

8. GU/GI Decreased Urinary output Retention, Hypokalemia

9. MSK Fatigue Immobility Muscle spasm

10. Developmental/Psych Reduced cognitive function Altered mood Increased anxiety Depression Addictive behaviors Future pain disorders Insomnia Suicidal ideation Fear Hopelessness

11. Holistic? Taking into account all the needs of a patient Physical Social Psychological Spiritual Essential element of palliative medicine

12. 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

13. 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

14. 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

15. 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

16. Cancer Pain Treatment Education of patient and family Administration Indications Addiction concerns Diversion concerns Tolerance concerns Cultural concerns

17. 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

18. 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

19. 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

20. 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)

21. 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

22. 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

23. 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

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

25. 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

26. 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

27. 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

28. 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

29. 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?

30. Humor Of questionable impact Studies conflicting But if it helps your patient then use it

31. 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

32. 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

33. Acupuncture Availability limited by provider availability Evidence is mixed Current Cochrane Collaboration is underway More evidence with nausea/vomiting associated with chemo

34. 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

35. 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’

36. 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

37. 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

38. 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

39. References Oxford Textbook of Palliative Medicine 4thed Pain Clinical Manual 2nded –McCaffery & Pasero Malone MD, Strube MJ, Scogin FR. Meta-analysis of non-medical treatments for chronic pain. Pain. 1988 Sep;34(3):231-44.br />The Cochrane Review – Pain, Palliative and Supportive Care Group

40. References Cold and Heat studies: Bini1984,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.