Cancer Pain TreatmentJan 24, 2014
Cancer pain affects about 50 percent of patients during their treatments and about 75 percent of patients when they’re at the end stages of cancer. Anesthesiologist Dr. Jill Sindt discusses the types of pain treatments for patients during the different stages of cancer. She also talks about the World Health Organization analgesic ladder and how it is used to determine the level of pain a patient is experiencing during cancer treatments and if it can be applied to non-cancer sufferers of chronic pain.
Announcer: Medical news and research from University Utah physicians and specialists can use for a happier and healthier life. You're listening to The Scope. Dr. Hoff: I'm Harriet Hoff, professor of anesthesiology at the University of Utah. I'm talking today with Dr. Jill Sindt an assistant professor at the University of Utah who is an anesthesiologist and a chronic pain specialist. How do you treat cancer pain?
Dr. Sindt: Sure, cancer pain is a huge problem. It affects about 50% of people during their treatment and about 75% of people when they're at their end stages of cancer or when they're dying from cancer. There's a lot of different treatments and fortunately we've become better and better at being able to control people's pain while they're undergoing treatment for cancer and when they survive their cancer as well. We use, in general, the World Health Organization analgesic ladder. So this is a ladder that was kind of developed by a lot of pain specialists in the world as a stepping stone for how to treat patients depending on how much pain they have. So, it starts out with the first step of the ladder, which is kind of mild medications, things like Tylenol or Ibuprofen or other anti-inflammatory agents and that's for mild pain and most patients fortunately do really well with those alone. For patients who don't, then you step up the ladder to the next step which is what we call weak opioids which are pain medications that are strong but not too strong. So, those are things like Hydrocodone if people have heard of that. That's what's in Lortab or Norco. There's also codeine which can be used very well for some patients too. In patients that fail that then there's another step which is when we use strong opioids. So, those are long acting opioids, things like Oxycontin or morphine, or very strong pain killers that are absolutely appropriate for patients with cancer who need that kind of pain control. Dr. Hoff: And that brings up to a question, is the WHO pain letter only for patients with cancer pain or is it something appropriate for patients with other kinds of pain?
Dr. Sindt: It's hard to say. It was certainly developed just for cancer patients; although it's been extrapolated as a way to treat non cancer pain. The problem with using it to treat non cancer pain is that as you noticed the second step of the ladder gets you into opioid pain medications which when used over a lot of time have a lot of side effects and so that kind of complicates things when someone has maybe chronic pain that they may live with for the rest of their life. The decision to use those kinds of pain medications needs to be made very carefully and may not be the right choice for them at all. Dr. Hoff: And where do things fit... are there places on the WHO ladder for implantable spinal cord simulators or nerve blocks or psychical therapy or other types of therapy?
Dr. Sindt: So certainly it's been postulated or suggested that we should have another step, a next step of the pain ladder -a fourth step- and that should be all of the interventional therapy. So, the therapies using, you know, needles and devices to help treat pain. Those would be things like spinal cord stimulators, which can be put in the space next to spinal cord called the epidural space that can basically give the spinal cord a different input other than pain so they kind of try to stimulate the spine with a buzzing or a tingling, or a cold type feeling instead of the feeling of pain in a person's limb for example. The other kind of major thing that we do is called a pain pump or intrathecal pump which is where we're able to give lots of different types of medications directly to the fluid surrounding the spinal cord instead of orally so they don't get those side effects like feeling foggy or sleepy or nauseated or constipated but they are still able to get pain control. There are also a number of nerve blocks we do for people who have pain in a specific area, for example in the face or in the stomach from something like a pancreatic cancer. We can do nerve blocks specifically to those nerves that will last a number of months at times. Dr. Hoff: Do you ever do those as sort of lower on the ladder or do you wait until you're on the strong narcotics before you do a block?
Dr. Sindt: We try to do it earlier if we can and it depends on the patient and their comfort level. But, when we're stepping up to that third step of the ladder, so that's when we get into the strong pain killers or the long acting pain killers, we know those come with a lot of side effects and so it's at the same time that we're thinking about stepping up a step that we're also thinking about are there better ways we can target people's pain in a specific location rather than just kind of treating their whole body with these pain killers. Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.