Pain management and cancer


Unfortunately Cancer and pain are often associated.

Transcript below:

For a person diagnosed with cancer, probably getting a consultation at the pain clinic isn't really the first thing on their mind. The first thing on their mind is going to be understanding, "What cancer do I have? What treatment do I need? What are my chances of getting a cure?" That and a bunch of other things going through that person's mind. So of course they're going to be focused on visiting the oncologist or visiting the surgeon that will be assisting them with surgery for their cancer. And that's obviously the first port of call, but surprisingly, perhaps somewhere between, say, 5% to 10% of patients over the course of their cancer treatment may actually be appropriate to be assessed in a pain clinic.

One of the commonest symptoms, of course, of cancer is pain, and sometimes that pain can be progressive if the actual tumor or cancer is itself progressive. In addition to that, of course, the treatment itself sometimes leads to pain. For example, chemotherapy agents that are used, which can be very effective for eradicating cancer, can also some of the time produce painful pins and needles in the hands or the feet, that can either be temporary or can, in fact, be persistent long-term. And so there are particular treatments that can be used by a general practitioner or an oncologist as regards to that, but if those symptoms are severe or not responding, then the pain clinic has various techniques used to treat that particular issue, for example.

So just going back to the patient who has cancer, is perhaps underway with treatment for their cancer and has a cancer team around them, the issue of pain then comes into being as to how we treat that. Now, obviously, people are quite familiar with perhaps how things are treated in terms of end of life care in a hospice, and that's usually with an unrestricted amount of opioids to manage a very advanced cancer pain. But for a patient who might be on a journey for 6-12 months and is at the beginning of that, and hopefully it's not going to progress to the end of that, as they'll get cure of their condition, then we have to think about, are there risks of those opioids for them? And we know, in fact, that if those opioid doses are escalated very high, very early, then for some of those classes of agents of opioids, they actually suppress the immune system.

Now, suppressing the immune system in cancer is not a great thing. That could, in theory or in practice, actually encourage tumor growth. And of course it may put the patient at risk of infections, especially if their own immune system is being weakened by things such as chemotherapy, for example. So we actually want to be quite careful and think cleverly and logically what type of analgesics, what type of opioids don't have this immune suppressant effect. And there are a couple of them that are out there. So we want to be making sure that the person is on the right medication for that. In particular, we know with opioids, and this is one of the reasons why they're not used long-term for patients who just have what we call chronic non-cancer pain, is that the body can develop tolerance to it over time. And with that phenomenon, then you can lose the original analgesic benefit, so the dose goes up. And that's a problem in chronic non-cancer pain.

Now, in patients with cancer pain who are actually going to have ultimately cure of their condition, we don't want them to go on higher and higher doses because they'll get side effects. So again, we're looking actually for that particular group of opioids that don't produce this issue of tolerance. And again, we have some of them that are out there. We typically refer to them as atypical opioids, meaning that they don't strongly activate the mu-opioid receptor, and we separate them from what we call the classical or pure mu-opioids that fully and only activate the mu-opioid receptor. They're the ones that tend to lead to tolerance. They're the ones that can also suppress the immune system.

So, a pain clinic can, in fact, be useful for a subset of patients who have cancer pain, especially where that cancer pain is not responding to standard treatment by the general practitioner or treatment by the oncologist. And in that particular setting, it's often nerve pain that the patient is experiencing. And what the pain clinic and a pain physician can bring to that scenario is their advanced ability to treat nerve pain. And there are various techniques that can be used. Those are pharmacology techniques. That means medications. But it also means what we call interventional techniques where we can use procedures to block nerve function, stun the nerve function, whilst preserving the ability to feel and to move your arm or your leg and so forth. So we're able to do a number of things in that area to produce relief of nerve pain.

Obviously, if things are going to actually be progressive and it's a case that ultimately the patient may move into a palliative role, then of course we tend to be much freer with the use of the opioids to manage the pain in that setting. But in addition, there'll be some conditions where tumor might be invading nerves. So, we have various constellation of nerves in the brachial plexus, in the sacral plexus, that can produce quite severe and difficult to control pain. And pain specialists have specialised techniques that they use to block pain back at the spinal cord level. We can inject agents to actually knock out nerve roots inside the spinal column to relieve pain. So there's a number of features that an oncologist might say to you, "Look, I think it's time to chat to one of the pain docs at the pain clinic. Let's see if they've got something to offer you to help us, because we're not really going in a winning direction at the moment."

So, in a cancer journey, I think the most important thing of all, really, is the patient becoming empowered. So, I've found the best results when the patient is an active participant in making decisions and is not a passive vehicle being managed by the medical system, but is actually making choices about what they want for themselves, what they want for their family. And my role, or the role of a pain physician, for example, is to lay out what the various options are and then have a discussion with that person, that patient, as to what's appropriate and what they're particularly looking for. And I think with that, we get higher levels of confidence, and that feeds through into reduced levels of distress and better quality of life. So that should be at the center of all the decisions that we make when it comes to cancer pain.

If you or your loved one need help with pain management, you can get in touch with us via https://pages.hunterpainspecia...

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