Ro This is for You

exerpts from new article that made me think of this post:
Russell Portenoy, MD: My Approach to Pain Management for Cancer Patients
OncologySTAT Editorial Team. 2011 Mar 4, Interview by L Scott Zoeller
Russell K. Portenoy, MD, is Chairman, Department of Pain Medicine and Palliative Care, Beth Israel Hospital; Chief Medical Officer, MJHS Hospice and Palliative Care; and Professor of Neurology and Anesthesiology, Albert Einstein College of Medicine.

OncologySTAT: What is the current thinking on prevention and management of therapy-induced neuropathy?

Dr. Portenoy: There is no accepted therapy to prevent chemotherapy-induced neuropathy. Patients who have neuropathic pain related to polyneuropathy should have access to aggressive pain management. In the setting of acute pain, or chronic pain associated with active cancer, opioid therapy is a mainstay. If opioids are not adequate, or if the patient is not a candidate for first-line opioid therapy, a variety of so-called adjuvant analgesics have been used specifically for neuropathic pain.

The most commonly used are the gabapentinoids, which comprise two drugs—gabapentin and pregabalin—that have the same mode of action but that can work differently in individual patients. It is important for oncologists to know how to dose these drugs, because underdosing is associated with a lower likelihood of success.

The second main group of agents that is used for neuropathic pain are the analgesic antidepressants. If a patient has a comorbid depression, one of the analgesic antidepressants should be used before the gabapentinoid. Certainly, for those patients who do not respond adequately to gabapentinoids, a trial of one or more of the analgesic antidepressants should be tried. The most effective antidepressants used for pain are the serotonin–norepinephrine-reuptake inhibitors, such as duloxetine, or the tricyclic antidepressants; the secondary amine tricyclic drugs, such as desipramine, are generally better tolerated and are tried first.

If patients do not respond to the gabapentinoids or the analgesic antidepressants, there still are many agents in a variety of different classes that could be tried for the neuropathic pain. Most commonly used drugs are other anticonvulsants. These drugs have different modes of action. The evidence for efficacy in neuropathy is limited, and they are typically selected empirically, based on the experience of the clinician and limited efficacy information.

Other drugs that might be considered include the cannabinoid agents, and there are new cannabinoids that are being developed that have established efficacy in cancer pain. Other drugs include alpha-2 adrenergic agonists, such as tizanidine or clonidine, the GABA agonist baclofen, and the NMDA receptor antagonists, such as memantine. These drugs, as well as others, can be tried sequentially in an effort to optimize the balance between analgesia and side effects that is gained with the opioid drug.

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OncologySTAT: How often do you think oncologists are using mind–body therapy, and should they be using it more frequently than they are?

Dr. Portenoy: It is well known that patients with cancer commonly access complementary and alternative medicine approaches, sometimes known generically as integrative therapies, either in an effort to manage the cancer itself or in an effort to manage symptoms. Patients with pain frequently seek out these strategies. It is important for oncologists to understand this very heterogeneous group of treatments, and to note that some actually have very good evidence of efficacy. This is particularly true of the mind–body therapies, considered mainstream therapies by those who treat pain or who do palliative care. Treatments such as biofeedback, medical hypnosis, guided imagery, and relaxation therapies have been shown over and over again in controlled trials to produce symptom control, enhance self-efficacy, and to have a positive effect on mood.

Oncologists should be able to make the referrals necessary so that appropriate patients can access mind–body therapy. In addition, some of these therapies are relatively simple to teach, and oncologists might actually choose to incorporate them into their own practices, providing the patient with some written materials and instructions. For example, specific relaxation techniques might be taught in the office and used during an event like chemotherapy or during times of increased pain.

Other complementary and alternative medicine strategies have much less evidence, and may not be endorsed by allopathic physicians because of concerns about safety. If there is no concern about safety, however, and the patient chooses to seek a treatment that has no evidence of efficacy, the oncologist may be best served by providing support to the patient, providing honest answers to questions about the treatment, but also supporting the patient if he or she decides that the therapy is one to pursue.