Supportive Care / Pain Management

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Supportive Care / Pain Management

Head and Neck Surgery
Author Credentials 

Aru Panwar, MD FACS
Head and Neck Surgical Oncology
Methodist Estabrook Cancer Center
Nebraska Methodist Hospital
8303 Dodge Street, Suite 304
Omaha, Nebraska 68114 
Tel: 402.354.5048
Email: arupanwar@gmail.com

Module Summary

Pain is a common symptom experienced by survivors of head and neck malignancies. Pain may be detrimental to a patient’s survivorship experience through limitations in activity, motivation, ability to speak or swallow, and may contribute to poor quality of life. Patients with head and neck cancer should be screened for pain at each clinical encounter. Pain related symptomatology should prompt a comprehensive evaluation including assessment of pain and related symptoms, its implications on the patient’s quality of life, and the underlying etiology. Comprehensive management of pain requires engagement between the patient, their caregivers at home, and a multidisciplinary healthcare team. Clinicians should consider individualized pain management strategies based on severity of pain, underlying etiology, and goals of care. Pharmacologic and non-pharmacologic options may be used in a complimentary fashion. Ethical and responsible prescribing practices must balance the need for opioid use for effective analgesia in carefully selected patients, against potential for opioid abuse. 

Module Learning Objectives 
  1. Describe the pathophysiology and restate key definitions related to pain management in patients with head and neck cancer.
  2. Recognize the role of pain in survivorship experiences of patients with head and neck cancer.
  3. Identify techniques for comprehensive assessment of pain, and goals of pain management strategies.
  4. Review algorithmic approach to pain management and apply tailored strategies for pain management in patients with varying needs.
Anatomy
  1. Review relevant neuroanatomy associated with pain.

 

References: 

  1. Schnitzler A, Ploner M. Neurophysiology and Functional Neuroanatomy of Pain Perception. Journal of Clinical Neurophysiology. 2000 Nov;17(6):592-603
Head and Neck Cancer- Related Pain Pathophysiology and Impact on Cancer Survivorship
  1. Define pain and cite incidence of pain in patients with head and neck cancer.
  2. Recognize the influence of pain management on quality of life and survival outcomes
  3. Differentiate between:
  • Acute and chronic pain
  • Nociceptive and neuropathic pain
  • Disease- related versus treatment related pain

 

References: 

  1. Adult Cancer Pain. NCCN Guidelines Version 3.2019. National Comprehensive Cancer Network. Retrieved August 5, 2019, from: https://www.nccn.org/professionals/physician_gls/pdf/pain.pdf  
  2. Merskey H, Bugduk N. Classification of Chronic Pain. Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms 2nd ed. Seattle, WA: IASP Press; 1994
  3. van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, et al. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol 2007;18:1437-1449
  4. Smith WH, Luskin I, Resende Salgado L, et al. Risk of prolonged opioid use among cancer patients undergoing curative intent radiation therapy for head and neck malignancies. Oral Oncol. 2019 May;92:1-5
  5. Silver N, Dourado J, Hitchcock K, et al. Chronic opioid use in patients undergoing treatment for oropharyngeal cancer. Laryngoscope 2019 Jan 6
  6. Cramer JD, Johnson JT, Nilsen ML. Pain in Head and Neck Cancer Survivors: Prevalence, Predictors, and Quality of Life Impact. Otolaryngol Head Neck Surg. 2018 Nov;159(5):853-858
  7. Bakitas MA, Tosteson TD, Li Z, et al. Early versis Delayed Initiation of Concurrent Palliative Oncology Care: Patient Outcomes in the ENABLE III Randomized Controlled Trial. J Clin Oncol. 2015 May 1;33(13):1438-45
  8. Caraceni A, Weinstein SM. Classification of cancer pain syndromes. Oncology (Williston Park) 2001;15:1627-1640
Patient Evaluation: Comprehensive Assessment of Pain
  1. Review goals in pain management (5As).
  2. Apply appropriate assessment tools to identify severity of pain.
  3. Determine differential diagnoses associated with acute, chronic and breakthrough pain, including recurrence, second primary malignancy, or early- or late-onset effects of treatment.
  4. Recognize barriers to effective assessment and management of pain.

 

References: 

  1. Adult Cancer Pain. NCCN Guidelines Version 3.2019. National Comprehensive Cancer Network. Retrieved August 5, 2019, from: https://www.nccn.org/professionals/physician_gls/pdf/pain.pdf 
  2. Survivorship. NCCN Guidelines Version 2.2019. National Comprehensive Cancer Network.  Retrieved August 5, 2019, from: https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf 
  3. Paice JA, Portenoy R, Lacchetti C, et al. Management of Chronic Pain in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 34:3325-3345. Available: www.asco.org/chronic-pain-guideline
  4. Ware LJ, Epps CD, Herr K, Packard A. Evaluation of the Revised Faces Pain Scale, Verbal Descriptor Scale, Numeric Rating Scale, and Iowa Pain Thermometer in older minority adults. Pain Manag Nurs 2006;7:117-125
  5. Serlin RC, Mendoza TR, Nakamura Y, et al. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain 1995;61:277-284
  6. Holen JC, Lydersen S, Klepstad P, et al. The Brief Pain Inventory: pain's interference with functions is different in cancer pain compared with noncancer chronic pain. Clin J Pain 2008;24:219-225
  7. Al-Atiyyat HNM. Cultural diversity and cancer pain. Journal of Hospice & Palliative Nursing 2009;11:154-164. Available: http://journals.lww.com/jhpn/Abstract/2009/05000/Cultural_Diversity_and_ Cancer_Pain.9.aspx 
  8. Ezenwa MO, Ameringer S, Ward SE, Serlin RC. Racial and ethnic disparities in pain management in the United States. J Nurs Scholarsh 2006;38:225-233
  9. Fairchild A. Under-treatment of cancer pain. Curr Opin Support Palliat Care 2010;4:11-15
Treatment
  1. Identify role of patient-centered multidisciplinary collaborative teams in ongoing management of pain, including need for specialty referral when appropriate. 
  2. Recognize need for ongoing reassessment of symptoms, goals and management strategies for patients being treated for head and neck cancer- related pain.
  3. Describe algorithm proposed by the World Health Organization for management of cancer-related pain.
  4. Identify options for comprehensive management of pain and associated risks and benefits of such modalities:
  • Pharmacologic management:
    • Opioid analgesics and opioid agonists
    • Non-opioid analgesics
      • Acetaminophen
      • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
    • Adjunct analgesics 
      • Topical anesthetic agents
      • Steroids
      • Anticonvulsants (e.g. gabapentin, pregabalin)
      • Anti-depressants (e.g. selective serotonin reuptake inhibitors [SSRIs], Tricylic antidepressants [TCA])
  • Non-Pharmacologic management
    • Physical modalities including heath or cold, physical exercise, TENS (transcutaneous electrical nerve stimulation)
    • Cognitive Behavioral Therapy
    • Spiritual and Psychological Support
    • Acupuncture, yoga, and others
  • Invasive techniques
    • Regional blocks
    • Cranial rhizotomy
    • Intrathecal injection
  1. Recognize differences between opioid naïve and opioid tolerant patients and their unique therapeutic requirements.

 

References: 

  1. Adult Cancer Pain. NCCN Guidelines Version 3.2019. National Comprehensive Cancer Network. Retrieved August 5, 2019 from: https://www.nccn.org/professionals/physician_gls/pdf/pain.pdf  
  2. Survivorship. NCCN Guidelines Version 2.2019. National Comprehensive Cancer Network. Retrieved August 5, 2019 from: https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf
  3. Jiang J, Li Y, Shen Q, et al. Effect of Pregabalin on Radiotherapy-Related Neuropathic Pain in Patients with Head and Neck Cancer: A Randomized Controlled Trial. J Clin Oncol. 2019 Jan 10; 37(2): 135-143
  4. McDermott JD, Eguchi M, Stokes WA, et al. Short- and Long-term Opioid Use in Patients with Oral and Oropharynx Cancer. Otolaryngol Head Neck Surg. 2019 Mar; 160(3):409-419
  5. Henry M, Alias A, Frenkiel S, et al. Contribution of psychiatric diagnoses to extent of opioid prescription in the first year post-head and neck cancer diagnosis: A longitudinal study. Psychooncology. 2019 Jan;28(1):107-115
  6. Carpenter PS, Shepherd HM, McCrary H, et al. Association of Celecoxib Use with Decreased Opioid Requirements After Head and Neck Cancer Surgery With Free Tissue Reconstruction.  JAMA Otolaryngol Head Neck Surg. 2018 Nov 1;144(11):988-994
  7. Adair M, Murphy B, Yarlagadda S, et al. Feasibility and Preliminary Efficacy of Tailored Yoga in Survivors of Head and Neck Cancer: A Pilot Study. Integr Cancer Ther. 2018 Sep;17(3):774-784
  8. Stjernsward J. WHO cancer pain relief programme. Cancer Surv 1988;7:195-208. 
  9. U.S. Food and Drug Administration. Transmucosal Immediate Release Fentanyl (TIRF) Risk Evaluation and Mitigation Stratgey (REMS). Silver Spring, MD: 2014. Retrieved August 5, 2019 from: http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM289730.pdf
  10. U.S. Food and Drug Administration. Extended-Release (ER) and Long-Acting (LA) Opioid Analgesics Risk Evaluation and Mitigation Strategy (REMS). Silver Spring, MD: 2015. Retrieved August 5, 2019 from: http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf
  11. Lussier D, Huskey AG, Portenoy RK. Adjuvant analgesics in cancer pain management. Oncologist 2004;9:571-591
  12. Johannessen Landmark C. Antiepileptic drugs in non-epilepsy disorders: relations between mechanisms of action and clinical efficacy. CNS Drugs 2008;22:27-47
  13. Wooldridge JE, Anderson CM, Perry MC. Corticosteroids in advanced cancer. Oncology (Williston Park) 2001;15:225-234; discussion 234-226
Responsible Prescription Practices and Preventing Opioid Misuse and Abuse
  1. Recognize the role of prescription opioids in the epidemic of opioid abuse, addiction and related deaths in the United States.
  2. Describe responsible prescribing practices in pain management.
  3. Identify pharmacologic and non-pharmacologic opioid sparing techniques. 
  4. Identify assessment tools to identify individuals at risk for aberrant use of opioids (Opioid Risk Tool, ORT).
  5. Illustrate available risk mitigation tools and resources for monitoring prescription opioid use (Prescription Drug Monitoring Programs, PDMPs).

 

References: 

  1. Opioid Overdose. Information for Providers. Centers for Disease Control. Retrieved August 5, 2019 from:   https://www.cdc.gov/drugoverdose/index.html
  2. FDA Education Blueprint for Health Care Providers Involved in the Treatment and Monitoring of Patients with Pain (September 2018). Retrieved August 5, 2019 from: https://www.accessdata.fda.gov/drugsatfda_docs/rems/Opioid_analgesic_2018_09_18_FDA_Blueprint.pdf
  3. Adult Cancer Pain. NCCN Guidelines Version 3.2019. National Comprehensive Cancer Network. Retrieved August 5, 2019 from: https://www.nccn.org/professionals/physician_gls/pdf/pain.pdf
  4. Pang J, Tringale K, Tapia VJ, et al. Chronic Opioid Use Following Surgery for Oral Cavity Cancer. JAMA Otolaryngol Head Neck Surg. 2017 Dec; 143(12): 1187-1194
  5. Svider PF, Arianpour K, Guo E, et al. Opioid prescribing patterns among otolaryngologists: Crucial insights among the medicare population. Laryngoscope 2018 Jul;128(7):1576-1581
  6. Oltman J, Militsakh O, D’Agostino M, et al. Multimodal Analgesia in Outpatient Head and Neck Surgery: A Feasibility and Safety Study. JAMA Otolaryngol Head Neck Surg. 2017 Dec 1;143(12):1207-1212
  7. Anghelescu DL, Ehrentraut JH, Faughnan LG. Opioid misuse and abuse: risk assessment and management in patients with cancer pain. J Natl Compr Canc Netw 2013;11:1023-1031
  8. Barclay JS, Owens JE, Blackhall LJ. Screening for substance abuse risk in cancer patients using the Opioid Risk Tool and urine drug screen. Support Care Cancer 2014;22:1883-1888
  9. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain - United States, 2016. MMWR Recomm Rep 2016;65:1-49
  10. ASCO Policy Statement on Opioid Therapy: Protecting Access to Treatment for Cancer-Related Pain; 2016. Retrieved August 5, 2019 from: http://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy- and-policy/documents/2016-ASCO-Opioid-policy-brief.pdf
Management of Head and Neck Procedure- Related Pain
  1. Identify role of multimodal analgesia in head and neck surgery and its association with reduced opioid use.

 

References: 

  1. Oltman J, Militsakh O, D’Agostino M, et al. Multimodal Analgesia in Outpatient Head and Neck Surgery: A Feasibility and Safety Study. JAMA Otolaryngol Head Neck Surg. 2017 Dec 1;143(12):1207-1212
  2. Militsakh O, Lydiatt W, Lydiatt D, et al. Development of Multimodal Analgesia Pathways in Outpatient Thyroid and Parathyroid Surgery and Association with Postoperative Opioid Prescription Patterns. JAMA Otolaryngol Head Neck Surg. 2018 Nov 1; 144(11):1023-1029
  3. Eggerstedt M, Stenson KM, Ramirez EA, et al. Association of Perioperative Opioid-Sparing Multimodal Analgesia with Narcotic Use and Pain Control after Head and Neck Free Flap Reconstruction. JAMA Facial Plast Surg. 2019 Aug 8
Cannabinoids and Medical Marijuana
  1. Analyze emerging science (including opportunities and limitations) related to cannabis and its derivatives in managing cancer related side effects including pain.
  2. Recognize factors that may affect use of cannabis or its derivatives for management of pain:
  • Patient values and preferences
  • State and Federal regulations
  • Quality of available evidence

 

References:

  1. Zhang H, Xie M, Archibald SD, et al. Association of Marijuana Use with Psychosocial and Quality of Life Outcomes Among Patients with Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg. 2018 Nov 1;144(11):1017-1022
  2. Elliott DA, Nabavizadeh N, Romer JL, et al. Medical marijuana use in head and neck squamous cell carcinoma patients treated with radiotherapy. Support Care Cancer. 2016 Aug;24(8):3517-24
  3. National Center for Complementary and Integrative Health. Marijuana and Cannabinoids. 2019. Retrieved August 5, 2019 from: https://nccih.nih.gov/health/marijuana
  4. Johnson JR, Burnell-Nugent M, Lossignol D, et al. Multicenter, double- blind, randomized, placebo-controlled, parallel-group study of the efficacy, safety, and tolerability of THC:CBD extract and THC extract in patients with intractable cancer-related pain. J Pain Symptom Manage 2010;39:167-179
  5. Portenoy RK, Ganae-Motan ED, Allende S, et al. Nabiximols for opioid-treated cancer patients with poorly-controlled chronic pain: a randomized, placebo-controlled, graded-dose trial. J Pain 2012;13:438- 449
Case Scenarios

A 74-year-old Hispanic woman with history of locoregionally advanced left oropharyngeal squamous cell carcinoma treated with definitive chemoradiotherapy presents for her 3-year oncologic surveillance visit. She reports recent onset, persistent, sharp pain and swelling over her left neck and face. What are the differential diagnoses in this setting? What are the next steps in management? 

A 36-year-old healthy man is planning to undergo a thyroid lobectomy for a suspicious appearing thyroid nodule with indeterminate cytology. How should this patient be counseled with regards to his post-operative pain management?

A 46-year-old woman presents with widely metastatic nasopharyngeal carcinoma and has severe pain related to compression fracture of 10th thoracic vertebral body. After a discussion with the multidisciplinary team, she elects for supportive care only, and declines any further chemotherapy. Describe potential options for management of her pain.

Review Questions
  1. What is the prevalence of pain in survivors of head and neck cancer?
  2. What is the appropriate pain assessment tool for a patient with limited ability for communication?
  3. What are the non-opioid pharmacologic agents that may be used to manage pain?
  4. What are the assessment tools that may be used to identify individuals at risk for aberrant use of opioids?

 

Resources 

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  1. Annual Meeting Webcast (AMW):