Download Pain-related barriers: The Edmonton Classification System

Pain-related barriers: The
Edmonton Classification
System
Dr. R. L. Fainsinger
Division of Palliative Care Medicine
Dept. of Oncology, University of Alberta
Edmonton, AB, Canada
Objectives
• Case study illustrating that poor assessment of
cancer pain can be life-threatening
• Discuss why we need to classify different types
of cancer pain
• Overview of the Edmonton Classification System
• Review evolving definitions of breakthrough pain
55 yr female Unknown primary with
bone mets
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Transferred to TPCU from rural hospital
Neuropathic & incident pain
Escalating opioids resulted in neurotoxicity
Fentanyl CSCI 4200 mcg/hr
Hydromorphone 30 mg sc X 8/day
MMSE 0/30
Myoclonus ++
Agitated
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Sedated with a CSCI of midazolam
Fentanyl tapered
Myoclonus & agitation settled
Midazolam tapered & D/C
Fentanyl replaced with methadone
MMSE up to 28/30
• Incident pain R arm – fell & sling for
pathological fracture
• Education for patient & family on incident
pain management
• Psychologist for coping & family issues
• Methadone 60 mg oral q8h
Why would we need to Classify
cancer patients with pain?
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Accurate assessment guides management
Poor assessment handicaps management
Teach basic approach often
More opioids and adjuvants will not solve
everything
• Wide variation in clinical and research
results in cancer pain medicine
How can we compare?
• TNM classification for cancer
• Allows a common language for clinicians &
research
• No similar international classification
system for cancer pain
• Difficult to compare pain treatment results
Pain Intensity Scales
Visual Analogue Scale (0 – 10 cm)
No pain
_____________________________________ Worst possible pain
Numerical Scale
No pain
0
1
2
3
4
5
6
7
8
9
10
Worst possible pain
One-dimensional not a multidimensional assessment
60-year-old Female With Breast
Cancer and Bone Metastases – Pain
8/10
Meaning
• My pain is 8/10 at
this moment
• It is also 8/10 when
I get up to move
Meaning
• My pain is 0/10 at
this moment
• It is 8/10 when I
get up to move
60-year-old Female With Breast
Cancer and Bone Metastases – Pain
8/10
Meaning
• My leg hurts where
I have bone cancer
• I need better pain
medicine
Meaning
• My leg hurts a bit
• I feel terrible about
my situation
• I cannot cope with
anything
• I express my
suffering through
my pain
The Death of Ivan Ilych Tolstoy
• “It was true, as the doctor said,
that Ivan Ilych’s sufferings were
terrible, but worse than the
physical sufferings were his
mental sufferings, which were his
chief torture.”
What May Complicate Pain
Management?
• Opioid use on
TPCU in 1991
MEDD > 600 mg
• State these are
complex patients
• How do we
compare?
Fainsinger RL et al J of Palliative Care 1996; 12(4):6-9.
Case 1
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65-year-old male
Prostate/bone mets cancer
Pain localized right arm and hip
Moves comfortably
Oriented and alert
On codeine 30 mg prn
Stable marriage and home life
No psychiatric history
No history of addiction
Case 2
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65-year-old male
Prostate/bone mets cancer
Burning/stabbing pain down right leg
Cannot move without severe pain
Evidence of confusion
Morphine increased 5 mg q4h to 100 mg q4h
over 7 days
• Divorced 3 times; lives alone
• History of depression and suicide attempts
• Long history of alcohol and benzodiazepine
abuse
Characteristics of a Cancer Pain
Classification System
• Comprehensive
• Prognostic
• Simple to use
Development of the Edmonton
Classification System for Cancer
Pain (ECS-CP)
1989 - 1995
ESS
ESS
2000 - 2005
rESS
rESS
2005 - ?
ECS-CP
ECS-CP
NeIiPxAoCi
Validation Studies
• Fainsinger et al. (JPSM;2005): A multicenter study of the
revised Edmonton Staging System for classifying cancer
pain in advanced cancer patients (n=746)
• Nekolaichuk et al. (PM;2005): A validation study of a
pain classification system for advanced cancer patients
using content experts (n=70)
• Fainsinger et al. (EAPC 2009 Vienna abstract): An
international multicentre validation study of a pain
classification system for advanced cancer patients
(n=1100)
Fainsinger RL et al JPSM 2005; 29(3):224
Nekolaichuk C et al Palliative Medicine 2005; 19(6):466
Summary of Reliability & Validity Studies
• moderate to high inter-rater reliability
(Fainsinger et al., 2005)
• good predictive value for complexity of care
(Fainsinger et al., 2005)
• construct validity evidence using expert panel
(Nekolaichuk et al., 2005)
• reproducibility across different settings
(Fainsinger et al., in progress)
Evolution of BTP, incident &
episodic pain in the ECS-CP
• Edmonton Staging System
• B.NATURE OF PAIN
B1 Non-incidental
B2 Incidental
• Pain is aggravated suddenly as a result of
movements, swallowing, defecation, or urination.
Pain control is usually excellent if the patient
remains immobile or refrains from performing
the pain causing maneuver.
Bruera E et al Pain 1989; 37:203
Bruera E et al JPSM 1995; 10:348
Incidental pain
• Pain often worse with movement
• Incorrect interpretation exaggerates stage
• Episodic/breakthrough concepts
Revised Edmonton Staging System
• I - Presence of Incidental pain
• Defined as discomfort sufficient to
significantly impact physical &/or
psychological function
Incidental pain revised construct validation
• Pain can be defined as incidental when a
patient has background pain of no more
than moderate intensity with severe
episodes of pain, usually having a sudden
onset & a predictable trigger
Incident Pain (I)
Present definition
Pain can be defined as incident pain when a
patient has background pain of no more than
moderate intensity with intermittent episodes
of moderate to severe pain, usually having a
rapid onset and often a known trigger.
(rESS Panel B, July 2004)
ECS-CP
Incident Pain (I)
Io
Ii
Ix
No incident pain
Incident pain present
Insufficient information to classify
6 key characteristics of incident pain, as
defined in the ECS-CP
• Relationship with background pain: The
intensity of incident pain is significantly
greater than background pain.
• Severity: The intensity of incident pain is
moderate to severe.
• Predictability: The trigger is often known,
such as movement, defecation, urination,
swallowing and dressing change.
However, clinically significant episodic
pain (i.e. no predictable trigger) can be
included (e.g. bladder or bowel spasm).
• Onset: Its onset is rapid, with intensity
often peaking within 5 minutes.
• Transiency: Incident pain is transient, and
may return to baseline shortly after the
trigger is stopped or removed.
• Recurrence: It is intermittent, recurring
when the trigger is reinitiated or reapplied.
Fainsinger RL Edmonton classification system for cancer pain (ECS-CP)
Administration manual
http://www.palliative.org/PC/Clinicalinfo/AssessmentToolsIDX.html
Audit of Resource Utilization in a
Regional Palliative Care Program Using
the ECS-CP
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July 2005 – Oct 2006
TPCU -124
RAH - 592
UAH - 469
Community team - 843
Amigo P et al J of Palliative Medicine 2008; 11(6):815-818
100.0%
80.0%
RAH
60.0%
UAH
40.0%
TPCU
20.0%
RPCPC
0.0%
Ii
Io
Ix
Blank
Classification of Cancer Pain – A
Systematic Literature Review and
Further Research Strategy
• Poor assessment leads to poor medicine
• EPCRC includes aim to develop
classification system for cancer pain
based on international consensus
• Conducted literature review as 1st step
Knudsen et al Pall Med 2008;22:481
Methods
• Medline and Embase 1986 – 2006
• Terms
– Classification
– Categorization
– Staging
– Neoplasm
– Cancer
– Pain
• English or German and adults
• All reports evaluated by 2 reviewers
Results
• 692 hits
• 95 analyzed
• 3 formal classification systems identified
– IASP Classification of Chronic Pain
– Cancer Pain Prognostic Scale
– Edmonton Classification System for Cancer
Pain (ECS-CP)
• Unvalidated systems described
• Several informal approaches
– Eg, pathophysiology, etiology, pain intensity,
other subjective signs and symptoms, and
disease and demographic factors
Conclusion
• IASP – descriptive system
• Other 2 include pain and patient-related
factors to predict pain control
• ECS-CP less complex and better defined
• Work within the EPCRC towards
development of an international research
and consensus-based system will start
with the ECS-CP
The Clinical Classification of
Malignant Tumours: The TNM
System
• Clinical Classification of Cancer pursued
for 50 years until international agreement
• Ongoing discussion and supervision
SELLERS AH CMAJ 1971;105:836
Administration manual for ECS-CP
www.palliative.org
>clinical information>Assessment tools
Challenges & Pitfalls
• Clinicians & researchers have different
needs
• Our needs sometimes overlap but can
conflict
• Avoid waiting for perfection
• Continue to improve (or replace) what we
are using