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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 • • • • • • • • 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 • • • • • • 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? • • • • 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 • • • • • • • • • 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 • • • • • • 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 • • • • • 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