Overcoming Challenges in Cancer Pain Management

This activity is jointly provided by Global Education Group and Integritas Communications.

This activity is supported by an educational grant from AstraZeneca.

Meeting space has been assigned to provide a satellite symposium supported by AstraZeneca during the Oncology Nursing Society’s 42nd Annual Congress, May 4-7, 2017 in Denver, Colorado. The Oncology Nursing Society’s assignment of meeting space does not imply product endorsement nor does the Oncology Nursing Society assume any responsibility for the educational content of the symposium.

ANTHONY J. Lembo, MD

FACULTY

FACULTY

Associate Professor of Medicine Harvard Medical School Director, GI Motility Laboratory Division of Gastroenterology Beth Israel Deaconess Medical Center Boston, Massachusetts

Dr. Anthony J. Lembo earned his bachelor’s degree in mathematics from Amherst College in Amherst, Massachusetts, and his medical degree from Tufts University School of Medicine in Boston, Massachusetts.

He subsequently completed his Internal Medicine Internship and Residency as well as a Gastroenterology Fellowship at the University of California, Los Angeles (UCLA) Medical Center in Los Angeles, California.

Following his fellowship he became a Clinical Instructor of Medicine at UCLA in 1996 and served as the CoDirector of the Functional Bowel Disorders and GI (gastrointestinal) Motility Center at UCLA Medical Center.

In 1997, Dr. Lembo joined the faculty at Beth Israel Deaconess Medical Center (BIDMC) in Boston, Massachusetts. He serves as Director of the GI Motility Laboratory in the BIDMC Division of Gastroenterology and as an Associate Professor of Medicine at Harvard Medical School in Boston, Massachusetts. His research interests include functional bowel disorders, such as irritable bowel syndrome, chronic constipation, and dyspepsia, as well as the role of placebo in functional bowel disorders.

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NICOLE M. Ross, MSN, CRNP, AOCNP FACULTY

Advanced Practice Clinician Advanced Oncology Certified Nurse Practitioner Department of Hematology/Oncology Fox Chase Cancer Center Philadelphia, Pennsylvania

Nicole M. Ross is an Oncology Nurse Practitioner in GI (gastrointestinal) Medical Oncology at Fox Chase Cancer Center in Philadelphia, Pennsylvania. A graduate of Immaculata University in Immaculata, Pennsylvania, she received her Master of Science in Nursing from LaSalle University in Philadelphia, Pennsylvania, and further certifications through programs of the Oncology Nursing Society (ONS) and the National Institutes of Health. She has been a Nurse Practitioner for 6 years, an Oncology Nurse for 12 years, and a member of the ONS since 2006 .

A member of the Educational Working Group at Fox Chase Cancer Center, Ms. Ross has a special interest in advancing nursing education. She is also particularly interested in palliative care and pain management. She collaborated on an article with Dr. Josh Jones and Erin McMenamin, CRNP, entitled, “Palliative Radiotherapy and Oncology Nursing,� which was published in Seminars in Oncology Nursing in 2014.

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MICHAEL J. Brennan, MD FACULTY

Medical Director, The Pain Center of Fairfield Fairfield, Connecticut Associate Director, Chronic Pain and Recovery Center Silver Hill Hospital New Canaan, Connecticut Senior Attending Physician, Department of Medicine Bridgeport Hospital Bridgeport, Connecticut

Dr. Michael J. Brennan received his medical degree from the State University of New York Downstate Medical Center, and completed a residency in physical medicine and rehabilitation at the New York Hospital-Cornell University Medical Center, where he served as chief resident. While at New York Hospital, Dr. Brennan also served as chief resident at the International Center for the Disabled in New York City.

After completing his residency, Dr. Brennan was appointed to the faculty of New York Hospital and Cornell Medical College in the Department of Physical Medicine and Rehabilitation. He served as acting chief of the rehabilitation service in the Department of Neurology at Memorial Sloan-Kettering Cancer Center. After leaving Sloan-Kettering, Dr. Brennan became the medical director of the Rehabilitation Center of Fairfield County and Ahlbin Centers for Rehabilitation Medicine and chief of the section of physical medicine at Bridgeport Hospital in Bridgeport, Connecticut. He is currently a senior attending physician in the Department of Medicine at Bridgeport Hospital, a consulting physician at St. Vincent’s Hospital in Bridgeport, Connecticut, and a board-certified physiatrist in private practice in Fairfield, Connecticut.

Dr. Brennan is especially interested in the management of pain and disability in patients suffering from the acute and long-term effects of musculoskeletal diseases, neurologic disorders, and cancer and various cancer treatments. He has published over 30 scholarly articles, abstracts, and textbook chapters on the treatment of cancer- and noncancer-related disabilities including lymphedema and pain. He is a reviewer for several medical journals and has served as guest editor for the Journal of Musculoskeletal Rehabilitation and as online editor for Pain.com. Recently, Dr. Brennan was awarded the Dr. Elizabeth Narcessian Memorial Award from Kessler Institute, recognizing his commitment to the treatment of patients suffering from chronic pain.

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MIHIR M. Kamdar, MD FACULTY

Associate Director, Division of Palliative Care & and Geriatric Medicine Department of Medicine Director, Cancer Pain Clinic Attending, Palliative Care and Anesthesia Pain Medicine Massachusetts General Hospital Instructor in Medicine Harvard Medical School Boston, Massachusetts

Dr. Mihir M. Kamdar graduated from Emory University School of Medicine in Atlanta, Georgia, and completed his residency in internal medicine at Brigham and Women’s Hospital in Boston, Massachusetts. After residency, he completed the Harvard Palliative Medicine fellowship and then a fellowship in Interventional Pain at the Massachusetts General Hospital (MGH) Department of Anesthesia’s Center for Pain.

Trained in both Palliative Care and Interventional Pain Management, Dr. Kamdar holds dual appointments at MGH within the Department of Palliative Care and the Department of Anesthesia Pain Medicine. He is the Associate Director of the Division of Palliative Care & Geriatric Medicine at MGH as well as the Director of the MGH Cancer Pain Clinic. His clinical and research focus centers on the management of refractory cancer pain and on minimally invasive pain interventions, such as neurolytic blockade and neuraxial drug delivery. He is on the teaching faculty at Harvard Medical School.

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PATTIE A. Jakel, RN, MN, AOCN FACULTY

Advanced Practice Nurse Advanced Oncology Certified Nurse Solid Tumor Program University of California, Los Angeles Medical Center Santa Monica, California

Patricia A. Jakel, is an Advanced Practice Nurse for the Solid Tumor Program at the University of California, Los Angeles (UCLA) Healthcare. She supervises the nursing staff, overseeing the care of 25-35 patients receiving chemotherapy, radiation therapy, symptom management, and end-of-life care. Ms. Jakel mentors new nurses in the art of oncology nursing, coordinates outreach classes for chemotherapy verification and oncology core curricula, and serves as an ongoing investigator for research on oncology nursing in ethically difficult situations.

Ms. Jakel earned her master’s degree in nursing in 1991 from UCLA and her undergraduate degree from Hartwick College in Oneonta, New York. She is certified as an Advanced Oncology Nurse by the Oncology Nursing Society, received the Advanced Practice Nurse of the Year Award in 1997 from the Los Angeles Chapter, and is a member of the American Nurses Association, the American Cancer Society, and the Oncology Nursing Society. Ms. Jakel is involved in nursing research looking at moral distress and compassion fatigue. A frequent speaker on symptom management, new oncology treatments, and ethics, she has numerous publications on ethics and oncology nursing, compassion fatigue, and chemotherapy agents.

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TARGET AUDIENCE The educational design of this activity addresses the needs of oncology nurses and other clinicians involved in assessing and managing patients with cancer and opioid-induced constipation (OIC).

EDUCATIONAL OBJECTIVES After completing this activity, the participant should be better able to: • Evaluate baseline and ongoing bowel function in patients with cancer who require opioid-based pain management

PREAMBLE

• Describe the mechanisms of action, published evidence, and practical considerations related to new treatment options for OIC • Recommend prophylactic bowel regimens and newer OIC treatment options when opioid-based treatment regimens are used to treat cancer pain • Communicate with opioid-treated patients with cancer pain to facilitate bowel assessment efforts and shared decision-making about OIC treatment options

STATEMENT of NEED/PROGRAM OVERVIEW As many as one in three patients with cancer suffers from clinically significant pain.1-3 Owing to a broad analgesic spectrum and marked dosing flexibility, opioids have long been the cornerstone of cancer pain therapy.4 Yet the side effects of prescription opioids can limit potential clinical benefits. This is especially true of the most common opioid-related adverse event, constipation, which can be more detrimental to patient function and quality of life than the underlying cancer-related pain.5-8 During this Engaging the Patient™ program, a multidisciplinary faculty panel will review the pathophysiology of OIC, bowel assessment strategies to help monitor opioid-treated oncology patients, prophylactic laxative treatment regimens, and newer agents that have been approved by the US Food and Drug Administration as effective and safe therapies for OIC. Prerecorded patient testimonials and examples of patient-clinician interactions will help shape the interactive faculty discussions. Attendees are sure to leave this educational session with new information and a fresh perspective on managing patients with OIC.

REFERENCES

1. Cohen MZ, et al. J Pain Symptom Manage. 2003;25(6):519-527.

2. Goudas LC, et al. Cancer Invest. 2005;23(2):182-190.

3. Dahl JL. J Natl Cancer Inst Monogr. 2004;32:124-126.

4. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Adult Cancer Pain. Version 2.2016.

5. Coyne KS, et al. Clinicoecon Outcomes Res. 2014;6:269-281.

6. Gatti A, Sabato AF. Clin Drug Investig. 2012;32(5):293-301.

7. Holzer P. Expert Opin Investig Drugs. 2007;16(2):181-194.

8. Rao SS. Gastroenterol Clin North Am. 2007;36(3):687-711.

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PROGRAM AGENDA 7:00 pm – 7:15 pm

Introduction and Preactivity Questionnaire

7:15 pm – 7:35 pm

Prevalence, Pathogenesis, and Burdens of OIC

7:35 pm –7:55 pm

Patient Assessment and Communication Strategies

7:55 pm –8:15 pm

Comprehensive Management Approaches for OIC

8:15 pm –8:30 pm

Postactivity Questionnaire and Q&A Session

NURSING CONTINUING EDUCATION PREAMBLE

Global Education Group is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

This educational activity for 1.5 contact hours is provided by Global Education Group. Nurses should claim only the credit commensurate with the extent of their participation in the activity.

NURSE PRACTITIONER CONTINUING EDUCATION This activity has been planned and implemented in accordance with the accreditation Standards of the American Association of Nurse Practitioners (AANP) through joint providership of Global Education Group and Integritas Communications. Global Education Group is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 110121. This activity is approved for 1.5 contact hours, which includes 0.1 hours of pharmacology.

Activity ID #2417L. This activity was planned in accordance with AANP CE Standards and Policies.

GLOBAL CONTACT INFORMATION For information about the accreditation of this program, please contact Global at 303-395-1782 or cme@globaleducationgroup.com.

INSTRUCTIONS to RECEIVE CREDIT In order to receive credit for this activity, the participant must complete the program evaluation.

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FEE INFORMATION & REFUND/CANCELLATION POLICY There is no fee for this educational activity.

DISCLOSURE of CONFLICTS of INTEREST

PREAMBLE

Global Education Group (Global) requires instructors, planners, managers, and other individuals and their spouses/life partners who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by Global for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

The faculty reported the following financial relationships or relationships to products or devices they or their spouses/life partners have with commercial interests related to the content of this CME activity: Anthony J. Lembo, MD Consultant/Independent Contractor: Alkermes plc, Ardelyx, Inc., Forest Laboratories, Inc., Ironwood Pharmaceuticals, Inc., Prometheus Laboratories Inc., Salix Pharmaceuticals, Inc.; Grant/Research Support: Prometheus Laboratories Inc. Nicole M. Ross, MSN, CRNP, AOCNP Honoraria: Eli Lilly and Company, Medscape, Taiho Oncology, Inc. Michael J. Brennan, MD Consultant/Independent Contractor: AstraZeneca, Cara Therapeutics Inc., Collegium Pharmaceutical Inc., Depomed, Inc., Progenics Pharmaceuticals, Inc., Purdue Pharma L.P., Teva Pharmaceuticals USA Inc.; Honoraria: AstraZeneca, Collegium Pharmaceutical Inc., Depomed, Inc., Progenics Pharmaceuticals, Inc., Purdue Pharma L.P., Teva Pharmaceuticals USA Inc.; Stockholder: Cara Therapeutics Inc. Mihir M. Kamdar, MD Consultant/Independent Contractor: Collegium Pharmaceutical Inc. Pattie A. Jakel, RN, MN, AOCN

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Speakers Bureau: Genentech, Inc., Merck & Co., Inc.

Ashley Marostica, RN, MSN

Nothing to disclose

Kristen Delisi

Nothing to disclose

Lindsay Borvansky

Nothing to disclose

Andrea Funk

Nothing to disclose

Laura Gilsdorf

Nothing to disclose

Rose O’Connor, PhD

Nothing to disclose

Jim Kappler, PhD

Nothing to disclose

DISCLOSURE of UNLABELED USE This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. Global Education Group (Global) and Integritas Communications do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of any organization associated with this activity. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

DISCLAIMER Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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PREAMBLE

The planners and managers reported the following financial relationships or relationships to products or devices they or their spouses/life partners have with commercial interests related to the content of this CME activity:

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GUIDELINES »» Emerging treatments in neurogastroenterology: a multidisciplinary working group consensus statement on opioid-induced constipation.

Camilleri M, et al. Neurogastroenterol Motil. 2014;26(10):1386-1395. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4358801/pdf/ nihms664356.pdf

»» Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.

Chou R, et al. J Pain. 2009;10(2):113-130. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4043401/

»» VA/DoD Clinical Practice Guideline: Management of Opioid Therapy for Chronic Pain, 2010.

Department of Veterans Affairs, Department of Defense http://www.va.gov/painmanagement/docs/cpg_opioidtherapy_fulltext.pdf

»» CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 Dowell D, et al. MMWR Recomm Rep. 2016;65(1):1-49. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

»» The management of constipation in palliative care: clinical practice recommendations.

RESOURCE CENTER

Larkin PJ, et al. Palliat Med. 2008;22(7):796-807. http://journals.sagepub.com/doi/pdf/10.1177/0269216308096908

»» NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain.

National Comprehensive Cancer Network. https://www.nccn.org/professionals/physician_gls/f_guidelines. asp#supportive

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PATIENT RESOURCES »» Patient Conversation Guide This patient tool can be completed prior to the visit with the health care provider to guide a meaningful conversation about bowel habits and constipation symptoms. https://www.theacpa.org/uploads/ACPA-Opioid_Constipation_Chart-V4.pdf

»» Patient Education Handout This leaflet provides patients with approaches to mitigating opioid-induced constipation and includes a list of questions about constipation for patients to ask their doctors or clinics. https://www.acponline.org/system/files/documents/patients_families/ products/health_tips/oic_en.pdf

CLINICAL ASSESSMENT TOOLS »» Bowel Function Index (BFI) The BFI provides a numerical score for the prior 7 days based on ease of defecation, feeling of incomplete evacuation, and personal judgment of constipation. http://www.exchangecme.com/resourcePDF/chronicpain/ BowelFunctionIndex.pdf

»» Bristol Stool Form Scale

RESOURCE CENTER

This visual scale is used to help patients characterize their stool. It classifies the most commonly passed stool forms into 7 types. https://www.niddk.nih.gov/health-information/health-communicationprograms/bowel-control-awareness-campaign/Documents/Bristol_Stool_ Form_Scale_508.pdf

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OTHER RESOURCES »» Consensus recommendations on initiating prescription therapies for opioid-induced constipation.

Argoff CE, et al. Pain Med. 2015;16(12):2324-2337. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4738423/pdf/PME-16-2324.pdf

»» A Clinical Guide to Opioid Analgesia. 2nd edition.

Fine PG, Portenoy RK. New York, NY: Vendome Group, LLC; 2007. https://www.amazon.com/A-Clinical-Guide-Opioid-Analgesia/dp/1933692626#

»» Consensus recommendations for the management of constipation in patients with advanced, progressive illness.

Librach SL, et al. J Pain Symptom Manage. 2010;40(5):761-773. http://www.jpsmjournal.com/article/S0885-3924(10)00599-3/pdf

»» Responsible Opioid Prescribing. A Clinician’s Guide. 2nd Edition, revised and expanded.

Wilson PR. Pain Med. 2015;16(5):1027-1028. https://academic.oup.com/painmedicine/article-lookup/doi/10.1111/pme.12711

SUGGESTED READINGS »» Constipation in people prescribed opioids.

RESOURCE CENTER

Ahmedzai SH, Boland J. BMJ Clin Evid. 2010;pii:2407. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907601/

»» Naloxegol for opioid-induced constipation in patients with noncancer pain.

Chey WD, et al. N Engl J Med. 2014;370(25):2387-2396. http://www.nejm.org/doi/pdf/10.1056/NEJMoa1310246

»» Opioid-induced constipation in patients with chronic noncancer pain in the USA, Canada, Germany, and the UK: descriptive analysis of baseline patientreported outcomes and retrospective chart review.

Coyne KS, et al. Clinicoecon Outcomes Res. 2014;6:269-281. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4041290/

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»» Opioid-induced bowel dysfunction: epidemiology, pathophysiology, diagnosis, and initial therapeutic approach.

Dorn S, et al. Am J Gastroenterol Suppl. 2014;2(1):31-37. http://www.nature.com/ajgsup/journal/v2/n1/pdf/ajgsup20147a.pdf

»» Establishing “best practices” for opioid rotation: conclusions of an expert panel.

Fine PG, et al. J Pain Symptom Manage. 2009;38(3):418-425. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4065110/pdf/nihms576124.pdf

»» Impact of constipation on opioid therapy management among long-term opioid users, based on a patient survey.

Gupta S, et al. J Opioid Manag. 2015;11(4):325-338. https://www.ncbi.nlm.nih.gov/pubmed/?term=26312960

»» A multi-institutional study analyzing effect of prophylactic medication for prevention of opioid-induced gastrointestinal dysfunction.

Ishihara M, et al. Clin J Pain. 2012;28(5):373-381. http://www.ncbi.nlm.nih.gov/pubmed/?term=ishihara+m+2012+clin+j+pain

»» A randomized, placebo-controlled trial of lubiprostone for opioid-induced constipation in chronic noncancer pain.

Jamal MM, et al. Am J Gastroenterol. 2015;110(5):725-732. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4424379/

»» Treatment with methylnaltrexone is associated with increased survival in patients with advanced cancer.

»» Phase 2b, randomized, double-blind, placebo-controlled study of naldemedine for the treatment of opioid-induced constipation in patients with cancer.

Katakami N, et al. J Clin Oncol. April 2017. [Epub ahead of print]. http://ascopubs.org/doi/pdf/10.1200/JCO.2016.70.8453

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RESOURCE CENTER

Janku F, et al. Ann Oncol. 2016;27(11):2032-2038. https://www.ncbi.nlm.nih.gov/pubmed/?term=27573565

»» The impact of opioid-induced constipation among chronic pain patients with sufficient laxative use.

LoCasale RJ, et al. Int J Clin Pract. 2015;69(12):1448-1456. http://onlinelibrary.wiley.com/doi/10.1111/ijcp.12718/abstract

»» Randomized, double-blind trial of oral methylnaltrexone for the treatment of opioid-induced constipation in patients with chronic noncancer pain.

Rauck R, et al. Pain Pract. November 2016. [Epub Ahead of Print]. http://onlinelibrary.wiley.com/doi/10.1111/papr.12535/epdf

»» Symptom severity of patients with advanced cancer in palliative care unit: longitudinal assessments of symptoms improvement.

Tai S-Y, et al. BMC Palliat Care. 2016;15:32. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4787050/pdf/12904_2016_Article_105.pdf

»» Randomized, double-blind, placebo-controlled trial of oral docusate in the management of constipation in hospice patients.

Tarumi Y, et al. J Pain Symptom Manage. 2013;45(1):2-13. http://www.jpsmjournal.com/article/S0885-3924(12)00249-7/pdf

»» A phase 2b, randomized, double-blind placebo-controlled study to evaluate the efficacy and safety of naldemedine for the treatment of opioid-induced constipation in patients with chronic noncancer pain.

RESOURCE CENTER

Webster LR, et al. Pain Med. March 2017. [Epub Ahead of Print]. https://www.ncbi.nlm.nih.gov/pubmed/28371937

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Please visit the CLINICAL RESOURCE CENTER for additional information and resources

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