Comprehensive Cancer Pain Management: Let’s Talk Constipation

MEDICAL COMMUNICATIONS INQUIRIES info@integritasgrp.com integritasgrp.com

FACULTY FACULTY

Mihir M. Kamdar, MD

Associate Director, Division of Palliative Care Director, Cancer Pain Clinic Attending, Palliative Care and Anesthesia Pain Medicine Massachusetts General Hospital Harvard Medical School Boston, Massachusetts Dr. Mihir M. Kamdar is the Associate Director of the Division of Palliative Care and Geriatrics at Massachusetts General Hospital (MGH) and the Director of the MGH Cancer Pain Clinic. Trained in Internal Medicine at Brigham and Women’s Hospital, he completed dual fellowships in both Palliative Care and Interventional Pain Medicine at MGH. He holds clinical appointments at the Department of Anesthesia, Critical Care and Pain Medicine as well as the Division of Palliative Care at MGH in addition to serving on the teaching faculty at Harvard Medical School.

Dr. Kamdar’s clinical and research interests center on the design of innovative models of care delivery for pain management and palliative care, with a particular focus on refractory cancer pain. He is a nationally recognized thought leader, lecturer, and researcher in both palliative care and pain medicine.

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FACULTY

Kathleen Madden, FNP, MSN, AOCNP, APHN Nurse Practitioner, Melanoma Program New York University Health NYU Langone Perlmutter Cancer Center New York, New York

Ms. Kathleen Madden has been a nurse for 25 years, with a focus on medical oncology as a nurse practitioner for 16 years. Her practice specialty is in melanoma and other skin-related malignancies. She participates in clinical research and has taught, lectured, filmed, and written extensively in her areas of expertise. Additionally, Ms. Madden holds numerous certifications in holistic nursing and integrative care techniques and modalities.

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Bill H. McCarberg, MD

FACULTY

Adjunct Assistant Clinical Professor University of California, San Diego School of Medicine San Diego, California

Dr. Bill McCarberg is Founder of the Chronic Pain Management Program for Kaiser Permanente (retired) in San Diego, California. He is currently working with Neighborhood Healthcare in Escondido California (Federally Qualified Health Center) and Elizabeth Hospice. He is treasurer and past president of the American Academy of Pain Medicine and president of the Western Pain Society.

He is also Adjunct Assistant Clinical Professor at the University of California at San Diego School of Medicine. Dr. McCarberg is a member of the American Academy of Family Physicians, the American Academy of Pain Medicine, the American Pain Society, and the International Association for the Study of Pain. Several of his award and leadership positions include national guideline committees for postoperative pain, fibromyalgia, and osteoarthritis; the Elizabeth Narcessian Award for Outstanding Educational Achievement in the Field of Pain, American Pain Society; Presidential Commendation, American Academy of Pain Medicine; Award of Honor for Excellence in Geriatric Medicine, the National Institute of Medicine; Mayday Pain and Society Fellowship; Award of Excellence, Southern California Pain Initiative; Highest Rated Physician, Member Appraisal of Physician Services, Kaiser Permanente; Ambassador of the Year, National Pain Foundation.

He has served the field on the Board of Directors of the American Pain Society and recently on the Professional Education and Training Subcommittee of the National Institutes of Health’s Interagency Pain Research Coordinating Committee, which proposed the US Department of Health and Human Service’s National Pain Strategy. He has given more than 250 presentations on pain management issues and is the author or coauthor of 115 articles, book chapters, and books.

Board certified by the American Board of Pain Medicine and the American Board of Family Practice, with additional certifications in Geriatrics and Hospice and Palliative Care, Dr McCarberg received his medical degree from Northwestern University Medical School in Chicago, Illinois. He completed a medical internship and a residency in family practice at Highland Hospital in Rochester, New York.

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TARGET AUDIENCE

The educational design of this activity addresses the needs of oncology nurses, medical oncologists, and other clinicians involved in the treatment of patients with opioid-induced constipation (OIC).

PREAMBLE

EDUCATIONAL OBJECTIVES

Upon completion of this activity, participants should be better able to: • Evaluate baseline and ongoing bowel patterns in patients with opioid-treated cancer pain • Discuss the clinical profiles and guideline recommendations for US Food and Drug Administration (FDA)-approved treatment options for opioid-induced constipation (OIC) • Recommend bowel regimens for patients with opioid-treated cancer pain who do not respond to traditional laxative therapy • Engage with patients with opioid-treated cancer pain to facilitate bowel assessment efforts and shared decision-making about OIC therapies

PROGRAM DESCRIPTION

Despite the growing number of options to treat constipation symptoms, many patients with cancer pain suffer the burden of OIC.1,2 Patients are often reluctant to discuss symptoms of constipation, underscoring the need for clinicians to provide ongoing education on the signs and symptoms of OIC as well as the need to monitor bowel patterns at each visit.3,4 A collaborative, team-based approach that utilizes shared decision-making to address patients’ unique preferences regarding OIC treatment is another critical aspect of care.5,6 During this Collaborative Care™ session, a multidisciplinary panel of expert faculty will review and discuss individualized management plans for OIC in patients with cancer pain. Prerecorded patient simulation videos will help guide attendees through proper OIC assessment with validated clinical tools, initiation and escalation of appropriate therapies with respect to updated evidence-based guidelines, and effective patient communication strategies for discussing opioidrelated bowel issues and available treatment options. Additionally, attendees will receive access to the online Clinical Resource Center™, an up-to-date web source for clinicians that provides the latest information in OIC care as well as patient education materials.

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REFERENCES 1. Rumman A, Gallinger ZR, Liu LWC. Opioid induced constipation in cancer patients: pathophysiology, diagnosis and treatment. Expert Rev Qual Life Cancer Care. 2016;1(1):25-35.

2. Gatti A, Sabato AF. Management of opioid-induced constipation in cancer patients: focus on methylnaltrexone. Clin Drug Investig. 2012;32(5):293-301.

3. Coyne KS, LoCasale RJ, Datto CJ, Sexton CC, Yeomans K, Tack J. Opioid-induced constipation in patients with chronic noncancer pain in the USA, Canada, Germany, and the UK: descriptive analysis of baseline patient-reported outcomes and retrospective chart review. Clinicoecon Outcomes Res. 2014;6:269-281.

5. Murray E, Charles C, Gafni A. Shared decision-making in primary care: tailoring the Charles et al. model to fit the context of general practice. Patient Educ Couns. 2006;62(2):205-211.

6. Joosten EA, DeFuentes-Merillas L, de Weert GH, Sensky T, van der Staak CP, de Jong CA. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother Psychosom. 2008;77(4):219-226.

AGENDA

6:00 pm–6:10 pm Welcome and Preactivity Questionnaire 6:10 pm–6:25 pm OIC Pathophysiology With 3D Animation Mihir M. Kamdar, MD 6:25 pm–6:50 pm A ssessing Patients for OIC With Patient Vignette Kathleen Madden, FNP, MSN, AOCNP, APHN 6:50 pm–7:15 pm T reatment of OIC With Patient Vignette Bill H. McCarberg, MD 7:15 pm–7:30 pm Postactivity Questionnaire and Q&A Session

PHYSICIAN ACCREDITATION STATEMENT

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Global Education Group (Global) and Integritas Communications. Global is accredited by the ACCME to provide continuing medical education for physicians.

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PREAMBLE

4. Coyne KS, Margolis MK, Yeomans K, et al. Opioid-induced constipation among patients with chronic noncancer pain in the United States, Canada, Germany, and the United Kingdom: laxative use, response, and symptom burden over time. Pain Med. 2015;16(8):1551-1565.

PHYSICIAN CREDIT DESIGNATION

Global Education Group designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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.

DISCLOSURE OF CONFLICTS OF INTEREST

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: Mihir M. Kamdar, MD Nothing to disclose Kathleen Madden, FNP, MSN, AOCNP, APHN Nothing to disclose Bill H. McCarberg, MD Consultant: Averitas Pharma, Inc., Pfizer Inc., Scilex Pharmaceuticals, Inc.; Speakers Bureau: Adapt Pharma, Inc.; Stock Shareholder: Biospecifics Technologies Corp., Collegium Pharmaceuticals, Inc., Johnson & Johnson Services, Inc., Sellas Life Sciences Group, Inc.

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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.

FEE INFORMATION

There is no registration fee for attending this program, however, seating is limited. Preregistration does not guarantee seating. We recommend arriving at the symposium location early.

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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: Lindsay Borvansky Nothing to disclose Andrea Funk Nothing to disclose Ashley Cann Nothing to disclose Ashley Marostica, RN, MSN Nothing to disclose Jim Kappler, PhD Nothing to disclose Celeste Collazo, MD Nothing to disclose

INSTRUCTIONS TO RECEIVE CREDIT

PREAMBLE

In order to receive credit for this activity, submit a completed activity evaluation form at the conclusion of the program. Your credit will be emailed within 4 weeks of the program date. If you have any questions regarding your credit or the accreditation of this program, please contact Global at 303-395-1782 or cme@globaleducationgroup.com.

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BOWEL FUNCTION INDEX

Please answer the following three questions by making a mark on the line between 0 and 100. Then transfer the results to the open squares at the bottom of the page. Add the three results and divide by three.

QUESTION 1 (Q1)

How would you rate the ease of defecation during the last 7 days according to patient assessment?

0=Easy/no difficulty

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100=Severe difficulty

QUESTION 2 (Q2)

Does your patient feel that his/her bowel evacuation has been incomplete during the last 7 days?

0=Not at all

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100=Very strongly

QUESTION 3 (Q3)

How would you judge your patient’s constipation throughout the last 7 days?

0=No constipation at all

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100=Very heavily constipated

RESULTS Q1

Q2

+

Q3

+

Sum

=

Adapted from Rentz AM, et al. J Med Econ. 2009;12(4):371-383.

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Total

/3=

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

National Comprehensive Cancer Network. https://www.nccn.org/professionals/physician_gls/default.aspx

»»American Gastroenterological Association Institute Guideline on the Medical Management of Opioid-Induced Constipation.

Crockett SD, et al. Gastroenterology. 2019;156(1):218-226 https://www.gastrojournal.org/article/S0016-5085(18)34782-6/pdf

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/wp-content/uploads/2017/08/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)

RESOURCE CENTER

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. https://www.exchangecme.com/resourcePDF/chronicpain/BFI2019.pdf

»»Bristol Stool Form Scale

This visual scale is used to help patients characterize their stool. It classifies the most commonly passed stool forms into 7 types. https://www.bladderandbowel.org/wp-content/uploads/2017/05/BBC002_BristolStool-Chart-Jan-2016.pdf

»»Patient Assessment of Constipation (PAC-SYM)

The PAC-SYM is a 12-item questionnaire of patient-reported symptoms during the 2 prior weeks with 3 subscales tracking bowel movements, rectal symptoms, and abdominal symptoms. https://doi.org/10.1080/003655299750025327 29

SUGGESTED READINGS »»Impact of constipation on opioid therapy management among longterm 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

»»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

»»Insights into the role of opioid receptors in the GI tract: experimental evidence and therapeutic relevance.

Galligan JJ, , Sternini C. Handb Exp Pharmacol. 2017; 239: 363–378. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6310692/

»»Efficacy of treatments for opioid-induced constipation: a systematic review and meta-analysis.

Nee J, et al. Clin Gastroenterol Hepatol. 2018;16(10):1569-1584. https://www.cghjournal.org/article/S1542-3565(18)30087-9/fulltext

»»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. 2017;17(6):820-828. https://onlinelibrary.wiley.com/doi/abs/10.1111/papr.12535

RESOURCE CENTER

»»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

»»A randomized, placebo-controlled trial of lubiprostone for opioidinduced 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/

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»»Randomized phase III and extension studies of naldemedine in patients with opioid-induced constipation and cancer.

Katakami N, et al. J Clin Oncol. 2017;35(34):3859-3866. https://ascopubs.org/doi/full/10.1200/JCO.2017.73.0853?url_ver=Z39.88-2003&rfr_ id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed

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

RESOURCE CENTER

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

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NOTES

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Please visit the CLINICAL RESOURCE CENTER for additional information and resources

ExchangeCME.com/OIC19Resources

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