Pain Awareness Month With Nida Khan, MD, and Joseph Kalis, PharmD, BCOP

Oncology Data Advisor: Welcome to Oncology Data Advisor. I'm Keira Smith. Today, we're having this interview in honor of Pain Awareness Month, and I'm joined by Dr. Nida Khan, who is one of our Fellows Forum members, and Dr. Joseph Kalis, who is one of our Editorial Board members. Thank you both so much for coming on the show today.

Nida Khan, MD: Thank you, thanks for having us.

Joseph Kalis, PharmD, BCOP: Yes, you're very welcome. I'm excited to be here.

Oncology Data Advisor: Would you both like to introduce yourselves and share a little bit about what your work focuses on?

Dr. Khan: Sure, I can take it away. I am currently a Medical Oncology and Palliative Care Fellow at The Ohio State University, currently wrapping up my second month now.

Dr. Kalis: I'm Joe Kalis. I'm officially an Ambulatory Oncology Pharmacy Specialist with the University of Colorado (UC) Health in Colorado Springs, Colorado. I'm practicing primarily in oncology and supportive care now, but my background has ranged from palliative care and hospice as well as in clinical oncology pharmacy.

Oncology Data Advisor: Awesome, I'm excited to talk with both of you today to raise a little bit of awareness in honor of Pain Awareness Month. To start off, for some background, what are the different types of pain trajectories and syndromes?

Dr. Khan: There are a lot of different pain trajectories and syndromes, and I think the main thing you're looking for when you're evaluating pain is whether it's chronic pain or acute pain. The chronic pain realm tends to be managed differently and separately versus if it was an acute pain. When it comes to cancer, that's another story. With a lot of patients who have cancer, they have a lot of cancer-related pain, especially if they have bony metastatic disease. That is managed with different agents, more long-term, longer-acting agents. Then if you attach acute pain into the mix, you're usually managing it with shorter-acting agents.

The main things we're looking at are chronic pain syndromes and acute pain syndromes. Then the trajectory really depends on what's going on. If you have a chronic pain patient who, let's say, has bony metastatic disease to the spine and they're undergoing a laminectomy, they're going to have underlying chronic bony pain, and then they're going to have acute post-operative pain. And those are going to be managed separately. You really need to look at pain trajectories and where you foresee that pain going in the future, and then that's how you can act and start to manage it.

Dr. Kalis: I think that's a great breakdown, especially practicing as a pharmacist and using different medications or recommending them. It's a great distinction to make. For patients I see and counsel, sometimes I'll ask them to describe the pain and what it feels like, thinking, "Okay, is it somatic pain? Maybe it's musculoskeletal, but then also perhaps neuropathic." Something that I've gotten more, I'll say, attuned to over my years of practice has been the concept of emotional or psychologic pain. I've had several patients where the pain from past traumas has manifested in a physical manner, and we can't really adequately control their pain until we address that emotional or psychologic cause. It's quite fascinating and a very interesting learning opportunity for me.

Dr. Khan: Joe, you bring up a fantastic point. A lot of patients are complex and they have a lot of different types of pain—things like emotional pain, chronic pain, acute pain, neuropathic pain, and some people have total pain. When you're looking at how you can manage it best, sometimes we try to attack different receptors and different pathways with the different types of medications we have in our tool belts. A lot of times, we look for medications that have a multimodal pain control. A lot of that has to do with where you think this pain is coming from and where it's contributing.

Oncology Data Advisor: Thank you, that was a really helpful breakdown of all the different trajectories. You mentioned the differences between cancer-related pain management versus other types of pain management. What do some of these differences include for patients with cancer specifically?

Dr. Khan: Sure, I can take it away. When you have cancer-related pain, a lot of it has to do with what you think is causing the pain. For most patients, it's metastatic pain, it's bony pain, or it can be nociceptive pain and neuropathic pain. Non–cancer-related pain, if you're thinking more acute, can be nociceptive pain. It can be pain, let's say, from an acute fracture. It can be neuropathic pain for people with radiculopathies and whatnot. In some ways the management is similar, but in some ways it's very different. With cancer-related pain, you're seeing a lot of these patients on long-term agents for managing their pain. Then a lot of them have shorter-acting PRN (as needed) pain medications on board to help with any spikes in pain they may be having.

More specifically, if you have a patient who is a cancer patient and you foresee their pain trajectory getting worse, meaning they have bony metastatic pain to, let's say, the pelvis or the sacrum, and you foresee that these osseous metastases (mets) are probably going to get worse—they're going to get osseous mets in the spine or maybe some nociceptive pain on top of that—you're thinking about how you can change some of their chronic pain medications. Maybe if they're on a long-acting morphine, can I have them on a higher dose? I foresee them being on a higher dose in the future. That's when pain trajectories are really important in what you foresee happening.

Dr. Kalis: I think, with my past practice experiences, cancer pain takes on a whole different nature, whether it's maybe a curative cancer versus a metastatic cancer. Then it's about how we're approaching that and what medications are often thought of. I think opioids are certainly a mainstay—morphine, oxycodone and others. I've used a fair bit of, like you said, multimodal agents such as methadone to really attack some of the neuropathic components, but also perhaps reversing the patient's prior opioid tolerance.

But there's still a large need and a large component with a lot of the concerns about the opioid epidemic and crisis now. I've had multiple patients express concern about, "I have cancer pain, this is real, it's a pancreatic tumor, but I'm still struggling to use pain medications," in what I think you and I would consider an appropriate manner. Folks are worried about, "Gosh, I don't want to get hooked on this." I tell them, "I understand that concern. However, you've got a serious tumor, and the pain's incapacitating you. Let's take a look at it from that angle." It opens up a whole different can of worms.

Dr. Khan: Right.

Oncology Data Advisor: I'm looking forward to hearing how you both approach pain management from your different specialties. Dr. Khan, as a Medical Oncology and Palliative Care Fellow, how do you go about approaching pain management for your patients from this standpoint?

Dr. Khan: Yes, great question. A lot of that has to do with what I think the underlying etiology is and what their primary diagnosis is. A lot of what I'm seeing day-to-day are patients who have cancer-related pain and symptoms associated with that. As I mentioned before, a lot of that has to do with the pain trajectory that you see them on. Here at my institution, we really like the multimodal pain control aspect. A lot of the cancer patients I'm seeing have nociceptive pain and they have neuropathic pain. Things like buprenorphine products and methadone are things that we have in our tool belt and that we actually use pretty often here.

To Joe's point, a lot of education is going on too. A lot of patients are coming in and they bring up, "I don't want to get addicted to this." There's a lot of talk in the community and in the news about opioids and about pain medications. I think what we're really trying to champion and really trying to educate about is that if we're using them the right way and they're dosed appropriately—which we are dosing them appropriately for you—then it's good for you and it's going to help with your pain. It's only going to help you in whatever cancer treatment you're undergoing and help you get through it. These are real symptoms you're having. We do a lot of education. We do a lot of looking at what we think their pain trajectory is going to be.

Then also we work medical oncology and palliative combined, so very closely with the oncology team. A lot of these patients can be candidates for things like steroids and anti-inflammatories. Steroids can really come in handy for pain control, and they act quickly too, sometimes. We speak with oncologists and ask, "Is this something that we can add in their treatment plan?" It can also help with the inflammation they've been feeling. If you have a patient who has bony metastatic disease, we ask the oncologists, "Is radiation oncology going to be involved or is this patient a candidate for palliative radiation?" That's also another tool for pain control. With all these different things, it's very multidisciplinary and involves looking at which ways we can attack this pain from.

Dr. Kalis: You bring up a great point with dexamethasone. I describe it to some of my incoming students and residents as oncology and palliative care duct tape. It can help with inflammation, it can help with bony pain, nausea, appetite. There are many, many uses for dexamethasone, so it's certainly one of the more common things I'll recommend. With my perspective in training, I'm the "drug guy" in the office, so a lot of things you recommend are often a medication, but like you said, there's still that stigma around opioids. Even if they are being dosed and used appropriately, patients might be afraid to use them.

I've made recommendations in the past for, we'll say, lighter opioids such as tramadol. It may or may not work for every patient, but it's worth a try. As part of my ongoing learning, there have even been a lot of even non-pharmacologic methods, such as guided imagery. I had one patient respond really well to that, or some patients have asked questions about aromatherapy or acupuncture. I think the theme is that folks are looking for that relief, and the way that we get there may differ from patient to patient, but the ultimate goal is still going to be the same.

Oncology Data Advisor: Dr. Kalis, same question of you—how do you go about approaching pain management as a pharmacist?

Dr. Kalis: Fantastic question. I'm usually coming in a little bit later into the treatment paradigm that perhaps Dr. Khan does. Typically, when I get consulted or asked to help with a patient, they are established on a regimen already. We may be looking to make tweaks or changes to that, perhaps changing from one opioid, say, morphine to another, perhaps oxycodone or hydromorphone. Other times I'll get involved is when, say, a patient's on a multimodal pain control regimen. Say we're doing something for neuropathic pain like gabapentin, and perhaps they develop an intolerance or a patient comes in with drug interactions, and we need to find another agent. I'll often make a lot of interventions and recommendations there.

I think another area as well is in that education piece. It's a big part of the role I'm in now, really speaking directly with patients about their medications. Some of the basics are, "Okay, here's what the medicine is, here's how it's recommended to take it. Here's what to expect from it." But the relationships I'm able to develop with patients, seeing them over and over, I think are crucial to developing some of that rapport and trust to really find out, "Well, maybe Mr. Smith said he's taking the oxycodone every four hours." But as a patient becomes more comfortable with you as a provider, you may learn, "Well, he's repeating that off of the label, because it said it's what he was supposed to be doing, but maybe he's afraid to take it. Or maybe he ran out a week early because he's taking it every two to three hours because his pain is that bad." It really gives an opportunity to delve into, "Well, why is that? What's happening? What are some other strategies or other medications we can use?"

Oncology Data Advisor: In light of Pain Awareness Month, what would you both like to share about pain management in hopes of raising more awareness of it?

Dr. Khan: I think it's important when you're talking about pain is to know what you think the etiology of it is. A lot of times, there's a lot of factors playing into it. As we mentioned throughout this so far, you can have emotional pain, total pain, and pain that's acting at different receptors or that you can target different receptors with the kind of medications you have. It's important to think about the etiology of the pain when you're thinking about how to manage it best, and to look at the patient holistically and where you see their pain trajectory going forward.

Dr. Kalis: I think assessing the patient as a whole person—body, mind, soul, however you wish to approach it—is super important. We've all had those cases where the patient comes in and they're talking as we are now, and they may say they have 10 out of 10 pain. I've learned that pain is what the patient says it is. I need to know to take that seriously to find out, "All right, maybe this has just been so chronic that this is their baseline, and they've learned to cover it up." If somebody comes in with a broken leg from a car accident, that's obvious to associate; it makes sense to us as clinicians. But it's important to take all pain seriously and try to understand, as you said, the etiology, and then use that etiology as a lighthouse to decide, "All right, what's the best way to treat it?"

Oncology Data Advisor: Great. Anything else either of you would like to mention?

Dr. Khan: I think just really listen to your patients. Take the time to listen to them and act off of what they're telling you. As I said before, know where you think their pain's going to be headed, and that can be a great clue when it comes to managing them.

Dr. Kalis: I might add in that we've got many, many tools at our disposal. The stigma around opioids is real, but they're one option. There are anti-inflammatories or steroids; you can get pretty esoteric. I've used ketamine, both intravenously (IV) and orally for patients. It's not something that comes to mind for many folks, but in the right person, it definitely can make a big difference. I'd encourage folks to keep an open mind.

Dr. Khan: Agreed. Dr. Kalis brings up a great point. There are a lot of pharmacologic and non-pharmacologic tools, and there are a lot of interventions, too. There are pain blocks for patients who have really chronic pain. You can institute your interventional radiology team or your pain team to help with that. You also have ketamine, and you have lidocaine drips that we use sometimes. We have a lot of different things in our tool belt that we can use, and it's important to think about all these different options.

Dr. Kalis: Again, it doesn't necessarily have to be, like you said, transdermal patches, whether it's fentanyl or lidocaine. If we've got patients that are able to swallow a pill or tablet or have physical reasons why they can't, maybe psychologic reasons they can't, we still have ways that their pain can be relieved. We can still help them find the quality of life that they're looking for.

Oncology Data Advisor: This has been such an informative conversation. I'm really glad that we were able to share these messages to raise more awareness this month. Thank you both so much again for joining in this conversation today.

Dr. Khan: Thank you.

Dr. Kalis: Thanks, glad to have been here.

About Dr. Khan and Dr. Kalis

Joseph Kalis, PharmD, BCOP, is an Ambulatory Oncology Clinical Pharmacy Specialist at the University of Colorado Health. In this position, he educates patients about their chemotherapy and immunotherapy treatments, reviews treatment plans and dose adjustments, and assists with supportive care. Dr. Kalis' professional interests include multiple myeloma and hematologic malignancies. He enjoys teaching learners from all walks of life. Dr. Kalis has spoken extensively for continuing education programs, along with various peer-reviewed papers on oncology and pharmacy.

Nida Khan, MD, is a Medical Oncology and Palliative Care Fellow at The Ohio State University Wexner Medical Center. She is passionate about treating cancer and cancer-related symptoms with a focus in thoracic malignancies. She also has specific interests in global health and education as applied to palliative care and oncology. Dr. Khan has taken part in several global health initiatives, including working with palliative care and oncology patients in Uganda.

Transcript edited for clarity. Any views expressed above are the speakers' own and do not necessarily reflect those of Oncology Data Advisor.