Transcript Cancer Pain Presentation

Cancer Pain
Juliana Howes RN, BNSc, MN
Clinical Nurse Specialist,
Palliative Care
Outline
Examine classifications of cancer pain
 Barriers to pain management
 Tolerance, Dependence, Addiction
 Pain Assessment
– Tools (ESAS)
– Special Populations
 Common Medications
– Opioids, Non-Opioids & Adjuvants

Outline Cont.
Treatments to reduce pain
– Radiation Therapy & Chemotherapy
 Guidelines for Use of Opioids
 Managing common side effects
– Constipation, dry mouth, N&V, sedation
 Case Studies

Definition of Pain

“an unpleasant sensory and emotional
experience associated with actual or
potential damage, or described in terms of
such damage”
(IASP, 1979)

“whatever the experiencing person says it
is, existing whenever the experiencing
person says it does”
(McCaffrey & Pasero, 1999)
Cancer Pain
 35%
experience pain at diagnosis
 74% in advanced cancer (40-50%
moderate to severe pain)
 85% at end of life
 Cancer
pain CAN be managed safely
& effectively
 Despite available options, up to 70%
do not experience adequate relief
Total Pain
Classification of Pain
Duration:
* Acute
* Chronic
* Breakthrough
* Incident
Quality:
* Nociceptive
- Visceral
- Somatic
* Neuropathic
Nociceptive
 Direct
stimulation of afferent nerves
in skin, soft tissue, viscera
Nociceptive: Somatic
 Skin,
joints, muscle, bone,
connective tissue
 Well localized
 Deep - aching, throbbing
 Surface – sharp
 Often worse with movement
 May be tender on palpation
 i.e. surgical incisions, bone mets
Nociceptive: Visceral
 Visceral
organs
 Poorly localized
 Gnawing, deep, pressure, stretching,
squeezing, cramping
 Referred pain (i.e. left arm with MI,
epigastric and back with pancreatic)
 i.e. bowel obstruction, liver mets
Neuropathic
 Abnormal
processing of sensory
input due to nerve damage/changes

Allodynia: pain from stimulus that does not
normally provoke pain

Hyperalgesia: increased response to painful
stimuli
Burning, stabbing, itching, numbing,
shooting, tingling, electrifying
 i.e. brachial plexopathy, cord compression

Barriers to Pain Management
 Health
–
–
–
–
Care Professionals
Lack of knowledge
Lack of assessment
Concern abut side effects
Concern about tolerance and addiction
 Health
Care System
– Not a priority, issues with availability
 Patients
– Fear (condition worsening, addiction)
– Not wanting to burden HCPs
Addiction
 Chronic
neurobiological disease with
genetic, psychosocial and
environmental factors
 3 C’s
– Impaired Control over drug use
– Craving/Compulsive use
– Continued use despite consequences
Dependence
 State
of adaptation manifested by
withdrawal syndrome from
– Abrupt cessation
– Rapid dose reduction
– Administration of
an antagonist
Tolerance
 State
of adaptation where exposure
to drug causes decrease in its effect
over time
Pseudos
 Pseudo
addiction
– Mistaken assumption of addiction in
patient seeking relief from pain
 Pseudo
tolerance
– Misconception that need for increasing
dose is due to tolerance rather than
disease progression
Assessment - ESAS
 Initial
and routine assessment of
pain & other symptoms
 Body diagram to show location of
pain
Assessment – Nonverbal or
Cognitively Impaired Patients
Gold Standard is self-report
 High potential for unrelieved &
unrecognized pain
 Non-verbal Cues

–
–
–
–
–

Facial Expressions
Body Movements
Protective Mechanisms
Verbalizations
Vocalizations
Family observations/perceptions
Commonly Used Opioids
 Morphine
 Hydromorphone
 Codeine
 Oxycodone
 Fentanyl
Morphine
 Moderate
to severe pain
 Gold Standard - affordable &
available
 Measure for dose equivalence
 Active metabolites – toxicity in
elderly & renal impairment
 Oral (IR/CR/Elixir), Parenteral,
Rectal, Intraspinal
Hydromorphone
5x more potent than morphine
 Oral (IR/CR/Elixir), Parental, Rectal,
Intraspinal
 Better tolerated in elderly

Codeine
Mild to moderate pain
 10x weaker than morphine
 Usually in combination with Tylenol
 Ceiling effect at 600mg/24 hrs, max
360mg/d if Tylenol #3
 Metabolized into active form (morphine)
by liver
 Up to 10% of population unable to convert
to active form – no pain relief
 Oral (IR/Elixir), Parenteral

Oxycodone
 1.5-2x
more potent than morphine
 Oral (IR/CR)
 Often combined with Tylenol
(Percocet)
 ?more issues with addiction
Fentanyl
 Not
for opioid naïve patients
 Difficult to convert as 25 mcg patch
= 45-135 mg PO morphine
*Tip: Duragesic 25mcg/hr patch =
Morphine 25 mg SC/24hrs
 Patch difficult to titrate as it takes
12-24 hours to see effect of change
 Transdermal, Sublingual, Parenteral
Non-Opioids
 Mild
to moderate pain
 Inflammation, Bony pain
 Used as adjuvant with opioids
 Acetaminophen: max 4g/d, 3 g/d in frail
elderly, Liver toxicity
 NSAIDs: inhibit synthesis of prostaglandins
preventing contribution to sensitization of
nociceptors
– i.e. Ibuprofen, Naproxen, COX2 (celebrex)
– Adverse effects: GI bleed, increased BP, decreased renal
function, impaired platelet function
Adjuvants
 Antidepressants
 Anticonvulsants
 Corticosteroids
 Local
Anesthetics
 Anticancer therapies
Antidepressants
 TCAs
i.e. amitriptyline, nortriptyline
for neuropathic (burning) pain
 Anticholinergic effects – sedation,
constipation, dry mouth
 Start low and titrate as needed q2-3
days
Anticonvulsants
 Neuropathic
(shooting) pain
 i.e. Gabapentin – start at 100mg TID
or 300mg OD and titrate up to
3600mg/day
 Decreased dose in elderly/renal
impairment
 Side effects can include sedation &
dizziness
Corticosteroids
 Pain
due to spinal cord compression,
headache due to increased ICP, bone
mets
 Can be used to stimulate appetite
 i.e. Decadron 4mg to 16mg/day
 Side effects include hyperglycemia,
psychosis, insomnia
Anticancer Therapy
 Palliative
Radiation: bone pain,
reduce tumour size to decrease pain
(i.e. chest pain in lung ca)
 Palliative Chemotherapy: reduce
tumour size if adequate
performance status and
not significant impact
on QOL
Guidelines for Use

Constant or frequent pain requires regular
medication
– Oral route preferred
– Start with IR to allow for titration
– Use opioid with best analgesia and fewest side effects

A breakthrough dose should be available as
needed
– 10% of daily total or 50% of q4h dose
– CMAX: PO 1h, SC 20-30 min, IV 5-10 min

Treat opioid side effects from the start
– Regular laxative order, PRN antiemetic

Adjuvants are often essential for adequate pain
control
Guidelines Cont.

Is patient opioid naïve?
– Opioid still required if moderate to severe pain,
start low and titrate

Choose route of administration
– Ability to swallow, absorption, compliance, pt.
preference

Determine dosing schedule
– IR q4h with BT doses q1h until relief
– Based on BT usage, titrate up
– When adequate dosage found, can switch to
long acting medication
Titration
 If
requiring more than 3-4
breakthrough in 24 hours:
– Look at pattern and reassess pain
– Increase q4h dose and BT accordingly
 Add
1/3
BTs to q4h dose or increase by
 i.e.
Morphine 5mg PO q4h and 2.5mg PO
q1h, pt used 6 BTs = 15mg
 30mg + 15mg = 45mg /6 doses
 New dose would be 7.5 mg PO q4h
Converting

Once stabilized, can switch to long acting
BID
– Take total daily dose and divide for BID
– i.e. Morphine 10mg PO q4h = MS Contin 30
mg PO q12h

If switching to a new opioid, need to
consider incomplete cross-tolerance
– Tolerance to new opioid may be less and so
can achieve pain relief with lower dose
– Thus need to reduce dose of new opioid by 2550% (usu. cut by ~ 1/3)
Pumps
 Allows
for self-administration of
parenteral BTs
 More consistent dosing as continuous
 CADD pump
Equianalgesic Table
PO
SC/IV
Codeine
100mg
---
Morphine
10mg
5mg
Oxycodone
5mg
---
Hydromorphone
2mg
1mg
Using the Table
Convert Percocet 2 tab PO q4h to Morphine
(1 Percocet = Oxycodone 5mg + Tylenol 325mg)
Oxycodone 10mg x 6 doses = 60mg
From Table Oxydone 5mg = Morphine 10mg
Thus, Oxycodone 60mg = Morphine 120mg
This would be Morphine 20mg PO q4h, but consider
incomplete cross-tolerance
Therefore, Morphine 15mg PO q4h with 7.5mg q1h PRN
Suggestions

Initial dosage of strong opioid in opioid
naïve patient
 Fit:
Morphine 5-10mg PO q4h or equivalent
 Frail: Morphine 2.5-5mg PO q4h or equivalent

Dosage of strong opioid in patients
already on opioids
 If
on weak opioid (i.e. Tylenol #3), not opioid naïve!
 Determine starting dose by using equianalgesic table
Side Effects of Opioids
 Common:
constipation, dry mouth,
nausea, vomiting, sedation
 Less Common: confusion, pruritis,
myoclonus, hallucinations, urinary
retention
 Rare: respiratory
depression
Constipation
 Opioids
inhibit peristalsis and
increase re-absorption of fluids in the
lining of the gut
 Standing order if on opioids
– Senokot 1-6 tab BID + Stool softener
– Lactulose 15-45 cc OD to TID
Sedation and N&V
Commonly experienced in first few days of
taking opioids or after increasing dose
 Body will adjust and these symptoms will
improve
 Minimize other meds that contribute to
drowsiness (i.e. Benzodiazepines)
 PRN anti-emetic (i.e. haldol 1mg
PO/SC/IV, stemetil 10mg PO/IV/PR,
maxeran 10 mg QID)

Dry Mouth
 Difficult
to avoid
 Strategies to minimize include:
 Frequent
mouthcare
 Fluids/Ice Chips
 Sugarless gums
 Artificial saliva
(i.e. Moi-Stir)
Summary

1.
2.
3.
4.



Pain Orders should include:
Regular Analgesic
PRN Analgesic
Standing Laxative
PRN Anti-emetic
Treat side effects from the beginning
Consider type of pain & use adjuvants
Ongoing re-evaluation
Case Study #1
 Mr.R,
46 yrs, met. lung ca., currently
taking Tylenol #3 2 tab q4h and
using 9 extra tablets/day for
breakthrough. He has no difficulty
swallowing the Tylenol #3.
 What is the problem with this
amount of Tylenol #3?
 What are your recommendations?
Calculate and provide new orders
Case Study #1 Cont.
After titrating his medication, Mr.R was
comfortable for a time. However, he has
begun to complain of right arm weakness
and shoulder pain causing shooting pain
down his arm.
 What type of pain do you suspect he is
experiencing?
 What medication and dose would you
recommend?

Case Study #2
Ms.Q, 63 yr old, met. breast ca., has been
taking MS Contin 30mg q12h and has
morphine 5mg tablets available for BT.
She is using about 4 tab/day, but still
having uncontrolled pain
 Main pain to low back that radiates along
the left side, an MRI confirms bone met to
L4 (no cord compression)

Case Study #2
 What
changes would you make to
her pain medication?
 What other treatments might be
considered?
 Ms.Q’s
condition deteriorates and she
is no longer able to swallow her
medications – What would be the
SC/IV dose?