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Management of Pain in Cancer Patient Dr. Khaled Abulkhair, PhD Medical Oncology SCE, Royal College, UK Ass. Professor of Clinical Oncology Mansoura University,

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Presentation on theme: "Management of Pain in Cancer Patient Dr. Khaled Abulkhair, PhD Medical Oncology SCE, Royal College, UK Ass. Professor of Clinical Oncology Mansoura University,"— Presentation transcript:

1 Management of Pain in Cancer Patient Dr. Khaled Abulkhair, PhD Medical Oncology SCE, Royal College, UK Ass. Professor of Clinical Oncology Mansoura University, Egypt

2 Purpose Review basic principles of pain management and analgesic therapy in cancer patients. Review basic principles of pain management and analgesic therapy in cancer patients. Case study illustrating common pain problems and suggested management. Case study illustrating common pain problems and suggested management. Self evaluation Self evaluation

3 Pain in Cancer Patients What is pain? An unpleasant feeling occurring as a result of injury or disease, usually localized in some part of the body. Bodily suffering characterized by such feelings. Mental or emotional suffering; distress.Incidence: 30-40% of patients at time of diagnosis or during disease -modifying treatment. 30-40% of patients at time of diagnosis or during disease -modifying treatment. 70- 90% in those with advanced disease. 70- 90% in those with advanced disease.

4 Pain is unpleasant sensation! Yet protective 4

5 Unlike other types of pain! Severe, sharp and short In healthy people Severe, Sharp, chronic in unhealthy patient 5

6 Pain in Cancer Patients Aetiology Direct tumour involvement: 62-78% Direct tumour involvement: 62-78% As a result of diagnostic or therapeutic interventions 19-25% As a result of diagnostic or therapeutic interventions 19-25% – Post- radiation ( enteritis; nerve injury; osteonecrosis) – Post-chemotherapy ( e.g. mucositis; peripheral neuropathy) – Post- operative pain- acute and chronic Cancer induced syndromes <10% Cancer induced syndromes <10% – Constipation, pressure sores, shingles Pain unrelated to malignancy or treatment 3-10% Pain unrelated to malignancy or treatment 3-10%

7 Direct Invasion by Cancer 7

8 Large Lytic Metastases 8

9 Bed Sores 9

10 Types of Pain Acute: Acute: e.g. procedural pain; pathological fracture; bowel/ureteric obstruction Chronic Chronic (Breakthrough pain) Acute on Chronic (Breakthrough pain) Malignant; Non-Malignant Malignant; Non-Malignant

11 Types of Pain Nociceptive: Direct response to tissue injury Nociceptive: Direct response to tissue injury Includes musculoskeletal (somatic) and visceral pain Neuropathic: Pain associated with damage to the nervous system Neuropathic: Pain associated with damage to the nervous system Mixed pain syndromes Mixed pain syndromes

12 12 Untreated Pain….. Untreated Pain….. Patients and caregivers need to understand that pain is important. There is an urgency. If pain is not controlled, their lives are out of control. Impact on Function Function Sleep Sleep Impaired cognitive function Impaired cognitive function Quality of life Quality of life Outcomes Depression Depression Decreased socialization Decreased socialization Increased health care utilization Increased health care utilization Increased costs Increased costs

13 13 “Pain is a more terrible lord of mankind than even death itself ” Albert Schweitzer

14 Outcome of cancer Pain Management There’s more to cancer care than simply helping patients survive. There's more to cancer treatment than simple survival. - > 80% will achieve good control - 15% will have fair control - < 5% will have poor or no control

15 Principles of Cancer Pain Management Start early…… Start early…… The most important step in treating pain is the assessment. The most important step in treating pain is the assessment. Oral route is preferred when available. Although the ratio of oral to parenteral morphine is commonly noted to be 6:1, clinical observation of chronic cases indicates that this ratio is closer to 3:1. Oral route is preferred when available. Although the ratio of oral to parenteral morphine is commonly noted to be 6:1, clinical observation of chronic cases indicates that this ratio is closer to 3:1. Choose the analgesic drug and dose to match the degree of pain suffered by the patient. Choose the analgesic drug and dose to match the degree of pain suffered by the patient. Before adding or changing to another drug, maximize the dose and schedule of the current analgesic drug. Before adding or changing to another drug, maximize the dose and schedule of the current analgesic drug. 15

16 For persistent severe pain, use a product with a long duration of action. Pain medications should always be administered on a scheduled basis or around the clock. It is always easier to prevent pain from recurring than to treat it once it has recurred. For persistent severe pain, use a product with a long duration of action. Pain medications should always be administered on a scheduled basis or around the clock. It is always easier to prevent pain from recurring than to treat it once it has recurred. As-needed dosing should be used for breakthrough pain. As-needed dosing should be used for breakthrough pain. If more than two as-needed doses are required for breakthrough pain in a 24-hour period, consider modifying the regimen. If more than two as-needed doses are required for breakthrough pain in a 24-hour period, consider modifying the regimen. Provide medications to prevent adverse events such as constipation and itching. Provide medications to prevent adverse events such as constipation and itching. Use appropriate adjuvant analgesics and nondrug measures to maximize pain control. Use appropriate adjuvant analgesics and nondrug measures to maximize pain control. 16

17 17 Abdou 83 year old widower: Lives alone 83 year old widower: Lives alone Ca Prostate with Bony metastases; Hx OA/ IHD/ Depression Ca Prostate with Bony metastases; Hx OA/ IHD/ Depression Brought in by daughter: Won’t leave the house Brought in by daughter: Won’t leave the house Increased pain in his shoulder and lower back for 2 weeks Increased pain in his shoulder and lower back for 2 weeks Constipated Constipated

18 18 Pain Assessment Tools Listen carefully: What are the words used? Listen carefully: What are the words used? May deny pain but will admit to having “discomfort”, “aching” or “soreness”  Do you hurt anywhere?  Are you uncomfortable?  How does it affect you? Because pain is subjective, it is best evaluated by the patient (i.e., not a caregiver and not the health professional). Because pain is subjective, it is best evaluated by the patient (i.e., not a caregiver and not the health professional). Believe the patient “pain is what the patient says hurts….the best judge of a patient’s pain is the patient” Bonica. Believe the patient “pain is what the patient says hurts….the best judge of a patient’s pain is the patient” Bonica.

19 19 OPQRSTUV O NSET: When did it start? P ATTERN: How often; When; How long? Q UALITY: Describe it: sharp, dull...Colic R ELIEVING/AGGRAVATING FACTORS S EVERITY: Scale of 1- 10 T REATMENTS: What helps; For how long U NDERSTANDING: What do you think is causing it?. How does it affect you? V ALUES: Goals Of Care; expectations

20 20 Tools Please rate your pain by circling the one number that best describes your pain _____________________________________________________________ 0 1 2 3 4 5 6 7 8 9 10 What is your Pain at it’s Best / Worst/ Present/ Average No Pain Pain as bad as you can imagine In the past 24 hours, how much RELIEF have pain treatments or medications provided? Please circle the one percentage that most shows how much. _____________________________________________________________ 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

21 21 Pain History: Abdou O(nset): Several months/  2 weeks O(nset): Several months/  2 weeks P(attern): R shoulder/lower back pain. Constant. Increased with movement (what would be named?). P(attern): R shoulder/lower back pain. Constant. Increased with movement (what would be named?). Q(uality): Steady aching pain Q(uality): Steady aching pain R(elief): Medication helps for about 2-3 hrs R(elief): Medication helps for about 2-3 hrs S(everity): 6/10. 10/10 with movement S(everity): 6/10. 10/10 with movement T(reatments): T#3 helps for about 2-3 hours. Takes about 12-15 T#3 a day T(reatments): T#3 helps for about 2-3 hours. Takes about 12-15 T#3 a day U(nderstanding): Not going on any Morphine. I’m not dead yet. U(nderstanding): Not going on any Morphine. I’m not dead yet.

22 22 Examination No evidence of fractures but clearly limited ROM in the shoulder due to pain No evidence of fractures but clearly limited ROM in the shoulder due to pain No vertebral tenderness and no neurological signs No vertebral tenderness and no neurological signs Bowel and bladder function normal…yet constipated Bowel and bladder function normal…yet constipated X-rays show bony mets. in shoulder and lumber spine X-rays show bony mets. in shoulder and lumber spine

23 23 Abdou– approach to treatment Develop a problem list to resolve  Somatic / bone pain  Acetaminophen dosing too high (~4 Gm)  Constipation contributing to pain intensity  Compliance issues

24 Do not under-estimate the patient’s condition based on his denial. Do not under-estimate the patient’s condition based on his denial. 24

25 25

26 26 How would you better manage Abdou’s pain? DRUGS

27 27 Pain Management is not only drugs Educate patient and family: - Myth: “Save it for..when it gets worse” FACT: Treating early prevents pain FACT: Treating early prevents pain FACT: No ceiling effect of strong opioids FACT: No ceiling effect of strong opioids - Myth: “I’ll become addicted” FACT: Addiction is rare. Boston study- 0.03% FACT: Addiction is rare. Boston study- 0.03% FACT: Tolerance is rare in Palliative Patients/PO route. FACT: Tolerance is rare in Palliative Patients/PO route. - Myth: Treatment worse than pain FACT: Side effects can be managed/treated FACT: Side effects can be managed/treated

28 28 Education Constant pain requires regular dosing  Avoid peaks of pain as with prn dosing  Smoother blood levels can provide more consistent pain control  More convenient  Less analgesia over time  Maintain uninterrupted sleep

29 WHO 3-step Ladder 29 Acetaminophen NSAIDs ± Adjuvants Codeine Oxycodone ± Adjuvants Morphine Hydromorphone Methadone Fentanyl Oxycodone ± Adjuvants

30 30 Drugs for Pain Management  Acetaminophen  NSAIDS  Opioids  Adjuvants/ Co analgesics A.Bisphosphonates/Calcitonin B.Antidepressants C.Anti-convulsants D.Disease specific therapies: Radiation/Chemotherapy/Surgery E.Steroids

31 31 Analgesics Step 1: Mild pain: Step 1: Mild pain: – Acetaminophen: Max 2.4 gm/day Can be very effective for mild-moderate pain if given regularly…caution with Hepatic patients. – NSAIDs: Issues re GI and renal toxicity Concerns in the elderly... Non-specific: Use with GI protection Non-specific: Use with GI protection COX 2 agents safer re GI morbidity and antiplatelet effects

32 32 NSAIDS Both peripheral and central effects Both peripheral and central effects Inhibit cyclo-oxygenase (COX) enzyme ->  Decreased prostaglandin production Inhibit cyclo-oxygenase (COX) enzyme ->  Decreased prostaglandin production Specific COX 2 inhibitors: Celecoxib, rofecoxib. Less GI effects Specific COX 2 inhibitors: Celecoxib, rofecoxib. Less GI effects Less effect on platelet function Less effect on platelet function “Non-Selective” COX 2 inhibitors: Diclofenac “Non-Selective” COX 2 inhibitors: Diclofenac Nonacetylated salicylates: Diflunisal Nonacetylated salicylates: Diflunisal

33 NSAIDs Ibuprofen Q4-6h, Max 2400 mg/day Ibuprofen Q4-6h, Max 2400 mg/day Diclofenac Potassium, Cataflam, Q 8-12h, Max 150 mg/day…first day 200 mg. Diclofenac Potassium, Cataflam, Q 8-12h, Max 150 mg/day…first day 200 mg. Diclofenac Sodium, Voltaren, Q 8-12h, 150 mg/day. Diclofenac Sodium, Voltaren, Q 8-12h, 150 mg/day. Indomethacin Q8-12h, Max 200 / day Indomethacin Q8-12h, Max 200 / day Naproxyn Q 12h, max1650 mg/day Naproxyn Q 12h, max1650 mg/day Meloxicam Q24h, Max 15mg/day Meloxicam Q24h, Max 15mg/day Tenoxicam, Epicotel, Q24h, max 20 mg Tenoxicam, Epicotel, Q24h, max 20 mg Celecoxib Q12h, Max 400mg/day Celecoxib Q12h, Max 400mg/day 33

34 34 Step 2 + 3 Opioid Use  Opioids help relieve moderate to severe pain ( and dyspnea in terminal patients).   Opioid receptors have been targeted for the treatment of pain and related disorders for thousands of years.   they produce analgesia primarily by inhibiting nociceptive transmission in the central nervous system  Episodic pain - Prescribe as needed  Constant pain = Regular dosing PLUS a “breakthrough” PRN dose  Right drug at the Right dose

35 35 Step 2: Moderate pain Tramadol…PO, IV … variable responses… variable responses… Max…400 mg/day Max…400 mg/day Constipation and mode changes Constipation and mode changes Myths Myths

36 Codeine…..Co Weak Opioid  About 10% of population lack enzyme to convert to Morphine  Ceiling effect: > 600 mg/day  Very constipating  Combination product or alone  Helpful for persistent pathological cough.  1:10 ( Morphine : Codeine)  Sustained release preparation : Codeine Contin 50,100,150, 200 mg 36

37 37 Oxycodone: Moderate ->Strong Opioid Active at the mu and kappa receptors Active at the mu and kappa receptors Safe with decreased renal function Safe with decreased renal function Potency Oxycodone 1.5 - 2 :1 Morphine Potency Oxycodone 1.5 - 2 :1 Morphine Less constipating than Codeine Less constipating than Codeine Lasts ~ 4-5 hours Lasts ~ 4-5 hours No ceiling effect/help Neuropathic pain No ceiling effect/help Neuropathic pain Alone or with ASA/Acetaminophen Alone or with ASA/Acetaminophen OxyContin 10, 20, 40, 80 mg OxyContin 10, 20, 40, 80 mg Start slow stop slow Start slow stop slow

38 Strong Opioids Morphine still is the gold standard Morphine still is the gold standard – Concerns re: metabolites in renal failure; elderly….Liver impairment. – Extensive first pass metabolism Hydromorphone: Hydromorphone: – More soluble. – Few metabolites – 5x more potent than Morphine.

39 39 Opioid Pharmacology C max = 60 mins (after PO dose) C max = 60 mins (after PO dose) 45 mins (after SC dose) 30 mins (after IM dose) 6 mins (after IV dose) 6 mins (after IV dose) t 1/2 =3-4 hours t 1/2 =3-4 hours Duration =20-24 hrs (immediate-release) Duration =20-24 hrs (immediate-release) 48-72 hrs (sustained-release) 48-72 hrs (sustained-release)

40 40 Strong Opioids Fentanyl: Not at mu receptor. More lipophilic Fentanyl: Not at mu receptor. More lipophilic – 100x more potent than Morphine. – Less constipation and nausea. – Less histamine release – Useful in true opioid allergy

41 41 Fentanyl Transdermal Patch: different strengths in mcg/hour: Transdermal Patch: different strengths in mcg/hour:  25 ~ 100 mg Morphine/day (45 -134)  50 ~ 200 mg (135-224), 75 (225-314),  100 ~ 400 mg (315-404 mg M/day)  Takes ~17 hours to reach steady state  Patch lasts 72 hours in 90% of patients Sublingual, intranasal, subcutaneous, IV routes Sublingual, intranasal, subcutaneous, IV routes

42 Methadone Semisynthetic used in maintenance treatment for opioid- dependent individuals as well as in patients taking opioids long term for moderate to severe pain Semisynthetic used in maintenance treatment for opioid- dependent individuals as well as in patients taking opioids long term for moderate to severe pain Has activity not only at the opioid receptors, but also at the NMDA (N-methyl-d-aspartate) receptor Has activity not only at the opioid receptors, but also at the NMDA (N-methyl-d-aspartate) receptor Complex pharmacokinetics with extended half-life, which creates difficulties in dosing and transitioning from one opioid to another Complex pharmacokinetics with extended half-life, which creates difficulties in dosing and transitioning from one opioid to another Associated with QT prolongation and/or torsades de pointes Associated with QT prolongation and/or torsades de pointes Effective long-acting agent; used for neuropathic pain Effective long-acting agent; used for neuropathic pain Start low and titrate slowly. Start low and titrate slowly. 42

43 43 Opioid Equi-analgesic Doses http://agencymeddirectors.wa.gov/mobile.html 10 mg PO morphine 10 mg PO morphine =5 mg SQ/IV morphine (half the oral dose) = 100 mg PO codeine (1/10) = 2 mg PO Hydromorphone (1mg SQ) (5x more potent) = 5 - 7.5 mg PO Oxycodone ( 1.5x) = 0.5- 1 mg PO/pr methadone ( not Q4H) ( ~~10 x more potent)

44 Steps for converting between opioids Calculate total mg dose taken in past 24-hours. Determine equi-analgesic dose. If pain is controlled on current opioid, reduce the new opioid daily dose by 25-50% to account for cross-tolerance, dosing ratio variation, and inter- patient variability. If pain is uncontrolled on the current opioid, increase opioid daily dose by up to 100-125%. Titrate liberally and rapidly to analgesic effect during first 24 hours. Monitor for adverse events and effectiveness. Reassess the analgesic effect every 2-3 days. 44

45 45 Abdou Proposed Management Strategy?

46 46 Abdou 12-15 T#3 = 350/30 mg not controlled 12-15 T#3 = 350/30 mg not controlled – 3900- 4875 mg Acetaminophen plus – 360- 450 mg Codeine ~ 36- 45 mg PO Morphine TDD (total daily dose ) ~ 7- 9 mg PO Hydromorphone ~ 25- 30 mg PO Oxycodone ~Patch? Concerns re Acetaminophen dose/ Approaching ceiling Codeine Concerns re Acetaminophen dose/ Approaching ceiling Codeine

47 47 Abdou Rotation to strong opioid: Rotation to strong opioid: Which one? Which one? Dose: ? Equi-analgesic Dose: ? Equi-analgesic - ? Increase dose - BT (Break Through)

48 48 Opioid Adverse Effects Constipation: “ The hand that writes the opioid prescription should start the laxative” Constipation: “ The hand that writes the opioid prescription should start the laxative” ٠ Stimulant (+/- softener) (+/- osmotic) ٠ Nausea: ٠ Approximately 50% will have some nausea in first week; 30% after that ٠ In those prone to nausea consider anti-emetic (metoclopramide)

49 49 Abdou: 2 days later Morphine SR 30 mg BID = 60 mg PLUS 6 BT of 5 mg = 30mg mg 90mg Increase to morphine SR 45 mg BID BT: 10% of TDD or 1/2 of Q4H dose

50 50 Bone Pain  What role would the following play?  Radiotherapy  NSAIDs  steroids  Bisphosphonates  calcitonin  What else might you do? Spiritual

51 51 Breakthrough Pain End of dose pain: End of dose pain:  Usually requires dose increase regular medication Paroxysmal/Idiopathic: Paroxysmal/Idiopathic:  Titrate to only 1-3 BT’s /day  BTD should be 10% of TDD/1/2 of Q4H Incident Pain Incident Pain  Precipitant. Peaks early. Short duration  65% last 30 minutes or less

52 Ideal Analgesic  Easily administered  Rapid onset  Short-duration of action  In patient’s control  Before the event 52

53 In Reality….Good and Bad  Side Effects  Expensive  In-availability  Tolerance  Toxicity 53

54 54 Abdou: 3 months later Confused, drowsy Confused, drowsy Not eating Not eating Pain on any weight bearing, despite recent RXT, radiating into his Left leg Pain on any weight bearing, despite recent RXT, radiating into his Left leg Some myoclonus Some myoclonus LAB: Normal Calcium, Creatinine 2mg/dl LAB: Normal Calcium, Creatinine 2mg/dl

55 55 Abdou Current medication: ٠ morphine SR 100 mg PO BID ٠ Also taking about 5 BT of 20 mg/day. ٠ 200 mg plus 100 mg = 300 mg morphine TDD What do you recommend re his pain management?

56 56 Abdou …Problem list?  Bone Pain with Incident Pain?  Opioid toxicity?  Neuropathic Pain?  New mets to brain or liver?  Constipation?

57 57 Opioid Toxicity….augmented by renal impairment  Sedation  Constipation  Urine retention  Nausea / vomiting  Hyperalgesia  Agitated delirium  Myoclonus  Respiratory depression

58 58 Opiate conversion: Knowing he was taking Morphine 300 mg /day. What dosage would you initiate the following with? – Hydromorphone? X 5 – Oxycodone? X 1.5 -2

59 Key learning - - Give medication orally whenever possible. - - less invasive, effective, convenient, cost effective analgesia. - - rapid onset of action with oral formulations can be achieved with: IR opioids, certain controlled-release opioids (e.g. CR oxycodone or CR codeine) 59

60 REMS: Risk Evaluation and Mitigation Strategy for Extended-Release/Long- Acting Opioid Analgesics On June 9, 2012, the FDA announced it would require manufacturers of extended- release and long-acting opioid analgesics to provide training for health care professionals who prescribe these agents. 60

61 Adjuvant analgesics Drugs whose primary indication is other than pain; they are used to manage specific pain syndromes. Most often, adjuvant analgesics are used in addition to, rather than instead of, opioids. Antidepressants Antidepressants Transdermal lidocaine Transdermal lidocaine Corticosteroids Corticosteroids Benzodiazepines Benzodiazepines NSAIDs NSAIDs Bisphosphanates Bisphosphanates 61

62 Bisphosphonates Family of drugs that prevents bone resorption by inhibiting osteoclasts. Family of drugs that prevents bone resorption by inhibiting osteoclasts. Helpful in bone pains due to metastases. Helpful in bone pains due to metastases. Best in use is zoledronic acid (zometa), given as 4 mg I.VI every 4 – 6 weeks. Best in use is zoledronic acid (zometa), given as 4 mg I.VI every 4 – 6 weeks. Renal impairment is an issue. Renal impairment is an issue. Oral forms are available. Issues regarding GIT upsets and nephrotoxicity. Oral forms are available. Issues regarding GIT upsets and nephrotoxicity. 62

63 Radiation Therapy Effective in palliating pain from bone mets, soft tissue masses. Effective in palliating pain from bone mets, soft tissue masses. 60-70% Response rates. 60-70% Response rates. Different machines, energies and techniques. Different machines, energies and techniques. Can be re-challenged. Can be re-challenged. Refer to a colleague Refer to a colleague 63

64 64 Neuropathic Pain Pain that arises from injury, disease or dysfunction in the peripheral or central nervous system. Incidence in Cancer : 30-50% Usually described as burning, numbness, stitching or crushing. Caused by (eg, trauma, ischemia, infections) or from ongoing metabolic or toxic diseases, infections, or structural disorders (eg, diabetes mellitus, amyloidosis, HIV infection, nerve entrapment, etc) which produce afferent impulses and signal damage to the nerve structures. Caused by (eg, trauma, ischemia, infections) or from ongoing metabolic or toxic diseases, infections, or structural disorders (eg, diabetes mellitus, amyloidosis, HIV infection, nerve entrapment, etc) which produce afferent impulses and signal damage to the nerve structures.

65 Herpes Reactivation 65

66 66 Treatment of Neuropathic Pain Treat early as central mechanisms can cause persistence of pain Treat early as central mechanisms can cause persistence of pain Adjuvant medications are essential Adjuvant medications are essential Titrate one medication at a time Titrate one medication at a time Push dose until pain relief or intolerable side effects seen Push dose until pain relief or intolerable side effects seen

67 67 Opioids in Neuropathic Pain  Should always be tried  Individual variation  Methadone may be the most useful opioid in neuropathic pain  Some evidence for oxycodone also being more useful

68 68 Antidepressants in Neuropathic Pain Tricyclic antidepressants still the best Tricyclic antidepressants still the best Effective in 50-65% of cases Nortriptyline = amitriptyline as first line Nortriptyline = amitriptyline as first line Desipramine for those who don’t tolerate Desipramine for those who don’t tolerate Starting dose 10 –25 mg Starting dose 10 –25 mg Usual therapeutic dose is 50 –150mg Usual therapeutic dose is 50 –150mg Analgesic effect seen 4-7 days after reaching therapeutic dose Analgesic effect seen 4-7 days after reaching therapeutic dose SSRI..Escitalopram # Omeprazole SSRI..Escitalopram # Omeprazole

69 69 Anticonvulsants in Neuropathic Pain Gabapentin … Try first Gabapentin … Try first Gabapentin has good evidence for efficacy Gabapentin has good evidence for efficacy Most respond to 2100 – 3600 mg/day Most respond to 2100 – 3600 mg/day Push dose to 6000mg/day 80%of patient can tolerate. Push dose to 6000mg/day 80%of patient can tolerate. Pregabalin (Lyrica): Pregabalin (Lyrica): 75 -300 mg BID 75 -300 mg BID Max 600 mg/day Max 600 mg/day Others: Carbamazepine; Clonazepam; Phenytoin Others: Carbamazepine; Clonazepam; Phenytoin

70 70 Miscellaneous Medications Corticosteroids useful with associated swelling and inflammation Corticosteroids useful with associated swelling and inflammation Baclofen if associated with muscle spasm Baclofen if associated with muscle spasm Calcitonin 100-200 units/day helpful with phantom limb pain and sympathetically maintained pain Calcitonin 100-200 units/day helpful with phantom limb pain and sympathetically maintained pain ketamine ketamine Clonidine Clonidine Mexiletine, flecanide, lidocaine Mexiletine, flecanide, lidocaine

71 Self Evaluation Questions 71

72 1- A 75-year-old man has metastatic prostate cancer. The main sites of metastatic disease are regional lymph nodes and bone (several hip lesions). He experiences aching pain with occasional shooting pains. The latter are thought to be the result of nerve compression by enlarged lymph nodes. He has been taking oxycodone- APAP 5 mg 2 tablets every 4 hours and ibuprofen 400 mg every 8 hours. His current pain rating is 8/10, and he states that his pain cannot be controlled. Which is the best recommendation to manage his pain at this time? 72

73 A. Increase oxycodone-APAP to 7.5 mg/325 mg, 2 tablets every 4 hours. B. Increase oxycodone-APAP to 10 mg/325 mg, 2 tablets every 4 hours. C. Discontinue oxycodone-APAP, discontinue ibuprofen, and add morphine sustained release every 12 hours. D. Discontinue oxycodone-APAP, and add morphine sustained release every 12 hours. 73

74 2-Which is the most appropriate adjunctive medication for this patient’s pain? A. Naproxen. B. Single-agent (single ingredient) APAP. C. Gabapentin. D. Baclofen. 74

75 3- A 60-year-old man has head and neck cancer with extensive involvement of facial nerves. His pain medications include transdermal fentanyl 100 mcg/ hour every 72 hours and oral morphine solution 40 mg every 4 hours as needed. He is still having problems with neuropathic pain. Which treatment is best to recommend? A. A. Begin gabapentin and decrease the dose of fentanyl. B. B. Increase the doses of fentanyl and morphine. C. C. Begin diazepam and increase the dose of fentanyl. D. D. Begin gabapentin and continue fentanyl and morphine. 75

76 76Summary: Comprehensive assessment is paramount. Comprehensive assessment is paramount. Avoid unnecessary delay in treating pain. Avoid unnecessary delay in treating pain. Educate patient, family & caregivers. Educate patient, family & caregivers. It is not a one man show. Use multi-disciplinary approach. Call your colleagues! It is not a one man show. Use multi-disciplinary approach. Call your colleagues! Choose medications based on stepped approach, as well as side effect profile Choose medications based on stepped approach, as well as side effect profile Tailor medication regimens to meet individual needs. Tailor medication regimens to meet individual needs. Remember interactions and dose reductions in organ failures. Remember interactions and dose reductions in organ failures. Consider non-pharmacological options Consider non-pharmacological options

77 77

78 78 References Bruera E, Sweeney C. Methadone use in cancer patients with pain: a review. J of PM 5(1): 127-138, 2002 Bruera E, Sweeney C. Methadone use in cancer patients with pain: a review. J of PM 5(1): 127-138, 2002 Bruera et al. A prospective open study of oral methadone in treatment of cancer pain. 9 th World Congress on Pain, 2000 Bruera et al. A prospective open study of oral methadone in treatment of cancer pain. 9 th World Congress on Pain, 2000 Lawlor PG, Turner KS, Hanson J, Bruera E. Dose ratio between morphine and methadone in patient with cancer pain - a retrospective study. Cancer 82(6): 1167-73, 1998 Lawlor PG, Turner KS, Hanson J, Bruera E. Dose ratio between morphine and methadone in patient with cancer pain - a retrospective study. Cancer 82(6): 1167-73, 1998 Ripamonti C. J Clinical Oncology, 1998 Ripamonti C. J Clinical Oncology, 1998 C Gannon. The Use of Methadone in the Care of the Dying, EJPC, 1997 C Gannon. The Use of Methadone in the Care of the Dying, EJPC, 1997 R Fainsinger, T Schoeller, E Bruera. Methadone in the Management of Cancer Pain: A Review. Pain 52: 137-147, 1993 R Fainsinger, T Schoeller, E Bruera. Methadone in the Management of Cancer Pain: A Review. Pain 52: 137-147, 1993 Bruera et al. Opioid Rotation in Patients with Cancer Pain. Cancer78(4): 852-857,1996 Bruera et al. Opioid Rotation in Patients with Cancer Pain. Cancer78(4): 852-857,1996


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