1. Cancer Pain Juliana Howes RN, BNSc, MN
Clinical Nurse Specialist, Palliative Care

2. 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

3. 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

4. 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)

5. 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

6. Total Pain Suffering of the whole person
If challenges controlling physical pain, question if other areas need attention
Psychological distress in 40-80%, often highest when confined to bed
Need to actively listen to patient, ask how they are coping and feeling
I’ve had patients where it has been extremely difficult to control their pain, but spending time with them each day and discussing their fears had a huge impact on their physical well-being, such that they were able to go home to die as per their wishes instead of remaining in hospital.

7. Classification of Pain
Duration: Quality:
* Acute * Nociceptive
* Chronic Visceral
* Breakthrough - Somatic
* Incident * Neuropathic

8. Nociceptive
Direct stimulation of afferent nerves in skin, soft tissue, viscera

9. 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

10. 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

11. 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

13. 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

14. 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

15. Dependence State of adaptation manifested by withdrawal syndrome from
Abrupt cessation
Rapid dose reduction
Administration of
an antagonist

16. Tolerance
State of adaptation where exposure to drug causes decrease in its effect over time

17. Pseudos Pseudo addiction Pseudo tolerance
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

19. Assessment - ESAS
Initial and routine assessment of pain & other symptoms
Body diagram to show location of pain

20. 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

22. Commonly Used Opioids Morphine Hydromorphone Codeine Oxycodone
Fentanyl

23. 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

24. Hydromorphone 5x more potent than morphine
Oral (IR/CR/Elixir), Parental, Rectal, Intraspinal
Better tolerated in elderly

25. 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

26. Oxycodone 1.5-2x more potent than morphine Oral (IR/CR)
Often combined with Tylenol (Percocet)
?more issues with addiction

27. Fentanyl Not for opioid naïve patients
Difficult to convert as 25 mcg patch = mg PO morphine
*Tip: Duragesic 25mcg/hr patch = Morphine 25 mg SC/24hrs
Patch difficult to titrate as it takes hours to see effect of change
Transdermal, Sublingual, Parenteral

28. 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

29. Adjuvants Antidepressants Anticonvulsants Corticosteroids
Local Anesthetics
Anticancer therapies

30. 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

31. 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

32. 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

33. 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

34. 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 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

35. 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

36. Titration If requiring more than 3-4 breakthrough in 24 hours:
Look at pattern and reassess pain
Increase q4h dose and BT accordingly
Add BTs to q4h dose or increase by 1/3
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
New BT should be mg, but if using pills only available in 5mg tabs – so leave at 2.5 or increase to 5mg depending how pt.’s response to the BT

37. 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 25-50% (usu. cut by ~ 1/3)

38. Pumps Allows for self-administration of parenteral BTs
More consistent dosing as continuous
CADD pump

39. Equianalgesic Table PO SC/IV Codeine 100mg --- Morphine 10mg 5mg
Oxycodone
Hydromorphone
2mg
1mg

40. 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

41. 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

42. Side Effects of Opioids
Common: constipation, dry mouth, nausea, vomiting, sedation
Less Common: confusion, pruritis, myoclonus, hallucinations, urinary retention
Rare: respiratory
depression

43. 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 cc OD to TID

44. 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)

45. Dry Mouth Difficult to avoid Strategies to minimize include:
Frequent mouthcare
Fluids/Ice Chips
Sugarless gums
Artificial saliva
(i.e. Moi-Stir)

46. Summary 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

47. 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
Exceeds 4g/d of Tylenol, exceeds ceiling dose of codeine
Switch to morphine
Codeine = 630
Thus, morphine 63 mg/d
Cut by ~1/3, this is not exact
Morphine 45mg/d
Morphine 7.5 mg PO q4h, morphine 5mg PO q1h PRN
OR can use dilaudid 1.5mg q4h with 0.5 or 1 mg BT

48. 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?
Neuropathic, likely r/t brachial plexopathy (damage to the nerves as tumour invades or compresses)
Shooting – anticonvulsant, start gabapentin at 300mg OD

49. 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)

50. 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?
Switch to IR to allow for titration
Morphine = 80/day
Could stick with morphine..and use 12.5 or 15mg q4h
Easier to change to dilaudid
80 /5 = 16mg/d
Cut by ~30%
Therefore, dilaudid 12mg/day = 2mg q4h
Radiation therapy!!
SC/IV dose would be dilaudid 1mg SC/IV q4h