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Cancer pain management

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An overview of how to manage the pain associated with cancer.

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Cancer pain management

  1. 1. Pain Management & Opioid Use for the Cancer Patient Suzana Makowski, MD MMM Co-Chief of Palliative Care Brenda Neil, NP Palliative Care Nurse Practitioner UMass Memorial Healthcare
  2. 2. The obligation of physicians to relieve suffering stretches back to antiquity. [However, there is] a modern paradox: Even in the best settings and with the best physicians, it is not uncommon for suffering to occur not only during the course of a disease, but also as a result of its treatment. -Eric Cassell, MD
  3. 3. Overview • Cancer Pain – background, assessment, treatment • Opioid Rotation • Pain Crisis/Pain Code • Dealing with Drug-Seeking Behavior
  4. 4. Cancer Pain - Reported 1of 3 patients with active cancer 3 of 4 patients with advanced cancer
  5. 5. Questions to keep in mind • Intensity • Etiology of pain – Tumor burden (and location) – Drug induced • Quality of pain • Time-line patter of pain • What has been tried before (helped or not)
  6. 6. Time-course of cancer pain Generally: – Constant pain with breakthrough periods Rarely: – True incident pain (movement only) – Tougher to treat – recommend pain specialist or palliative care specialist to evaluate. • May need intervention (intrathecal pain pump), radiation, etc.
  7. 7. Effects of undertreated pain
  8. 8. Challenges to treatment of cancer pain Pain
  9. 9. WHO’s Pain Relief Ladder Step 1 Step 2 Step 3
  10. 10. Principles of Opioid Pharmacology Time to max effect (cmax) For prn dosing Half-life (t½) For scheduled dosing PO/PR 40-60 minutes 4 hours SQ/IM 20 minutes 3-4 hours IV 6-12 minutes (depending on opioid) 3-4 hours Does not apply to methadoneDoes not apply to methadone
  11. 11. Opioid Rotation • Why? • How?
  12. 12. Opioid Rotation • Why? • How?
  13. 13. Case of Hector G. – part 1 • 56 yo Puerto Rican gentleman with metastatic prostate cancer to bone. s/p radiation, undergoing chemotherapy and hormone therapy. • Medications: – Percocet 5/320 mg 1-2 tabs q4 hours prn – Senna and colace • Comes to visit for increased pain – ran out of medications
  14. 14. Case of Hector G. – part 1 • Prescribe long-acting and short-acting. – Why? – How to calculate? – Which medications? Step 1: Calculate 24 hour dose of current opioid use Hector is taking on 12 tablets of Percocet per day = 60mg oxycodone + 3900mg acetaminophen per day Which medication total is more concerning?
  15. 15. Case of Hector G. – part 1 • Prescribe long-acting and short- acting. – Why? – How to calculate? – Which medications? Step 2: Convert 24 hour current opioid to new opioid (or stay with current opioid) and calculate long acting dose 60mg oxycodone = Oxycontin 30mg bid OR 60mg x (15 morphine/10 oxycodone)= Morphine ER 45mg bid Step 3: if starting new opioid, consider adjusting for cross-tolerance:
  16. 16. Case of Hector G. – part 1 • Prescribe long-acting and short-acting. – Why? – How to calculate? – Which medications? Step 3: Calculate breakthrough dose based on 10-20% of daily long-acting 60mg oxycodone ER  oxycodone IR 5-10mg prn 60mg morphine ER  morphine IR 7.5-15mg prn Frequency: q2 hours prn – up to 6 doses per day Morphine IR 15mg, ½-1 tab q2 hours prn, up to 6 doses per day #180 (perhaps #120) If patient requires more than 6 doses in 24 hours, they should call
  17. 17. Case of Hector G – part 2 more calculations 1. Hector is admitted to hospital and is made NPO. • How do you convert his opioid to IV? 1. Hector’s cancer progresses, he is now in renal failure with urine output less than 100ml per day. He does not wish dialysis or IV fluids. • What do you convert him to and why? • What if he is NPO? • What if he cannot have IV or SQ access? Answers are in separate handoutAnswers are in separate handout
  18. 18. Pain Crisis “This is as much of a crisis as a code” – Natalie Moryl MD http://jama.ama-assn.org/content/299/12/1457.full.pdf
  19. 19. Approach to Pain Crisis
  20. 20. Assess Pain Crisis • Keep in mind emergencies and their associated symptoms: – cord compression, hypercalcemia, opioid neurotoxicity, acute abdomen, etc. • What medications has the patient tried so far? How much? Intensity • quality • timeline • associated symptoms • medications tried • other changes to painIntensity • quality • timeline • associated symptoms • medications tried • other changes to pain
  21. 21. Treat Pain Crisis “Pain Code” • Parenteral opioids are best for crisis • Convert all of last 24 hours into continuous IV • To get pain under control – Double highest home regimen PRN dose and convert to IV as starting point – Then provide doses based on time to max effect (approximately 10 minutes) until patient is comfortable. Prescriber should stay at bedside. – If first dose has no effect, double it with next dose. • Monitoring patient – Pain intensity scale • sedation scale • respiratory rate/O2 Sat • Once pain is controlled – PCA or nurse boluses – Anticipate conversion to non-parenteral regimen
  22. 22. Treat Pain Crisis • Adjunct Therapies to consider: – Steroids (dexamethasone for bone pain, tumor burden) – Radiation therapy may be helpful – Interventional pain/radiology for nerve blocks – Aggressive adjust therapies that specialists may employ include lidocaine or ketamine drips, epidural drips, etc. – Non-pharmacologic interventions: cool or heat therapy, touch, etc.
  23. 23. Engage and Support in Pain Crisis • Nursing and Pharmacy colleagues • Social work and chaplaincy • Family • Outside agencies – hospice may be helpful
  24. 24. At end of life… CMO ≠ Continuous Morphine Only Treat pain and other symptoms Assess for side effects of therapies Watch urine output if on continuous or long-acting opioid (other than fentanyl) Treat pain and other symptoms Assess for side effects of therapies Watch urine output if on continuous or long-acting opioid (other than fentanyl)
  25. 25. Cancer and drug-seeking behavior
  26. 26. Tending to the Addict’s Pain MH 63 yo disabled woman with metastatic breast cancer Severe pain due to brachial plexopathy History of smoking and addiction – high opioid tolerance LS 53 yo disabled woman with metastatic lung cancer. Pain is due to bone metastases History of addiction Current smoker Tx: Methadone 60mg TID, Fentanyl patch 100mcg/hour, Morphine 90 mg q2 hours prn up to 5 times per day Tx: Fentanyl patch 25mcg/hour, Oxycodone 10mg q4 hours prn up to 5 times per day
  27. 27. Tending to the Addict’s Cancer Pain • Function is key • Transparency is key (being explicit) – “I am here to care for you: take care of you pain and not feed your addiction.” • Aim to utilize principally long-acting opioids, minimize short-acting • Pain contract • Ongoing request for more short-acting without increase of long-acting is concern Potential diversion
  28. 28. Tending to the Addict’s Cancer Pain • Inpatient principles: – PCA is a good test • Does function increase or decrease? – Tolerance to opioids will be high, requirement will likely be high – Partner with patient, nursing, social work, pharmacy – Set clear goals (mutually determined)
  29. 29. TJ 53 yo ex-pro football player, heroin addict on methadone x 20+ years Admitted with pain crisis Treatment: Hydromorphone gtt 40mg/hour Methadone 30mg IVP q8 hours (then switch to ketamine gtt) Lidocaine gtt 20mg/kg/hour PRN: Hydromorphone 10mg IVP q30 min prn
  30. 30. Prescribing opioids: (“My general rules” for residents on rotation)
  31. 31. Thank you Suzana Makowski, MD: Suzana.makowski@umassmemorial.org Office: Debbie Horgan – (508) 344-8630 Delila Katz, PharmD: Delila.katz@umassmemorial.org New cancer center pharmacy
  • TubaGnaydn4

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    Jan. 15, 2017
  • mohammadrezaaboutorabi

    Jan. 6, 2017

An overview of how to manage the pain associated with cancer.

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