Basic Cancer Pain Management: Case Studies For Medical Students, Medical Residents, and Hematology

1. Basic Cancer Pain Management: Case StudiesFor Medical Students, Medical Residents, and Hematology/Oncology Fellows This work was produced by the University of Maryland Palliative Care Educational Initiative, funded by an R25E grant (R25CA 66940) from the National Cancer Institute.

2. Learning Objectives � �BATS� BARRIERS Recognize patient, healthcare professional, and healthcare and legal system-related barriers to good pain management ASSESSMENT Properly assess pain across a broad range of patient types and quantify its severity Distinguish between pain types � nociceptive (e.g., bone, visceral, other somatic) and neuropathic Incorporate the 5th vital sign into patient care/treatment plans. Define and recognize the opioid pseudoaddiction syndrome in pain assessment. For the original case report, see Pain 1989: 3:363-6. Recognize opioid abuse and drug-abusive behavior TREATMENT Institute proper pain management based on the severity and type of pain Recognize severe somatic nociceptive pain and titrate opioid medications appropriately Recognize severe nociceptive bone pain and treat with opioids and appropriate adjuvant medications Recognize neuropathic pain and treat with appropriate adjuvant medications. Calculate appropriate equianalgesic doses for switching from one opioid to another, or switching routes of administration Prescribe appropriate �breakthrough� pain medications for patients with chronic pain taking long acting opioids Titrate opioids to control worsening pain caused by progressive cancer in a patient already taking pain medications SIDE EFFECTS Recognize, pre-empt or treat opioid side effects (e.g., constipation, sedation, respiratory depression, nausea, pruritis, delirium, myoclonus, urinary retention).

3. Case studies� Ms. YL is 43-year-old inpatient on day 14 of a high-dose, timed-sequential induction regimen for AML. Her nurse reports that Ms. YL did not sleep at all the previous night, and complained of mouth numbness (tingling) and pain. Her pain scores have been 6 to 10/10 throughout the night. Ms. YL refused the PO or IV PRN pain meds offered. Ms. YL was born and raised in China, but has lived in the U.S. since she was 20 years old. On exam, you see evidence of early mucositis. She seems reluctant to talk about her mouth and discomfort, and attributes her sleepless night to things other than pain. She rates her pain only 4 or 5/10 when you ask her. You suggest titration with potent pain medications, but the she says she does not need pain medications now, and assures you that she will be OK. But your overall assessment is that she appears to be in considerable discomfort.