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PAIN CONTROL IN CANCER

PAIN CONTROL IN CANCER. Dr.Krishna K Bitra Manorlands Hospice. Learning Objectives. Initiate and convert opioids. Switch one opioid to other. Manage pain effectively. Basic Consideration Patients opioid exposure and experience Patient fears (stigma / addiction)

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PAIN CONTROL IN CANCER

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  1. PAIN CONTROL IN CANCER Dr.Krishna K Bitra Manorlands Hospice

  2. Learning Objectives • Initiate and convert opioids. • Switch one opioid to other. • Manage pain effectively.

  3. Basic Consideration Patients opioid exposure and experience Patient fears (stigma / addiction) Family/ Carers attitudes, preferences and biases Compliance Convenience Cost Pharmaco-clinical Considerations – P/t sensitivities & allergies Administration and absorption limitations Metabolism and clearance Opioid profile Initiating Opioid Therapy

  4. Adjuvant Therapies • NSAID: for bone pain, liver pain or inflammatory pain • Antidepressants /Anticonvulsants: for nerve pain. Start at low dose. Check BNF for prescribing information • Steroids: Dexamethasone - 16mg/day for Intracranial pressure - 12mg/day for nerve pain - 4-8mg/day for liver pain • TENS, Nerve Block, Radiotherapy, Bisphosphonates, Ketamine

  5. Dosing Opioids for Pain Remember to titrate slowly and monitor carefully. We can continue to increase the dose until one of these two END points is reached : Reasonable Pain Relief OR Persistent and Unmanageable Side Effects

  6. Titration of Morphine for Pain Relief • If starting from weak opioids, start with 10mg every 4 hours and PRN. • If elderly or in those where group 2 analgesics have been omitted, start at 5mg every 4 hourly and PRN. • If patient takes 2 or more PRN doses in 24 hours then, increase regular dose by 30-50% every 2-3 days. i.e. 5→7.5→10→15→20→30mg • Once pain is controlled convert normal / modified release morphine for maintenance. NB: If pain not improving after 48 hours contact Palliative Care

  7. Breakthrough Pain • Prescribe Immediate Release Morphine @ 1/6th of regular PO Morphine dose PRN. • Change breakthrough dose if regular dose changes.

  8. Opioid Toxicity • Increasing drowsiness/sedation • Vivid dreams / Hallucinations / Delirium • Myoclonus / Muscle twitching / Jerking • Reduce Opioid dose by 1/3, ensure patient is well hydrated; review and re-titrate. • Consider adjuvant Th/p +/- Alternative opiods. SIGN Guideline 101 August 2010

  9. When Converting from an oral strong Opioid to TD Fentanyl • If taking 4 hourly oral opioid – CONTINUE for 12 hours AFTER applying TD Fentanyl. • If taking 12 hourly oral opioid – GIVE last dose when first TD patch is applied. • If taking 24 hourly oral opioid – apply first TD patch 12 hours AFTER last dose.

  10. Changing Routes of Administration S/C Diamorphine Fentanyl Patch Dihydrocodiene ÷ 10 ÷ 3.6 ÷ 1.5 ÷ 2 to 3 ÷ 10 Codiene PO Oxycodone PO Morphine ÷ 1.5 to 2 ÷ 1.5 to 2 ÷ 10 ÷ 2 ÷ 2 No Change Tramadol S/C Oxycodone S/C Morphine

  11. Step 1 + Fentanyl + Hydromorphone Step 1 + Hydromorphone Step 4 Step 1 + Tramadol Step 3 Paracetamol +/- Adjuvants Step 2 Adapted from Palliative Care Formulary

  12. Non Pharmacological Pain Management • Acupuncture • CBT • Meditation/Relaxation • TENS • Massage • Others – Reflexology, Reiki, Hypnotherapy etc

  13. References: • SIGN Guideline 106- Control of Pain in adults with cancer. • Palliative drug information online: http://www.palliativedrugs.com

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