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Cancer Pain

Cancer Pain. Juliana Howes RN, BNSc, MN Clinical Nurse Specialist, Palliative Care. Outline. Examine classifications of cancer pain Barriers to pain management Tolerance, Dependence, Addiction Pain Assessment Tools (ESAS) Special Populations Common Medications

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Cancer Pain

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  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

  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

  12. 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

  13. 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

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

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

  16. Pseudos • Pseudo addiction • 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

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

  18. 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

  19. Commonly Used Opioids • Morphine • Hydromorphone • Codeine • Oxycodone • Fentanyl

  20. 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

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

  22. 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

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

  24. Fentanyl • Not for opioid naïve patients • Difficult to convert as 25 mcg patch = 45-135 mg PO morphine *Tip: Duragesic 25mcg/hr patch = Morphine 25 mg SC/24hrs • Patch difficult to titrate as it takes 12-24 hours to see effect of change • Transdermal, Sublingual, Parenteral

  25. 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

  26. Adjuvants • Antidepressants • Anticonvulsants • Corticosteroids • Local Anesthetics • Anticancer therapies

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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 20-30 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

  32. 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

  33. 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

  34. 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)

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

  36. Equianalgesic Table

  37. 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

  38. 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

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

  40. 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 15-45 cc OD to TID

  41. 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)

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

  43. 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

  44. 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

  45. 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?

  46. 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)

  47. 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?

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