Pain II: Cancer Pain Management

Dr. Leah Steinberg

Mr. Peters: Cont’d

• 52 year old man with met lung cancer

• Soft tissue and vertebral metastases • Compressing at T4 – 8 and L2• Pain 10/10• Suffering!!

What do you do next?

Learning Objectives

1. Describe a model for pain management2. Describe non-pharmacologic

management of cancer pain;3. Learn the basics of how to use opioid

analgesics;4. Describe some of the adjuvant

medications for pain.

Objective 1: Pain and Symptom

ManagementSTEP 1: Assess for etiology/severity/risksSTEP 2: Non-pharmacological

treatments STEP 3: Pharmacological treatmentsSTEP 4: MonitorSTEP 5: EducateSTEP 6: In not successful --

Step 1: Assessment (Diagnosis)

• From your assessment, you learn: PHYSICAL DOMAIN:– Somatic and neuropathic pain (plus inflammation)– Vertebral metastases, T4 – T7, L1, L2;– Soft tissue compression of spinal cord

PSYCHOSOCIAL DOMAIN:– Support from family, poor disease understanding,

financial stressors

Step 2: Non-pharmacological therapy• Techniques to relieve pain or reverse

process causing pain, for example,– Radiotherapy– Surgery– Interventional anaesthesia– Chemotherapy– Stents

Step 2: Mr. Peters

• What are the non-pharmacologic treatments for Mr. Peters?

Step 3: Opioid management

• When pain still present;• Pain is frequent and often severe;• Unethical to not relieve suffering;• Opioids are the mainstay of pain

relief;• Myths!• Fears!

Principles of opioid use:

• How to choose• Starting dose• Breakthrough• Route of administration• Titration• Rotation• Side effects

Opioids: How do you choose one?• Codeine• Morphine• Oxycodon• Hydromorphone• Fentanyl• Methadone

Principles of opioid use:

• How to choose• Starting dose• Route of administration• Titration• Breakthrough• Rotation• Side effects

Opoids: Starting Dose

• IR Morphine 2.5 mg – 5.0 mg po

• Does that seem like a lot of morphine?

Mr. Peters:

Codeine 30 mg tablets, 2 tabs q 4 hrsEquals 360 mg codeine/dayNow need to convert to morphineHow much morphine is EQUIVALENT to 360 mg of codeine?

Equianalgesic TablesOPIOID Oral Dose (mg) s/c Dose (mg)

Codeine 100 ----

Morphine 10 5Oxycodone 5 ---

Hydromorphone 2 1Fentanyl ***

Mr. Peter’s morphine dose:

360 mg of codeine = 36 mg morphine/day

How often?Every 4 hours, regularlySo, dose is 36 mg/6 = 6 mg every 4 hours

Mr. Peter’s morphine order:

• Morphine sulphate 5 mg po q 4 hrs• Morphine sulphate 10 mg po q 4 hrs

Principles of opioid use:

• How to choose• Starting dose• Breakthrough• Route of administration• Titration• Rotation• Side effects

Breakthrough Dosing

• To provide pain relief in-between scheduled doses: initial titration or pain flare

• 10% total daily dose or ½ the q4hr dose

• Ordered q 1 hr prn for po and q 30 mins sc

• What formulation?

Mr. Peter’s complete order:

• Morphine sulphate 10 mg q 4 hrs • Morphine sulphate 5 mg q 1hr prn• Anti-emetic prn• Laxatives standing!

Principles of opioid use:

• How to choose• Starting dose• Breakthrough• Route of administration• Titration• Rotation• Side effects

Routes of administration

• PO route is always our first choice, • HOWEVER:• When patients cannot swallow• Use S/C or TD when PO route not

available;– Vomiting/nausea/MBO/ileostomy/severe

pain/actively dying

Principles of opioid use:

• How to choose• Starting dose• Breakthrough• Route of administration• Titration• Rotation• Side effects

Titration:

• After first 24 hrs, Mr. Peters has had:– 10 mg morphine po, q 4 hrs standing– 6 doses of 5 mg po morphine

breakthrough– Pain is now 6/10

• What would you do now?

Titration:

• 10 mg q 4 hrs = 60 mg• 6 doses of 5 mg = 30 mg• New daily dose = 90 mg• Divided into 6 doses (q 4 hr)• 15 mg q 4 hr• Breakthrough = ?

Principles of opioid use:

• How to choose• Starting dose• Breakthrough• Route of administration• Titration• Rotation• Side effects

Opioid rotation:

• Used if side effects; • Toxicity;• Renal impairment develops;

Principles of opioid use:

• How to choose• Starting dose• Breakthrough• Route of administration• Titration• Rotation• Side effects

Side effects of opioids

• What are the four common side effects of opioids?

• How do prevent them?

• How do you treat them if they occur?

What about respiratory depression?

Test!!

• Morphine 5 mg q 6 hrs standing• Morphine 10 mg q 4 hrs standing and

morphine 5 mg q 4 hrs prn• MS Contin 30 mg q 4 hrs standing

and morphine 5 mg q 1 hr prn• MS Contin 45 mg q 4 hrs prn

Mr. Peter’s (one more time)

• Morphine 30 mg po q 4 hrs, 15 mg po q 1 hr prn

• Back pain much better, but still holding chest when you go in – says “it is still squeezing in my chest”

Adjuvants

• Neuropathic pain:– Tricyclics, anticonvulsants– Steroids

• Bone pain:– NSAIDS– Steroids– ?Bisphosphonates

Remember the beginning?

• Meet Mr. Peters• 52 yr old patient with lung cancer• Holding his chest• “It feels like I’m being squeezed and

it is burning” • “I can’t sleep…”• His wife is crying at his side…

What did we do?• Assessed his pain

– Neuropathic/somatic– Cord compression

• Non-pharmacological treatment– Radiotherapy + Dexamethasone

• Pharmacological treatment– Morphine sulphate IR 15 mg q 4 hrs and BT– Gabapentin 300 mg po tid

• Educate, Monitor and Support

THANK YOU