pain ii: cancer pain management dr. leah steinberg
DESCRIPTION
What do you do next?TRANSCRIPT
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Pain II: Cancer Pain Management
Dr. Leah Steinberg
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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!!
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What do you do next?
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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.
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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 --
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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
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Step 2: Non-pharmacological therapy• Techniques to relieve pain or reverse
process causing pain, for example,– Radiotherapy– Surgery– Interventional anaesthesia– Chemotherapy– Stents
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Step 2: Mr. Peters
• What are the non-pharmacologic treatments for Mr. Peters?
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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!
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Principles of opioid use:
• How to choose• Starting dose• Breakthrough• Route of administration• Titration• Rotation• Side effects
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Opioids: How do you choose one?• Codeine• Morphine• Oxycodon• Hydromorphone• Fentanyl• Methadone
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Principles of opioid use:
• How to choose• Starting dose• Route of administration• Titration• Breakthrough• Rotation• Side effects
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Opoids: Starting Dose
• IR Morphine 2.5 mg – 5.0 mg po
• Does that seem like a lot of morphine?
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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?
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Equianalgesic TablesOPIOID Oral Dose (mg) s/c Dose (mg)
Codeine 100 ----
Morphine 10 5Oxycodone 5 ---
Hydromorphone 2 1Fentanyl ***
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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
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Mr. Peter’s morphine order:
• Morphine sulphate 5 mg po q 4 hrs• Morphine sulphate 10 mg po q 4 hrs
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Principles of opioid use:
• How to choose• Starting dose• Breakthrough• Route of administration• Titration• Rotation• Side effects
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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?
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Mr. Peter’s complete order:
• Morphine sulphate 10 mg q 4 hrs • Morphine sulphate 5 mg q 1hr prn• Anti-emetic prn• Laxatives standing!
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Principles of opioid use:
• How to choose• Starting dose• Breakthrough• Route of administration• Titration• Rotation• Side effects
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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
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Principles of opioid use:
• How to choose• Starting dose• Breakthrough• Route of administration• Titration• Rotation• Side effects
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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?
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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 = ?
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Principles of opioid use:
• How to choose• Starting dose• Breakthrough• Route of administration• Titration• Rotation• Side effects
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Opioid rotation:
• Used if side effects; • Toxicity;• Renal impairment develops;
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Principles of opioid use:
• How to choose• Starting dose• Breakthrough• Route of administration• Titration• Rotation• Side effects
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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?
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What about respiratory depression?
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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
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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”
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Adjuvants
• Neuropathic pain:– Tricyclics, anticonvulsants– Steroids
• Bone pain:– NSAIDS– Steroids– ?Bisphosphonates
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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…
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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
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THANK YOU