Bone Pain: A Practical Approach to Management Dr Rowan Hearn, Consultant in Palliative Medicine University College London Hospital

The patient with myeloma Challenging patients, challenging pain Age Co-morbidities Multiple causes of pain Cancer pain vs chronic pain Setting realistic expectations Assessment and monitoring

Assessing pain Site Radiation Onset Time intensity Character Severity The (very, very) basics…. Site Radiation Onset Time intensity Character Severity Aggravating factors Relieving factors Associated factors

Assessing pain What does it mean? “My 2 is your 10” 0-10 pain score What does it mean? “My 2 is your 10” What’s a good reduction? What is acceptable? What are we measuring? Functional ability Other scoring systems

Management options Bisphosphonates, radiotherapy and balloon kyphoplasty/vertebroplasty Pharmacological options Paracetamol Opioids Calcium channel modulators (gabapentin, pregabalin) (NSAIDs) Non-Pharmacological options Exercise Psychological support Complimentary therapies

Opioids: Counsel, titrate, negotiate “I don't want to become addicted to it” “I might overdose if take too much” Drug driving legislation, March 2015 Morphine, codeine, diamorphine, benzodiazepines

Opioids: Counsel, titrate, negotiate Low and slow! Rapid escalation of pain = rapid escalation of analgesia! How much pain is acceptable? Follow-up and side effects

Which opioid?

Weak opioids Daily oral equivalent Codeine 15-60mg 6 hourly 24mg morphine Tramadol 50-100mg 6 hourly 20-40mg morphine 12 hourly and 24 hourly preparations Buprenorphine 5-20mcg/hr 7 days BuTrans 10-55mg morphine 35-70mcg/hr 3 days Hapoctasin 75-190mg morphine 35-70mcg/hr 4 days Transtec 75-190mg morphine

Strong opioids Morphine 2.5-5mg 4 hourly Oramorph liquid Oxycodone (twice as strong as morphine) 1-2.5mg 4 hourly Oxynorm liquid Fentanyl patches 12mcg/hr = 35-70mg oral morphine Pain management plan: “Take one dose and wait one hour. If still in pain, take a second dose and wait another hour. If still in pain, take a third dose and wait another hour. If still in pain, call for advice.”

Beware….. Rapidly absorbed fentanyl Constipation Sedation Nausea Hypogonadic hypogonadism!

Take home points One size does not fit all Decide on a standard assessment for pain in your service Assess functional ability as well as a pain score Set realistic expectations of pain relief Opioid selection is individual, based on science Consider endocrine suppression as a cause of fatigue

References Snowden J, Ahmedzai S, et al, “Guidelines for supportive care in multiple myeloma”, British Journal of Haematology, (Blackell Publishing Ltd, 2011, 154;76-103) Picture accessed 11/3/16: http://www.rmgnetworks.com/blog/bid/365859/Internal-communications-is-not-one-size-fits-all Picture accessed 12/3/16: http://www.practicalpainmanagement.com/treatments/interventional/injections/perioperative-pain-plan-why-it-needed Picture accessed 12/3/16:http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hematology-oncology/cancer-pain/