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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Which opioid?

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

15. 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.”

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

17. 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

19. 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)
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