1. Pain II: Cancer Pain Management Dr. Leah Steinberg

2. 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!!

3. What do you do next?

4. Learning Objectives 1.Describe a model for pain management 2.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.

5. Objective 1: Pain and Symptom Management STEP 1: Assess for etiology/severity/risks STEP 2: Non-pharmacological treatments STEP 3: Pharmacological treatments STEP 4: Monitor STEP 5: Educate STEP 6: In not successful --

6. 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

7. Step 2: Non-pharmacological therapy Techniques to relieve pain or reverse process causing pain, for example, –Radiotherapy –Surgery –Interventional anaesthesia –Chemotherapy –Stents

8. Step 2: Mr. Peters What are the non-pharmacologic treatments for Mr. Peters?

9. 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!

10. Principles of opioid use: How to choose Starting dose Breakthrough Route of administration Titration Rotation Side effects

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

12. Principles of opioid use: How to choose Starting dose Route of administration Titration Breakthrough Rotation Side effects

13. Opoids: Starting Dose IR Morphine 2.5 mg – 5.0 mg po Does that seem like a lot of morphine?

14. Mr. Peters: Codeine 30 mg tablets, 2 tabs q 4 hrs Equals 360 mg codeine/day Now need to convert to morphine How much morphine is EQUIVALENT to 360 mg of codeine?

15. Equianalgesic Tables OPIOIDOral Dose ( mg ) s/c Dose (mg) Codeine100 ---- Morphine105 Oxycodone5 --- Hydromorphone21 Fentanyl ***

16. Mr. Peter’s morphine dose: 360 mg of codeine = 36 mg morphine/day How often? Every 4 hours, regularly So, dose is 36 mg/6 = 6 mg every 4 hours

17. Mr. Peter’s morphine order: Morphine sulphate 5 mg po q 4 hrs Morphine sulphate 10 mg po q 4 hrs

18. Principles of opioid use: How to choose Starting dose Breakthrough Route of administration Titration Rotation Side effects

19. 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?

20. Mr. Peter’s complete order: Morphine sulphate 10 mg q 4 hrs Morphine sulphate 5 mg q 1hr prn Anti-emetic prn Laxatives standing!

21. Principles of opioid use: How to choose Starting dose Breakthrough Route of administration Titration Rotation Side effects

22. 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

23. Principles of opioid use: How to choose Starting dose Breakthrough Route of administration Titration Rotation Side effects

24. 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?

25. 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 = ?

26. Principles of opioid use: How to choose Starting dose Breakthrough Route of administration Titration Rotation Side effects

27. Opioid rotation: Used if side effects; Toxicity; Renal impairment develops;

28. Principles of opioid use: How to choose Starting dose Breakthrough Route of administration Titration Rotation Side effects

29. 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?

30. What about respiratory depression?

31. 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

32. 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”

33. Adjuvants Neuropathic pain: –Tricyclics, anticonvulsants –Steroids Bone pain: –NSAIDS –Steroids –?Bisphosphonates

34. 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…

35. 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

37. THANK YOU