Cancer Pain Juliana Howes RN, BNSc, MN Clinical Nurse Specialist, Palliative Care.
-
Upload
quentin-preston -
Category
Documents
-
view
219 -
download
0
Transcript of Cancer Pain Juliana Howes RN, BNSc, MN Clinical Nurse Specialist, Palliative Care.
Cancer Pain
Juliana Howes RN, BNSc, MN
Clinical Nurse Specialist, Palliative Care
OutlineOutline
Examine classifications of cancer painExamine classifications of cancer pain Barriers to pain managementBarriers to pain management Tolerance, Dependence, AddictionTolerance, Dependence, Addiction Pain AssessmentPain Assessment
– Tools (ESAS)Tools (ESAS)– Special PopulationsSpecial Populations
Common MedicationsCommon Medications– Opioids, Non-Opioids & AdjuvantsOpioids, Non-Opioids & Adjuvants
Outline Cont.Outline Cont.
Treatments to reduce painTreatments to reduce pain– Radiation Therapy & ChemotherapyRadiation Therapy & Chemotherapy
Guidelines for Use of OpioidsGuidelines for Use of Opioids Managing common side effectsManaging common side effects
– Constipation, dry mouth, N&V, sedationConstipation, dry mouth, N&V, sedation Case StudiesCase Studies
Definition of PainDefinition of Pain ““an unpleasant sensory and emotional an unpleasant sensory and emotional
experience associated with actual or experience associated with actual or potential damage, or described in terms of potential damage, or described in terms of such damage”such damage”
(IASP, 1979)(IASP, 1979)
““whatever the experiencing person says it whatever the experiencing person says it is, existing whenever the experiencing is, existing whenever the experiencing person says it does”person says it does”
(McCaffrey (McCaffrey & Pasero, 1999)& Pasero, 1999)
Cancer PainCancer Pain
35% experience pain at diagnosis35% experience pain at diagnosis 74% in advanced cancer (40-50% 74% in advanced cancer (40-50%
moderate to severe pain)moderate to severe pain) 85% at end of life85% at end of life
Cancer pain CAN be managed safely Cancer pain CAN be managed safely & effectively & effectively
Despite available options, up to 70% Despite available options, up to 70% do not experience adequate reliefdo not experience adequate relief
Total Pain Total Pain
Classification of PainClassification of Pain
Duration:Duration: Quality:Quality:
* Acute* Acute * Nociceptive* Nociceptive* Chronic * Chronic - Visceral- Visceral
* Breakthrough* Breakthrough - Somatic- Somatic
* Incident* Incident * Neuropathic* Neuropathic
NociceptiveNociceptive
Direct stimulation of afferent nerves Direct stimulation of afferent nerves in skin, soft tissue, viscerain skin, soft tissue, viscera
Nociceptive: SomaticNociceptive: Somatic
Skin, joints, muscle, bone, connective Skin, joints, muscle, bone, connective tissuetissue
Well localized Well localized Deep - aching, throbbingDeep - aching, throbbing Surface – sharpSurface – sharp Often worse with movementOften worse with movement May be tender on palpationMay be tender on palpation i.e. surgical incisions, bone metsi.e. surgical incisions, bone mets
Nociceptive: VisceralNociceptive: Visceral
Visceral organs Visceral organs Poorly localizedPoorly localized Gnawing, deep, pressure, stretching, Gnawing, deep, pressure, stretching,
squeezing, crampingsqueezing, cramping Referred pain (i.e. left arm with MI, Referred pain (i.e. left arm with MI,
epigastric and back with pancreatic)epigastric and back with pancreatic) i.e. bowel obstruction, liver metsi.e. bowel obstruction, liver mets
NeuropathicNeuropathic
Abnormal processing of sensory Abnormal processing of sensory input due to nerve damage/changesinput due to nerve damage/changes
Allodynia:Allodynia: pain from stimulus that does not pain from stimulus that does not normally provoke painnormally provoke pain
Hyperalgesia:Hyperalgesia: increased response to painful increased response to painful stimulistimuli
Burning, stabbing, itching, numbing, Burning, stabbing, itching, numbing, shooting, tingling, electrifyingshooting, tingling, electrifying
i.e. brachial plexopathy, cord compressioni.e. brachial plexopathy, cord compression
Barriers to Pain ManagementBarriers to Pain Management
Health Care ProfessionalsHealth Care Professionals– Lack of knowledgeLack of knowledge– Lack of assessmentLack of assessment– Concern abut side effectsConcern abut side effects– Concern about tolerance and addictionConcern about tolerance and addiction
Health Care SystemHealth Care System– Not a priority, issues with availabilityNot a priority, issues with availability
PatientsPatients– Fear (condition worsening, addiction)Fear (condition worsening, addiction)– Not wanting to burden HCPsNot wanting to burden HCPs
AddictionAddiction
Chronic neurobiological disease with Chronic neurobiological disease with genetic, psychosocial and genetic, psychosocial and environmental factorsenvironmental factors
3 C’s3 C’s– Impaired Control over drug useImpaired Control over drug use– Craving/Compulsive useCraving/Compulsive use– Continued use despite consequencesContinued use despite consequences
DependenceDependence
State of adaptation manifested by State of adaptation manifested by withdrawal syndrome fromwithdrawal syndrome from– Abrupt cessationAbrupt cessation– Rapid dose reductionRapid dose reduction– Administration of Administration of
an antagonistan antagonist
ToleranceTolerance
State of adaptation where exposure State of adaptation where exposure to drug causes decrease in its effect to drug causes decrease in its effect over timeover time
PseudosPseudos
Pseudo addictionPseudo addiction– Mistaken assumption of addiction in Mistaken assumption of addiction in
patient seeking relief from painpatient seeking relief from pain Pseudo tolerancePseudo tolerance
– Misconception that need for increasing Misconception that need for increasing dose is due to tolerance rather than dose is due to tolerance rather than disease progressiondisease progression
Assessment - ESASAssessment - ESAS
Initial and routine assessment of pain Initial and routine assessment of pain & other symptoms& other symptoms
Body diagram to show location of Body diagram to show location of painpain
Assessment – Nonverbal or Assessment – Nonverbal or Cognitively Impaired PatientsCognitively Impaired Patients
Gold Standard is self-reportGold Standard is self-report High potential for unrelieved & High potential for unrelieved &
unrecognized painunrecognized pain Non-verbal CuesNon-verbal Cues
– Facial ExpressionsFacial Expressions– Body MovementsBody Movements– Protective MechanismsProtective Mechanisms– VerbalizationsVerbalizations– VocalizationsVocalizations
Family observations/perceptionsFamily observations/perceptions
Commonly Used OpioidsCommonly Used Opioids
MorphineMorphine HydromorphoneHydromorphone CodeineCodeine OxycodoneOxycodone FentanylFentanyl
MorphineMorphine
Moderate to severe painModerate to severe pain Gold Standard - affordable & Gold Standard - affordable &
availableavailable Measure for dose equivalenceMeasure for dose equivalence Active metabolites – toxicity in Active metabolites – toxicity in
elderly & renal impairmentelderly & renal impairment Oral (IR/CR/Elixir), Parenteral, Rectal, Oral (IR/CR/Elixir), Parenteral, Rectal,
IntraspinalIntraspinal
HydromorphoneHydromorphone
5x more potent than morphine5x more potent than morphine Oral (IR/CR/Elixir), Parental, Rectal, Oral (IR/CR/Elixir), Parental, Rectal,
IntraspinalIntraspinal Better tolerated in elderlyBetter tolerated in elderly
CodeineCodeine
Mild to moderate painMild to moderate pain 10x weaker than morphine10x weaker than morphine Usually in combination with TylenolUsually in combination with Tylenol Ceiling effect at 600mg/24 hrs, max Ceiling effect at 600mg/24 hrs, max
360mg/d if Tylenol #3360mg/d if Tylenol #3 Metabolized into active form (morphine) Metabolized into active form (morphine)
by liverby liver Up to 10% of population unable to convert Up to 10% of population unable to convert
to active form – no pain reliefto active form – no pain relief Oral (IR/Elixir), ParenteralOral (IR/Elixir), Parenteral
OxycodoneOxycodone
1.5-2x more potent than morphine1.5-2x more potent than morphine Oral (IR/CR)Oral (IR/CR) Often combined with Tylenol Often combined with Tylenol
(Percocet)(Percocet) ?more issues with addiction?more issues with addiction
Fentanyl Fentanyl
Not for opioid naïve patientsNot for opioid naïve patients Difficult to convert as 25 mcg patch Difficult to convert as 25 mcg patch
= 45-135 mg PO morphine= 45-135 mg PO morphine
*Tip: Duragesic 25mcg/hr patch = *Tip: Duragesic 25mcg/hr patch = Morphine 25 mg SC/24hrsMorphine 25 mg SC/24hrs
Patch difficult to titrate as it takes Patch difficult to titrate as it takes 12-24 hours to see effect of change12-24 hours to see effect of change
Transdermal, Sublingual, ParenteralTransdermal, Sublingual, Parenteral
Non-OpioidsNon-Opioids
Mild to moderate painMild to moderate pain Inflammation, Bony painInflammation, Bony pain Used as adjuvant with opioidsUsed as adjuvant with opioids Acetaminophen: Acetaminophen: max 4g/d, 3 g/d in frail max 4g/d, 3 g/d in frail
elderly, Liver toxicityelderly, Liver toxicity NSAIDs: NSAIDs: inhibit synthesis of prostaglandins inhibit synthesis of prostaglandins
preventing contribution to sensitization of preventing contribution to sensitization of nociceptorsnociceptors– i.e. Ibuprofen, Naproxen, COX2 (celebrex)i.e. Ibuprofen, Naproxen, COX2 (celebrex)– Adverse effects: GI bleed, increased BP, decreased renal Adverse effects: GI bleed, increased BP, decreased renal
function, impaired platelet functionfunction, impaired platelet function
AdjuvantsAdjuvants
AntidepressantsAntidepressants AnticonvulsantsAnticonvulsants CorticosteroidsCorticosteroids Local AnestheticsLocal Anesthetics Anticancer therapiesAnticancer therapies
AntidepressantsAntidepressants
TCAs i.e. amitriptyline, nortriptyline TCAs i.e. amitriptyline, nortriptyline for neuropathic (burning) painfor neuropathic (burning) pain
Anticholinergic effects – sedation, Anticholinergic effects – sedation, constipation, dry mouthconstipation, dry mouth
Start low and titrate as needed q2-3 Start low and titrate as needed q2-3 daysdays
AnticonvulsantsAnticonvulsants
Neuropathic (shooting) painNeuropathic (shooting) pain i.e. Gabapentin – start at 100mg TID i.e. Gabapentin – start at 100mg TID
or 300mg OD and titrate up to or 300mg OD and titrate up to 3600mg/day3600mg/day
Decreased dose in elderly/renal Decreased dose in elderly/renal impairmentimpairment
Side effects can include sedation & Side effects can include sedation & dizzinessdizziness
CorticosteroidsCorticosteroids
Pain due to spinal cord compression, Pain due to spinal cord compression, headache due to increased ICP, bone headache due to increased ICP, bone metsmets
Can be used to stimulate appetiteCan be used to stimulate appetite i.e. Decadron 4mg to 16mg/dayi.e. Decadron 4mg to 16mg/day Side effects include hyperglycemia, Side effects include hyperglycemia,
psychosis, insomniapsychosis, insomnia
Anticancer TherapyAnticancer Therapy
Palliative Radiation: bone pain, Palliative Radiation: bone pain, reduce tumour size to decrease pain reduce tumour size to decrease pain (i.e. chest pain in lung ca) (i.e. chest pain in lung ca)
Palliative Chemotherapy: reduce Palliative Chemotherapy: reduce tumour size if adequate tumour size if adequate
performance status and performance status and
not significant impact not significant impact
on QOLon QOL
Guidelines for UseGuidelines for Use Constant or frequent pain requires regular Constant or frequent pain requires regular
medicationmedication– Oral route preferredOral route preferred– Start with IR to allow for titrationStart with IR to allow for titration– Use opioid with best analgesia and fewest side effectsUse opioid with best analgesia and fewest side effects
A breakthrough dose should be available as A breakthrough dose should be available as neededneeded– 10% of daily total or 50% of q4h dose10% of daily total or 50% of q4h dose– CMAX: PO 1h, SC 20-30 min, IV 5-10 min CMAX: PO 1h, SC 20-30 min, IV 5-10 min
Treat opioid side effects from the startTreat opioid side effects from the start– Regular laxative order, PRN antiemeticRegular laxative order, PRN antiemetic
Adjuvants are often essential for adequate pain Adjuvants are often essential for adequate pain controlcontrol
Guidelines Cont.Guidelines Cont.
Is patient opioid naïve?Is patient opioid naïve?– Opioid still required if moderate to severe pain, Opioid still required if moderate to severe pain,
start low and titrate start low and titrate Choose route of administrationChoose route of administration
– Ability to swallow, absorption, compliance, pt. Ability to swallow, absorption, compliance, pt. preferencepreference
Determine dosing scheduleDetermine dosing schedule– IR q4h with BT doses q1h until reliefIR q4h with BT doses q1h until relief– Based on BT usage, titrate upBased on BT usage, titrate up– When adequate dosage found, can switch to When adequate dosage found, can switch to
long acting medicationlong acting medication
Titration Titration
If requiring more than 3-4 If requiring more than 3-4 breakthrough in 24 hours:breakthrough in 24 hours:– Look at pattern and reassess painLook at pattern and reassess pain– Increase q4h dose and BT accordinglyIncrease q4h dose and BT accordingly
Add BTs to q4h dose or increase by Add BTs to q4h dose or increase by 1/3 1/3
i.e. Morphine 5mg PO q4h and 2.5mg PO i.e. Morphine 5mg PO q4h and 2.5mg PO q1h, pt used 6 BTs = 15mgq1h, pt used 6 BTs = 15mg
30mg + 15mg = 45mg /6 doses30mg + 15mg = 45mg /6 dosesNew dose would be 7.5 mg PO q4hNew dose would be 7.5 mg PO q4h
ConvertingConverting
Once stabilized, can switch to long acting Once stabilized, can switch to long acting BIDBID– Take total daily dose and divide for BIDTake total daily dose and divide for BID– i.e. Morphine 10mg PO q4h = MS Contin 30 mg i.e. Morphine 10mg PO q4h = MS Contin 30 mg
PO q12hPO q12h If switching to a new opioid, need to If switching to a new opioid, need to
consider incomplete cross-toleranceconsider incomplete cross-tolerance– Tolerance to new opioid may be less and so Tolerance to new opioid may be less and so
can achieve pain relief with lower dosecan achieve pain relief with lower dose– Thus need to reduce dose of new opioid by 25-Thus need to reduce dose of new opioid by 25-
50% (usu. cut by ~ 1/3)50% (usu. cut by ~ 1/3)
PumpsPumps
Allows for self-administration of Allows for self-administration of parenteral BTsparenteral BTs
More consistent dosing as continuousMore consistent dosing as continuous CADD pump CADD pump
Equianalgesic TableEquianalgesic TablePOPO SC/IVSC/IV
CodeineCodeine 100mg100mg ------
MorphineMorphine 10mg10mg 5mg5mg
OxycodoneOxycodone 5mg5mg ------
HydromorphoneHydromorphone 2mg2mg 1mg1mg
Using the TableUsing the Table
Convert Percocet 2 tab PO q4h to MorphineConvert Percocet 2 tab PO q4h to Morphine
(1 Percocet = Oxycodone 5mg + Tylenol 325mg)(1 Percocet = Oxycodone 5mg + Tylenol 325mg)
Oxycodone 10mg x 6 doses = 60mgOxycodone 10mg x 6 doses = 60mg
From Table Oxydone 5mg = Morphine 10mgFrom Table Oxydone 5mg = Morphine 10mg
Thus, Oxycodone 60mg = Morphine 120mg Thus, Oxycodone 60mg = Morphine 120mg
This would be Morphine 20mg PO q4h, but consider This would be Morphine 20mg PO q4h, but consider incomplete cross-tolerance incomplete cross-tolerance
Therefore, Morphine 15mg PO q4h with 7.5mg q1h PRNTherefore, Morphine 15mg PO q4h with 7.5mg q1h PRN
SuggestionsSuggestions
Initial dosage of strong opioid in opioid Initial dosage of strong opioid in opioid naïve patientnaïve patient
Fit: Morphine 5-10mg PO q4h or equivalentFit: Morphine 5-10mg PO q4h or equivalent Frail: Morphine 2.5-5mg PO q4h or equivalentFrail: Morphine 2.5-5mg PO q4h or equivalent
Dosage of strong opioid in patients already Dosage of strong opioid in patients already on opioidson opioids
If on weak opioid (i.e. Tylenol #3), not opioid naïve!If on weak opioid (i.e. Tylenol #3), not opioid naïve! Determine starting dose by using equianalgesic tableDetermine starting dose by using equianalgesic table
Side Effects of OpioidsSide Effects of Opioids
Common: constipation, dry mouth, Common: constipation, dry mouth, nausea, vomiting, sedationnausea, vomiting, sedation
Less Common: confusion, pruritis, Less Common: confusion, pruritis, myoclonus, hallucinations, urinary myoclonus, hallucinations, urinary retentionretention
Rare: respiratory Rare: respiratory
depressiondepression
ConstipationConstipation
Opioids inhibit peristalsis and Opioids inhibit peristalsis and increase re-absorption of fluids in the increase re-absorption of fluids in the lining of the gutlining of the gut
Standing order if on opioidsStanding order if on opioids– Senokot 1-6 tab BID Senokot 1-6 tab BID + + Stool softener Stool softener – Lactulose 15-45 cc OD to TIDLactulose 15-45 cc OD to TID
Sedation and N&VSedation and N&V
Commonly experienced in first few days of Commonly experienced in first few days of taking opioids or after increasing dosetaking opioids or after increasing dose
Body will adjust and these symptoms will Body will adjust and these symptoms will improveimprove
Minimize other meds that contribute to Minimize other meds that contribute to drowsiness (i.e. Benzodiazepines)drowsiness (i.e. Benzodiazepines)
PRN anti-emetic (i.e. haldol 1mg PO/SC/IV, PRN anti-emetic (i.e. haldol 1mg PO/SC/IV, stemetil 10mg PO/IV/PR, maxeran 10 mg stemetil 10mg PO/IV/PR, maxeran 10 mg QID)QID)
Dry MouthDry Mouth
Difficult to avoidDifficult to avoid Strategies to minimize include:Strategies to minimize include:
Frequent mouthcareFrequent mouthcareFluids/Ice ChipsFluids/Ice ChipsSugarless gumsSugarless gumsArtificial saliva Artificial saliva
(i.e. Moi-Stir)(i.e. Moi-Stir)
SummarySummary
Pain Orders should include:Pain Orders should include:
1.1. Regular AnalgesicRegular Analgesic
2.2. PRN AnalgesicPRN Analgesic
3.3. Standing LaxativeStanding Laxative
4.4. PRN Anti-emeticPRN Anti-emetic Treat side effects from the beginningTreat side effects from the beginning Consider type of pain & use adjuvantsConsider type of pain & use adjuvants Ongoing re-evaluationOngoing re-evaluation
Case Study #1Case Study #1
Mr.R, 46 yrs, met. lung ca., currently Mr.R, 46 yrs, met. lung ca., currently taking Tylenol #3 2 tab q4h and taking Tylenol #3 2 tab q4h and using 9 extra tablets/day for using 9 extra tablets/day for breakthrough. He has no difficulty breakthrough. He has no difficulty swallowing the Tylenol #3.swallowing the Tylenol #3.
What is the problem with this What is the problem with this amount of Tylenol #3?amount of Tylenol #3?
What are your recommendations? What are your recommendations? Calculate and provide new ordersCalculate and provide new orders
Case Study #1 Cont.Case Study #1 Cont.
After titrating his medication, Mr.R was After titrating his medication, Mr.R was comfortable for a time. However, he has comfortable for a time. However, he has begun to complain of right arm weakness begun to complain of right arm weakness and shoulder pain causing shooting pain and shoulder pain causing shooting pain down his arm.down his arm.
What type of pain do you suspect he is What type of pain do you suspect he is experiencing?experiencing?
What medication and dose would you What medication and dose would you recommend?recommend?
Case Study #2Case Study #2
Ms.Q, 63 yr old, met. breast ca., has been Ms.Q, 63 yr old, met. breast ca., has been taking MS Contin 30mg q12h and has taking MS Contin 30mg q12h and has morphine 5mg tablets available for BT. morphine 5mg tablets available for BT. She is using about 4 tab/day, but still She is using about 4 tab/day, but still having uncontrolled painhaving uncontrolled pain
Main pain to low back that radiates along Main pain to low back that radiates along the left side, an MRI confirms bone met to the left side, an MRI confirms bone met to L4 (no cord compression)L4 (no cord compression)
Case Study #2Case Study #2
What changes would you make to What changes would you make to her pain medication?her pain medication?
What other treatments might be What other treatments might be considered?considered?
Ms.Q’s condition deteriorates and Ms.Q’s condition deteriorates and she is no longer able to swallow her she is no longer able to swallow her medications – What would be the medications – What would be the SC/IV dose?SC/IV dose?