Palliative Care - Oncology Pain Management

What are the first line treatments for neuropathic pain?

-Antidepressants: TCAs (amitriptyline), SNRIs (duloxetine, venlafaxine) -Anticonvulsants (gabapentin, pregabalin)

What drugs are used for excessive daytime sedation?

-Caffeine -Methylphenidate -Dextroamphetamine -Modafinil

What drugs are used to treat cachexia?

-Megestrol acetate -Olanzapine -Dexamethasone -Dronabinol

What drugs are used for dyspnea?

-Morphine -Lorazepam - added to opioid if associated with anxiety -Anticholinergics - scopolamine, atropine, glycopyrrolate (reduces excessive secretions associated with dyspnea)

What are some general opioid principles?

-Use lowest dose that relieves pain throughout dosing interval without significant adverse effects -Titrate cautiously -Use pure opioid product at higher doses to avoid toxicity of non-opioid -Must begin bowel management

What are some common adverse effects of opioids?

1. Constipation - no tolerance develops Tolerance may develop 2. N/V 3. Urticaria, Pruritus 4. Dry mouth 5. Sedation 6. Respiratory depression 7. Dysphoria/euphoria 8. Motor/cognitive impairment 9. Urine retention

What is the purpose of adding adjuvant medications to opioid therapy?

1. Enhance the effects of opioids or NSAIDs 2. Can help manage opioid adverse effects

Which drugs are preferred agents in the management of cancer pain due to their short half-life allowing easy titration?

1. Morphine 2. Hydromorphone 3. Fentanyl 4. Oxycodone

What are the goals of pain management (4 A's)?

1. Optimize analgesia 2. Optimize activities of daily living 3. Minimize adverse effects 4. Avoid aberrant drug taking

The IV dose of morphine is ________ that of an oral dose of morphine.

1/3

In opioid rotation, if prior pain regimen inadequate, consider starting new agent at ______________% equianalgesic dose.

100-125

In opioid rotation, if prior agent adequately controlled pain, consider starting new agent at ______________% dose reduction.

25-50

What is the conversion factor for oral oxymorphone to oral morphine?

3:1

When should you reassess a patient's pain level?

60 mins (oral) and 15 mins (IV) *If pain improved, continue current dose PRN *If pain unchanged/worsened, increase dose by 50-100% and reassess

If a patient is opioid tolerant, what dose of opioid should be administered?

Administer dose 10-20% of total amount consumed in the prior 24 hr.

If patient has persistent dysphagia which drug should be considered for opioid rotation?

Fentanyl

If patient has persistent pruritus which drugs should be considered for opioid rotation?

Fentanyl or hydromorphone

If patient has persistent constipation which drugs should be considered for opioid rotation?

Fentanyl or methadone

Which drug is safe to use in renal failure?

Fentanyl; or methadone

__________ is the most established model of palliative care for those with a prognosis of <6 months.

Hospice

Which drug is used for severe pain requiring ATC opioids?

Hydrocodone ER (Hysingla ER or Zohydro ER)

What treatment should be used for end of dose failure?

Increase dose or frequency of regularly scheduled drugs

What treatment should be given to patients with chronic persistent pain?

Long-acting opioid ATC (50-100% of daily opioid requirement) with short-acting PRN pain medication

Which drugs should be avoided in hepatic failure?

Meperidine and codeine

What type of pain is related to peripheral or CNS injury and is described as burning, tingling, stabbing and shooting pain?

Neuropathic pain

What type of pain is related to noxious stimuli/result of injury?

Nociceptive pain

Which pain scale is used most commonly?

Numerical Rating Scale

What are the third line treatments for neuropathic pain (inadequate or no response to 1st or 2nd line)?

Opioids - consult pain specialist

What initial dose of opioids should be given to opioid-naive patients?

Oral: 5-15 mg morphine sulfate/equivalent IV: 2-5 mg morphine sulfate/equivalent

Which drug should be taken 1 hour before or 2 hours after eating due to the fact that food can increase the AUC causing adverse effects?

Oxymorphone

________ is described as an unpleasant and emotional experience associated with actual or potential tissue damage or described in relation to such damage.

Pain

What treatment should be given to patients with breakthrough pain?

Short-acting opioids at 10-20% of total 24 hr oral dose up to every 1 hour PRN

What type of nociceptive pain arises from the skin, bone, joint or muscle and is described as sharp, throbbing, well-localized, pressure-like?

Somatic nociceptive pain

What prophylactic bowel regimen should be used in patients who are taking opioids?

Stimulant laxative +/- stool softener or PEG -Senna-Docusate 2 tabs PO qHS -PEG 1 cap-17 gm in 8 oz water PO BID

What are the second line treatments for neuropathic pain?

Topical local anesthetics (lidocaine patches, diclofenac gel or patch, capsaicin)

______________ is used for mild to moderate pain, while ______________ is used for moderate to severe pain.

Tramadol; Tapentadol

True or False: Cognitive and behavioral functions can modify pain (i.e. depression/anxiety can worsen pain, relaxation techniques can relieve pain).

True

True or False: For patients who have hepatic failure, you should initiate opioids at lower doses and dose them less frequently.

True

True or False: It is important to quantify pain intensity and characterize quality of pain at each visit.

True

True or False: Survival may be linked to symptom control.

True

True or False: You should increase the laxative dose if the opioid dose is increased.

True

What treatment should be used for patients with incidental pain (caused by activity or injury)?

Use rescue doses in anticipation of event - take 30-60 minutes before the event

What type of nociceptive pain arises from internal organs and is described as aching, cramping, diffuse?

Visceral nociceptive pain