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