12 Cancer Pain Management Chow

Question 1

What are the causes of pain in cancer patients?

Answer 1

Organ invasion/bone metastasis. Nerve damage. Endothelial/Vascular inflammation. Injection site pain. Perioperative pain

Question 2

What is Nociceptive pain?

Answer 2

Result of nociceptor activation d/t injury to somatic and visceral structures. “Aching”, “Throbbing”, “Pressure”, usually “Localized”

Question 3

What are some examples of Nociceptive Pain?

Answer 3

Bruises, burns. Bone fractures/metastasis. Obstruction, inflammation

Question 4

What is Neuropathic Pain?

Answer 4

Injury to central or peripheral nervous system. “Numb”, “Tingling”, “Shooting pain”, “Electric Shock”

Question 5

What are some examples of Neuropathic Pain?

Answer 5

Spinal stenosis. Diabetic neuropathy. Chemotherapy (Paclitaxel, Vincristine)

Question 6

For the NCCN Adult Cancer Pain, what is done for Mild Pain (1-3)?

Answer 6

Non-opiods: Acetaminophen, NSAIDs. Re-evaluate at each contact

Question 7

For the NCCN Adult Cancer Pain, what is done for Moderate Pain (4-6)?

Answer 7

Titrate short-acting opiods: Codeine, Tramadol, Morphine, etc. Reassess pain score within 15-60 minutes

Question 8

For the NCCN Adult Cancer Pain, what is done for Severe Pain (7-10)?

Answer 8

RAPIDLY titrate short-acting opiod: Morphine, etc. Reassess pain score within 15-60 minutes

Question 9

What is done for Opioid-Tolerant patients?

Answer 9

Calculate opioid usage for the previous 24hrs. Give 10-20% of previous 24hr-requirement as initial dose for breakthrough pain. Reassess efficacy (chain in pain score) and adverse effects

Question 10

What is done for Maintenance opiod analgesics for CHRONIC cancer pain?

Answer 10

Consider converting to long-acting or extended release formulations. Provide around-the-clock AND breakthrough medications. Use the same opiod for extended-release and short-acting formulations if possible. Consider opioid conversion/rotation to provide adequate pain control and minimize side effects

Question 11

What are “Mild” Opioids?

Answer 11

Tramadol, Codeine

Question 12

What are “Strong” Opioids?

Answer 12

Morphine, Fentanyl

Question 13

What are the 1st line analgesics for mild to moderate pain?

Answer 13

NSAIDs

Question 14

What are the cons with NSAIDS?

Answer 14

Caution in patients with thrombocytopenia, bleeding disorder, or renal insufficiency. Many drug-drug interactions (e.g. decreases clearance of MTX)

Question 15

What are some considerations with Acetaminophen use?

Answer 15

No anti-inflammatory properties. Caution in hepatic impairment. Often in combination pain medications (increased risk of accidental overdose). Anti-pyretic (increased risk of masking fever in neutropenic patients)

Question 16

What are the characteristics of Codeine?

Answer 16

For acute pain. Prodrug of morphine with 5-10% conversion via CYP 2D6. Requires dosage adjustment based on renal function. Usual dose: 30-120mg PO Q4-6hrs PRN pain

Question 17

What are the characteristics of Tramadol?

Answer 17

For acute pain. Weak m-receptor agonist, serotonin inhibitor, NE reuptake inhibitor. Usual dose: 50-100mg PO Q4-6hrs PRN pain (Max of 400mg/day)

Question 18

What are some cautions with Tramadol use?

Answer 18

Decreases seizure threshold. Increases risk of serotonin syndrome with SSRI/MAOI

Question 19

What are the general characteristics of Morphine?

Answer 19

Gold standard of opioid analgesics, in practice and in clinical studies. Many dosage forms. Oral and parenteral formulations are effective for acute pain; long-acting formulations are available for chronic pain management

Question 20

What are the initial starting doses for Morphine?

Answer 20

PO: 5-15mg. IV/IM: 2-5mg. SQ: 2-5mg. For Opioid-tolerant patients: give 10-20% of 24hr-requirements as breakthrough dose

Question 21

What are some general things to remember when using Opioid analgesics for Chronic Pain?

Answer 21

Oral route should be considered first. ATC, scheduled regimens are preferred for continuous pain control. “Rescue” doses of short-acting opioids should be available for breakthrough pain relief. Many oral “modified-release” products are available, in addition to transdermal delivery

Question 22

What is MS Contin?

Answer 22

Controlled release morphine Q8-12h. Dual-control polymer matrix that consists of a hydrophilic polymer and a hydrophobic polymer

Question 23

What is Kadian?

Answer 23

Sustained Release Morphine Q12-24h. Polymer coated extended-release pellets of morphine. Capsule may be opened and sprinkled onto applesauce; do not crush pellets

Question 24

What is Avinza?

Answer 24

Extended Release Morphine: Q24h. An immediate release component and an extended release component. Capsule may be opened and sprinkled onto applesause; do not crush pellets. Not interchangeable with other extended-release morphine products

Question 25

What is Exalgo?

Answer 25

Hydromorphone extended release. Usual dose: 8-64mg PO QD. Do NOT chew or crush tablets; avoid alcohol or sedatives

Question 26

What is Fentanyl?

Answer 26

One of the most potent m-receptor agonists (100x morphine). Less histamine release effect vs. morphine (lower hypotension and flushing)

Question 27

When is the Fentanyl transdermal patch used?

Answer 27

Only for OPIOID-TOLERANT patients receiving > 60mg PO morphine equivalent/day for 1 week or longer

Question 28

When should you use caution with Fentanyl Transdermal Patch?

Answer 28

Patients with elevated body temperature (e.g. febrile, strenuous exercise)

Question 29

What is Actiq?

Answer 29

Fentanyl Transmucosal Lozenge. Used for breakthrough cancer pain in opioid-tolerant patients

Question 30

What is Fentora?

Answer 30

Fentanyl Buccal tablet

Question 31

What are the key points about Fentayl Products?

Answer 31

Fentanyl patch is for the management of chronic pain in opioid-tolerant patients. Fentanyl lozenge, tablet, buccal soluble film, nasal spray products are for management of acute, breakthrough cancer pain in opioid-tolerant patients

Question 32

What should you do because of incomplete cross tolerance?

Answer 32

If pain has been adequately controlled, reduce dose by 25-50% dose when switching between opioids

Question 33

What are the exceptions for incomplete cross tolerance?

Answer 33

May not need dose reduction if patient has severe pain. No reduction when converting to transdermal fentanyl patch using conversion table. Larger reduction when changing to methadone, depending on opioid usage history. Larger reduction in elderly patients, or those with renal hepatic dysfunction

Question 34

What are the side effects of opiate narcotics?

Answer 34

Nausea. Pruritus. Urine retention. Sedation. Delirium. Constipation. Respiratory depression

Question 35

Which opiates have the highest constipation rate?

Answer 35

Morphine > Codeine, Meperidine

Question 36

What are the peripheral m-Opioid receptor antagonists?

Answer 36

Oral Naloxone. Methylnaltrexone (Relistor). Alvimopan (Entereg)

Question 37

What is used for neuropathic pain?

Answer 37

Antidepressant. Anticonvulsant

Question 38

What is used for bone pain?

Answer 38

Bisphosphonates. Corticosteroids. NSAIDs

Question 39

Which Antidepressants are used?

Answer 39

Bupropion. Duloxetine. Venlafaxine. Amitriptyline, Imipramine, Nortriptyline, Desipramine

Question 40

Which Anticonvulsants are used?

Answer 40

Gabapentin. Pregabalin

Question 41

What are the general characteristics of Bone metastasis and Bone Pain?

Answer 41

Pain if often very severe and progressive as disease worsens, profoundly compromising quality of life. Complications: falls, bone fractures, hypercalcemia

Question 42

What are the common cancer types to cause bone metastasis and bone pain?

Answer 42

Breast. Prostate. Lung. Multiple myeloma

Question 43

What is used in the treatment of bone pain?

Answer 43

Combination of: RT, chemotherapy and/or hormonal therapy for primary diagnosis, Surgical intervention for fractures and compression, Pharmacological therapy (for pain relief)

Question 44

What are Bisphosphonates used for?

Answer 44

Bone metastases. Zoledronic acid, Pamidronate. MOA: binds to bone surface and inhibits osteoclast bone resorption

Question 45

What are RANK Ligand Inhibitors used for?

Answer 45

Bone metastases. Denosumab. MOA: binds to RANK ligand (signaling molecule that stimulates function and survival of osteoclasts)