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3: Surgery Y3 - Cancer Care [1] (check ILOs) > [16] Pain Management > Flashcards

[16] Pain Management Flashcards

1
Q

Is cancer pain a manageable concern?

A

Yes, in most cases

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2
Q

What % of cancer pain can be relieved relatively simply, with oral analgesics and adjuvant drugs?

A

80-90%

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3
Q

What is the problem with inadequate pain control in cancer?

A

It may exacerbate other problems

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4
Q

What other problems might be exacerbated by inadequate pain control in cancer?

A
  • Fatigue
  • Nausea
  • Constipation
  • Depression
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5
Q

Why might pain affect compliance in cancer?

A

It is more difficult for a patient in pain to continue with demanding cytotoxic treatments and hospital visits

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6
Q

What should be done when a patient presents with cancer pain?

A

A careful history should be taken to identify any reversible or remediable causes of the patient’s pain

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7
Q

What might cancer pain derive from?

A
  • Tumour progression and related pathology
  • Procedural intervention
  • Treatment toxicity
  • Infection
  • MSK issues
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8
Q

Specifically, what are the most common causes of pain in cancer patients?

A
  • Peripheral neuropathies secondary to chemotherapy or tumour invasion
  • Tissue injury secondary to radiotherapy
  • Chronic post-surgical incisional pain
  • Bone metastases
  • Visceral pain
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9
Q

What can aggravate cancer pain?

A
  • Other physical symptoms
  • Psychological symptoms
  • Social factors
  • Spiritual or existential suffering
  • Medical crisis
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10
Q

What other physical symptoms can exacerbate cancer pain?

A
  • Insomnia
  • Loss of appetite
  • Fatigue
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11
Q

What psychological symptoms can exacerbate cancer pain?

A
  • Distress
  • Anxiety
  • Depression
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12
Q

What happens even though cancer pain is manageable?

A

It is often undertreated

this card is bit dodgy sorry lol

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13
Q

What medical failures most commonly contribute to uncontrolled cancer pain?

A
  • Inadequate assessment
  • Failure to detect general distress
  • Lack of systemic approach to analgesia
  • Lack of knowledge of opioid pharmacology
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14
Q

How can inadequate assessment lead to uncontrolled cancer pain?

A

Can result in misdiagnosis of the cause and type of pain

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15
Q

How can failure to detect general distress lead to uncontrolled cancer pain?

A

Lowers pain threshold

??? lol

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16
Q

Give an example of when lack of knowledge of opiate prescribing can lead to uncontrolled cancer pain

A

Failure to anticipate and prevent side effects

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17
Q

Why is it important to understand the patient’s pain in cancer

A

Because treatment must be tailored for the individual, according to the nature, likely mechanisms, and subjective component of pain

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18
Q

Is a diagnosis of cancer a sufficient explanation for the patient feeling pain?

A

No

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19
Q

What is the result of a diagnosis of cancer being an insufficient explanation for the patient experiencing pain?

A

You need to determine what is the actual cause

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20
Q

What might pain of a sudden onset suggest in cancer?

A
  • Acute complication of the malignancy

- Unrelated cause, e.g. new pathological fracture, mucositis due to radiotherapy

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21
Q

What might chronic escalating pain be caused by in cancer?

A

Underlying disease progression, e.g. soft tissue or nerve root infiltration

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22
Q

What are the different natures of pain?

A
  • Somatic
  • Visceral
  • Neuropathic
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23
Q

What are the characteristics of somatic pain?

A

Typically localised and persistent

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24
Q

Give 2 examples of causes of somatic pain in cancer

A
  • Bone metastases

- Localised inflammation such as cellulitis

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25
Q

What are the characteristics of visceral pain?

A

Usually poorly localised, of variable intensity, and often occurring with associated symptoms such as nausea

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26
Q

Give 2 examples of causes of visceral pain in cancer

A
  • Hepatic metastases

- Malignant abdominal lymphadenopathy

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27
Q

What are the characteristics of neuropathic pain?

A
  • Classically described as ‘shooting pain’ or ‘burning’
  • Usually follows a nerve distribution
  • Typically less responsive to opiate therapy
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28
Q

Give an example of a cause of neuropathic pain in cancer

A

Compression of spinal nerve root

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29
Q

What is the result of pain having a strong affective component?

A

It is greatly influenced by mood and morale

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30
Q

Why is it important to consider the affective component of pain when managing it?

A

An understanding of the patient’s perception of pain will help formulate an effective management plan

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31
Q

What psychological aspects should be addressed when managing pain?

A
  • Anger
  • Fear
  • Distress
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32
Q

What is the result of managing anger, fear, and distress when managing cancer pain?

A

It will increase the likelihood of achieving satisfactory pain control

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33
Q

What does the approach to cancer pain management entail?

A

A foundation of pharmacologic management, which is tailored with individualised care

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34
Q

What does pharmacological pain management follow in cancer pain?

A

The WHO analgesic ladder

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35
Q

What is step 1 in the WHO analgesic ladder?

A

The initial treatment of mild to moderate pain with non-opioid analgesia

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36
Q

What analgesics might be used in step 1 of the WHO analgesic ladder?

A
  • Paracetamol
  • NSAIDs
  • Combination of paracetamol and NSAIDs
  • Cox-2 inhibitors
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37
Q

What is paracetamol?

A

Analgesic and anti-pyretic

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38
Q

Does paracetamol have anti-inflammatory action?

A

No

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39
Q

Are adverse reactions common with paracetamol?

A

Rare at prescribed doses

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40
Q

Give 2 examples of NSAIDs used in step 1 of WHO analgesic ladder

A
  • Ibuprofen

- Naproxen

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41
Q

What should you be aware of when prescribing NSAIDs?

A

Issues regarding gastric protection and renal function

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42
Q

Give an example of a cox-2 inhibitor

A

Celecoxib

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43
Q

What is the action of celecoxib?

A

Anti-inflammatory

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44
Q

What is the advantage of celecoxib over NSAIDs?

A

May result in lower incidence of gastric irritation and renal toxicity

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45
Q

What is the disadvantage of celecoxib?

A

Associated with increased risk of MI and stroke

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46
Q

What can non-opioid analgesics be paired with?

A

Adjuvants

47
Q

Give 3 adjuvants that can be paired with non-opioid analgesics

A
  • Agents for neuropathic pain
  • Bisphosphonates for bone pain
  • Corticosteroids for bone pain
48
Q

Give 3 examples of agents for neuropathic pain

A
  • Gabapentin
  • Duloxetine
  • Amitriptyline
49
Q

Where are bisphosphonates a useful adjunct?

A

Particularly in breast cancer and multiple myeloma, but also in lung, GI, and prostate cancer

50
Q

Give 2 examples of corticosteroids used as a pain adjunct

A
  • Prednisolone

- Dexamethasone

51
Q

What is step 2 in the WHO analgesic ladder?

A

Treatment of mild to moderate pain that is not responsive to step 1 therapy, or for the initial treatment of severe pain

52
Q

What does step 2 in the WHO analgesic ladder involve?

A

Low doses of opioid analgesia

53
Q

What drugs may be used in step 2 of the WHO analgesic ladder?

A
  • Codeine phosphate

- Low dose morphine, or similar dose of oxycodone

54
Q

What dose of codeine phosphate is given in step 2?

A

30-50mg tds

55
Q

What is the problem with codeine phosphate?

A

It can cause substantial nausea and vomiting in many patients

56
Q

What should be done as a result of the potential for codeine phosphate to cause substantial nausea and vomiting?

A

Consider adding anti-emetic when prescribing

57
Q

What dose of morphine is used in step 2?

A

<40mg total daily dose

58
Q

Should the patient continue their regular non-opioid analgesics in step 2?

A

Yes, continue alongside the opioids

59
Q

What can step 2 agents be combined with?

A

Adjuvants

60
Q

What is the purpose of combining step 2 agents with adjuvants in pain management?

A

To tailor the pain management plan to the patients needs

61
Q

What are the possible side effects of opioid analgesia?

A
  • Nausea

- Constipation

62
Q

In what manner should the side effects of opioid analgesia be managed?

A

Preventatively

63
Q

What does step 3 in the WHO analgesic ladder involve?

A

More potent doses of opioid analgesia

64
Q

What opioid analgesics are generally used for cancer pain?

A
  • Morphine
  • Oxycodone
  • Fentanyl
  • Hydromorphone
  • Methadone
65
Q

What do morphine metabolites do in the body?

A

Contribute to side effects

66
Q

What side effects do morphine metabolites contribute to?

A
  • Nausea
  • Myoclonus
  • Sedation
67
Q

What can happen to morphine metabolites in the body?

A

They can accumulate

68
Q

When are morphine metabolites particularly likely to accumulate?

A

In patients with liver or renal dysfunction

69
Q

What opioids don’t have the same metabolites as morphine?

A
  • Oxycodone
  • Fentayl
  • Hydromorphone
70
Q

What is the result of oxycodone, fentanyl, and hydromorphine having different metabolites to morphine?

A

They may have few side effects

71
Q

What are the additional benefits of metadone?

A
  • May be prescribed for neuropathic pain

- Very inexpensive

72
Q

What is the disadvantage of methadone?

A

Unpredictable half life

73
Q

What is the result of methadone having an unpredictable half life?

A

Should be prescribed by experienced clinicians only

74
Q

What opiate regime should be used in step 3?

A

Sustained release product, combined with immediate-release formulation for breakthrough pain and inadequate analgesia

75
Q

What initial opiate dose should be used in step 3?

A

Start at 40-80mg OME/day

76
Q

When should the starting opiate dose be reduced in step 3?

A
  • Elderly patients

- Patients with liver or renal dysfunction

77
Q

By how much should the starting opiate dose be reduced to in elderly patients/patients with liver or renal dysfunction?

A

50-75%

78
Q

What should you do when you have established the starting dose of opiates in step 3?

A

Titrate the drug to the desired analgesic effect and tolerable side effects

79
Q

What are the main side effects of opiates?

A
  • Nausea
  • Constipation
  • Dry mouth
  • Hallucinations
  • Respiratory depression
80
Q

How is nausea caused by opiates prevented?

A

Prescribe an anti-emetic

81
Q

Give an example of an anti-emetic that can be prescribed to prevent nausea with opiates

A

Metaclopramide

82
Q

What dose of metaclopramide is given to prevent nausea with opiates?

A

5-10mg every 6 hours as needed

83
Q

How is constipation caused by opiates prevented?

A

Co-prescribe a laxative plus stool softener

84
Q

How is dry mouth caused by opiates prevented?

A
  • Access to fluids

- Mouth care

85
Q

How are hallucinations caused by opiates treated?

A

Haloperidol 1.5-3mg as needed

86
Q

Is respiratory depression caused by opiates common?

A

No, it is rare in cancer patients

87
Q

When is respiratory depression caused by opiates seen?

A

Usually only at doses above those required for analgesia, or if the drug is accumulating

88
Q

Give an example of when opiates may accumulate

A

Renal impairment

89
Q

How is respiratory depression caused by opiate toxicity managed?

A

Naloxone

90
Q

What does breakthrough pain refer to?

A

Intemittent flares of pain that occur even though the patient is properly taking around-the-clock analgesics, and pain is generally well managed

91
Q

What proportion of cancer patients will experience breakthrough pain?

A

1/2 to 2/3

92
Q

How should breakthrough cancer pain be managed?

A

Alongside each long-acting sustained release opioid, you should prescribe an immediate-release opioid

93
Q

What dose of immediate-release opioid should be given for breakthrough pain?

A

Approx 10% of the long acting dose

94
Q

What should the dose of immediate-release opioid for breakthrough cancer pain be adjusted for?

A

Efficacy vs side effects based on the patients report of symptoms

95
Q

When giving opioids, what should be anticipated over time?

A

A slow increase in opiate requirements

96
Q

Why should you except a slow increase in opiate requirement over time?

A

Opioid responsiveness falls along a continuum

97
Q

Add in card about how to titrate opiate dose

A

cant remember if you divide by 2 or 4 lol

98
Q

spare in case you need it

A

jj

99
Q

What might limit the titration of opioids?

A

Unacceptable side effects, e.g. sedation

100
Q

What should be done when the titration of opioids is limited by unacceptable side effects?

A

Adjuvant analgesics should be used

101
Q

What should be considered when the patient has persistent pain despite appropriate use of analgesics?

A

If the patient has developed;

  • Progressive disease
  • Tolerance
  • Withdrawal
  • Hyperalgesia
102
Q

What is the most common cause of pain that is suddenly difficult to control in cancer patients?

A

Progressive disease

103
Q

What does tolerance to opiates lead to?

A

Increasing doses of analgesics being required to maintain the same level of pain control

104
Q

Is tolerance to opiates common in cancer patients?

A

No, it is rare

105
Q

What does tolerance to opiates usually respond to? W

A
  • Increase in opiate dose

- Switching to different opioid

106
Q

What causes opiate withdrawal in cancer patients?

A

Decreasing or stopping an opioid

107
Q

What can opiate withdrawal cause?

A

Worsening pain

108
Q

How can pain caused by opiate withdrawal be managed?

A

Adding back the opioid, or increasing opioid dose

109
Q

What is opioid-induced hyperalgesia?

A

When opioids lead to increasing pain as the opioid is increased

110
Q

When should referral to a pain specialist be considered?

A

If standard adjustments to the patient’s analgesic regime do not lead to improved pain control

111
Q

What are many patients and families concerned about with opiates?

A

The possibility of addiction to strong opiates

112
Q

What kinds of dependance can develop with opiates?

A
  • Physical
  • Psychological
  • Due to habituation
113
Q

What should patients be reassured of regarding addiction to opiates?

A

When properly managed, addiction is not an issue, and the risk of addiction in cancer patients is about 1 in 1000

3: Surgery Y3 - Cancer Care [1] (check ILOs) (47 decks)

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