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Clinical 2 (Part B) > 20 - Cancer Pain > Flashcards

20 - Cancer Pain Flashcards

1
Q

What are patient barriers in cancer pain?

A

Fears relating to analgesic use:

  • Addiction
  • Side effects
  • Fear of injections
  • Tolerance

Beliefs that affect communication about pain:

  • Disease progression
  • Distract the doctor
  • “Be good”
  • Fatalism
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2
Q

What are some health care worker barriers?

A

Opiophobia:

  • Fear of addiction
  • Fear of side effects
  • Fear of tolerance

Anxiety about regulation of controlled substances

Poor assessment

Lack of adequate training and pain management experience

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3
Q

___% of cancer patients experienced errors in opioid dosing

A

76

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4
Q

What are some cancer pain conclusions?

A
  • Cancer pain is common
  • Cancer pain is often not treated optimally
  • Cancer pain significantly affects patient’s lives
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5
Q

Define opioid addiction

A

Is a primary, chronic disease of brain reward, motivation, memory, and related circuitry
-No published reports in CA patients with no previous hx

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6
Q

Define physical dependence

A

Occurrence of abstinence syndrome when opioid is suddenly stopped
-Fairly common, need gradual withdrawal

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7
Q

Define Tolerance

A

Decrease is one or more effects of the opioid

-Decreased analgesic effect due to tumor progression

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8
Q

Nociceptive Pain

A
  • Direct stimulation of intact nociceptors
  • Transmission along normal nerves
  • Somatic (easy to describe and localize)
  • Visceral (difficult to describe and localize)
  • Tissue injury apparent
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9
Q

Neuropathic Pain

A
  • Disordered peripheral or central nerves
  • Compression, infiltration, ischemia, metabolic injury
  • Pain may exceed observable injury
  • Less responsive than nociceptive pain
  • Poorly responsive syndromes likely have a neuropathic component

*In the treatment of cancer, we can damage nerves and lead to post-cancer neuropathic pain

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10
Q

Describe somatic pain type

A

achy, stabbing, throbbing, squeezing, tender and/or deep

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11
Q

Describe visceral pain type

A

sharp, stabbing, squeezing, cramps, and/or gnawing

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12
Q

Describe neuropathic pain

A

burning, shooting, tingling sensation, numbness, scalding, may be associated with allodynia and/or hyperalgesia

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13
Q

What are some causes of cancer pain?

A

1) The cancer itself: 75-80%
- Tumor involvement of the bone (30-70%)
- Tumor involvement of nervous tissue, visor, blood vessels

2) The treatment of cancer: 15-19%
- Chemotherapy: peripheral neuropathy, mucositis
- Radiotherapy: plexopathy, pelvic pain
- Post-surgical: neuropathies

3) Unrelated to the cancer 3-5%
4) The debility of cancer

  • If it spreads to another area, can get visceral pain
  • If cancer is present on nerves, can have neuropathic pain
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14
Q

____ cancer pain is the most complicated

A

bone

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15
Q

What are some pharmacological agents for cancer bone pain?

A
  • Acetaminophen
  • NSAIDs/Cox-2 inhibitors
  • Steroids (don’t use NSAIDs and steroids together)
  • Opioids
  • Neuropathic agents
  • Bisphosphonates (pamidronate, zoledronic acid)

*often bc there is destruction of bone, we add on a bisphosphonate

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16
Q

Describe radiation tx for cancer bone pain?

A
  • Single treatment or multiple treatment
  • Often effective immediately
  • Maximal effect 4-6 weeks
  • 60-80% of patients get relief
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17
Q

What are some surgical options for treating cancer bone pain?

A

Pathologic (splint, cast, ORIF)

  • Intramedullary support
  • Spinal cord decompression
  • Vertebral reconstruction
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18
Q

What is best to treat somatic pain?

A
  • Acetaminophen
  • NSAID
  • Opioid
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19
Q

What is best to treat visceral pain?

A
  • Opioids
  • Steroids
  • Surgery
  • Chemo - radiation Tx
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20
Q

Certain chemo treatments can cause ______

A

neuropathy

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21
Q

How else can cancer Tx cause pain?

A

1) Tx-related mucositis (located in whole GI tract)

2) Surgical
- Phantom limb pain
- Post-mastectomy syndrome
- Post-thoractomy syndrome

3) Tx-related immunosuppression
- Example: Post herpetic neuralgia
- Example: Shingles rash
- Example: Herpes Zoster Ophthalmicus

Bc of chemo, they are immunosuppressed, then they can develop shingles (in proper age group and had chicken pox before)

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22
Q

What are total pain components?

A
  • Physical source
  • Patient’s emotional status
  • Patient’s personality
  • The family
  • Patient and family context
  • Health care professionals
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23
Q

If person has spinal curve abnormality (spinal cord curving and pressing on nerves), what type of pain is this?

A
  • prob partly somatic and partly neuropathic
  • if it’s actual changes in the back = somatic
  • if it’s pressing on nerves = neuropathic
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24
Q

Codeine is metabolized to ______ by CYP2D6

A

morphine

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25
Q

___% of patients taking codeine will have NO analgesic effect

A

5-10

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26
Q

___% will have a more pronounced effect

A

1-29

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27
Q

Do not use codeine with which drugs?

A
  • paroxetine, fluoxetine
  • quinidine, haloperidol

*anti-depressants block CYP 2D6 so if they are taking these, they won’t have any analgesia effect

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28
Q

Do not use codeine in ____ & ____ dysfunction

A

renal and hepatic

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29
Q

Codeine has lots of ____ side effects

A

GI

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30
Q

What type of ppl are more likely to have duplication of CYP 2D6 alleles

A

african/ethiopian

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31
Q

Morphine undergoes ____ metabolism

A

hepatic

32
Q

What are morphines metabolites?

A

60% morphine-3-glucuronide:
-hyperalgesia, allodynia, hyperactivity

10% morphine-6-glucuronide:
-greater analgesic properties, fewer adverse effects

4% normorphine, non-active, non-toxic

33
Q

Avoid morphine in ____ dysfunctional and failure

A

renal

34
Q

Use with caution in severe liver dysfunction, describe this

A
  • increase dosing interval from q6h to q8h

- dosage conversion from IV to PO becomes 1:1

35
Q

What is hydromorphone metabolized to?

A

hydromorphine 3-glucuronide

36
Q

When is hydromorphine preferred over morphine ?

A
  • renal failure
  • elderly (>60) due to decreased renal function
  • history of rashes
  • when nausea and constipation are a problem
  • when sedation is a problem
37
Q

When is fentanyl the preferred agent over morphine and hydromorphone ?

A
  • Elderly (>60 yo) due to decreased renal function
  • Renal failure and severe liver dysfunction
  • History of rashes
  • When nausea and constipation are a problem
  • When sedation is a problem
38
Q

What drugs should we caution the use of fentanyl with?

A

Inhibitors of CYP 3A4:
-Clarithromycin, Voriconazole, Grapefruit

Inducers of CYP 3A4:
-Dilantin, Rifampin, Steroids

39
Q

What is the oral bioavailability of methadone ?

A

> 85%

40
Q

Methadone is metabolized by ____

A

liver

41
Q

Does methadone have active metabolites?

A

No

42
Q

Methadone MOA

A

blocks NMDA receptors

43
Q

Who should a fentanyl patch never be started in?

A
  • an opioid naive patient
  • < 18 yo
  • acute pain
44
Q

Correct dose is a compromise between ?

A
  • sufficient pain relief
  • good cognitive function
  • acceptable side effect profile
45
Q

If they still have mild pain, increase dose by ___%

A

25

46
Q

If they still have moderate pain, increase dose by _____%

A

25-50

47
Q

If they still have severe pain, increase dose by ____%

A

50-100

48
Q

How much oral codeine is equivalent to morphine 10 mg?

A

100 mg

49
Q

How much oral oxycodone is equivalent to morphine 10 mg?

A

5 mg

50
Q

How much oral hydromorphone is equivalent to morphine 10 mg?

A

2 mg

51
Q

How much oral methadone is equivalent to morphine 10 mg?

A

1 mg

52
Q

How much IV codeine is equivalent to 5 mg of IV morphine ?

A

50 mg

53
Q

How much IV hydromorphone is equivalent to 5 mg of IV morphine ?

A

1 mg

54
Q

How much IV fentanyl is equivalent to 5 mg of IV morphine ?

A

50 ug

55
Q

How much IV sufentanil is equivalent to 5 mg of IV morphine ?

A

5 ug

56
Q

What is the starting dose of fentanyl patch?

A

25 ug/hr

57
Q

What is the 12 ug/hr patch used for?

A

titrating between doses (say from 25-50)

58
Q

What fentanyl patch do you give for 45-69 mg PO morphine ?

A

12 ug/hr

59
Q

What fentanyl patch do you give for 60-134 mg PO morphine ?

A

25 ug/hr

60
Q

What fentanyl patch do you give for 135-179 mg PO morphine ?

A

37 ug/hr

61
Q

What fentanyl patch do you give for 180-224 mg PO morphine ?

A

50 ug/hr

62
Q

What fentanyl patch do you give for 225-314 mg PO morphine ?

A

75 ug/hr

63
Q

What fentanyl patch do you give for 315-404 mg PO morphine ?

A

100 ug/hr

64
Q

Describe the 5 steps to calculating equianalgesic dosing ?

A

Step 1:

  • Calculate total daily opioid intake
  • Regular and breakthrough doses

Step 2:
-Convert to morphine equivalents

Step 3:
-Convert from morphine equivalent to new opioid

Step 4:
-Start new product at 50-75% of calculated dosage

Step 5:
-Evaluate frequently for uncontrolled pain and re-titration, if needed.

65
Q

Breakthrough dose = ___% of daily dose

A

10-15

66
Q

It takes ___ hours to achieve therapeutic fentanyl serum levels. Therefore must provide the patient with opioid coverage during the conversion period

A

12-16

67
Q

When switching to fentanyl, should be given _____ immediate release 2 mg at time zero (time of patch application), 4 hours after patch application, and 8 hours after patch application

A

hydromorphone

68
Q

Upon system removal, ___ hours or more are required for a 50% decrease in serum fentanyl concentrations

A

17

69
Q

Can you try long acting morphine before short acting?

A

No

70
Q

Common SE of Opioids

A
  • constipation
  • nausea
  • somnolence, mental clouding
71
Q

Less Common SE of Opioids

A
  • urinary retention
  • pruritus
  • myoclonus
  • amenorrhea
  • sexual dysfunction
  • headache
72
Q

What are symptoms of opioid induced neurotoxicity?

A
  • nausea
  • twitching, myoclonus, seizures
  • sleeping a lot
  • change in mental status, delirium, hallucinations
  • hyperalgesia
73
Q

What is the Tx for opioid induced neurotoxicity?

A
  • hydration
  • change opioid, reduce opioid dose
  • treat symptoms: hallucinations/agitation
74
Q

What pharmacologic Tx do we have for neuropathic pain?

A
  • Opioids
  • Steroids - dexamethasone, prednisone
  • Anticonvulsants: gabapentin, pregabalin, carbamazepine
  • Antidepressants: amitriptyline, desipramine, nortriptyline, venlafaxine, duloxetine
  • NMDA-R antagonists: methadone, ketamine, cannabinoids
75
Q

Describe inhibitors of CYP 3A4 that interact with codeine metabolism and what happens

A

clarithromycin & voriconazole

*bc these inhibit CYP 3A4, then it all gets metabolized by CYP 2D6 which goes to morphine and then morphine-6-gluc and morphine-3-gluc

Clinical 2 (Part B) (30 decks)

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