cancer pain Flashcards by Keri Courtnage

what are the 3 physical pain syndromes

somatic (nociceptive)
visceral (nociceptive)
neuropathic

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what is somatic pain

pain arising from damage to muscle, bone, skin: well localized
sharp, intense, throbbing, localized

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what is visceral pain

pain arising from damage to organs; not well localized- can be referred
gnawing, cramping, squeezing, diffuse, distant

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what is neuropathic pain

pain arising from a lesion or disease of the somatosensory nervous system
shooting, burning, numb, tingling, enhanced sensitivity to heat/cool

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what is the PQRSTUV of pain assessment

Precipitating/palliating
Quality
Region/radiating
Severity
Timing/temporal
Utilization
Values

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how to treat tumor-related pain

first line: APAP, NSAIDs, OPIOIDS

non opioids:
-nociceptive: NSAID, APAP, corticosteroid, ketamine
-neuropathic: gabapentin, TCA, SNRI, lidocaine

radiation, anti-tumor therapy

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how to treat bone metastasis pain

APAP, NSAID, OPIOID, corticosteroid, bisphosphonates, radation, surgery

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how to treat chemotherapy-induced peripheral neuropathy (CIPN)

duloxetine (Cymbalta) 30 mg PO daily x 1 week, then increase to 60 mg PO daily: THE ONLY PHARM THERAPY RECOMMENDED IN THE ASCO GUIDELINES FOR CIPN
+/- adjunct therapy with topical agents, TCAs, anticonvulsants (gabapentin, pregabalin) though data limited

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what are risk factors for chemotherapy-induced peripheral neuropathy (CIPN)

higher initial/cumulative doses
longer treatment duration
advanced age
race
concomitant therapy
pre-existing conditions associated with peripheral neuropathy development such as diabetes

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which non-pharm therapies have a higher level of evidence in cancer pain

massage and acupuncture

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bisphosphonates are indicated for ____

bone pain

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cannabinoids are indicated for ____

opioid-refractory cases of cancer pain
though evidence is NOT strong for its use with cancer pain

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corticosteroids are indicated for _____

cancer pain related to inflammation (bone pain, lymphedema, increased intracranial pressure)

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what are some class ADRs of opioids

GI: n/v, constipation
Autonomic: xerostomia, urinary retention
Derm: pruritis, sweating
Neuro: sedation, dizziness, delirium, hallucinations, myoclonus, hyperalgesia
Cardiopulmonary: respiratory depression, bradycardia, hypotension
Immuno: immune suppression
Endo: hypogonadism, sexual dysfunction

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ADRs specific to CODEINE

ultra-rapid metabolizers have higher risk of respiratory depression

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ADRs specific to methadone

QTc prolongation

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ADRs specific to morphine

higher rates of itching, hypotension due to histamine release upon binding

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ADRs specific to tramadol/tapentadol

lower seizure threshold and increased risk of serotonin syndrome

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management of opioid-induced constipation

prevention is the best treatment: initiate scheduled bowel regimen when starting opioid therapy
try senna, miralax, bisacodyl
DOCUSATE IS NOT RECOMMENDED BECAUSE IT SOFTENS THE STOOL BUT DOESN’T MAKE YOU GO

lubiprostone, methylnaltrexone, naldemedine, naloxegol are for refractory opioid-induced constipation

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management of nausea/vomiting with opioids

prochlorperazine 5-10 mg PO/IV Q6H PRN

management of itching with opioids

diphenhydramine 25 mg PO q6h prn
hydroxyzine 25 mg PO q6h prn

management of sedation/lethargy with opioids

sedation/lethargy occurs before respiratory depression
utilize naloxone for reversal of overdose
consider ordering naloxone as a precaution for patients on high dose opioids >50 mg OME per CDC

avoid _____ in renal dysfunction due to?

morphine
high number of active metabolites

codeine active metabolites

morphine
M6G

oxycodone active metabolites

oxymorphone

hydrocodone active metabolites

hydromorphone

tramadol active metabolites

which drugs don't have active metabolites

fentanyl

how to initiate opioids in opioid-naive patients

select a short acting (immediate release) PO medication (ex morphine, oxycodone, hydromorphone)-- but if they are in the hospital with acute pain you can use IV do not use long-acting agents, fentanyl patches, or methadone

define "opioid tolerant"

patients who require at least 60 mg OME daily x 1 week

IV opioids: what is the onset, peak, duration

onset 5 min peak 15 min duration 3-4 hours (2 hours for fentanyl)

PO opioids: what is the onset, peak, duration

onset 30 min peak 60 min duration 3-4 hours

when can you safely re-dose an opioid?

after it reaches its peak effect (ex after 15 minutes for IV)

how can you modify opioids for uncontrolled pain?

1. increase the dose (by 25-50% if mild-moderate pain <6, by 50-100% if severe pain >7) 2. utilize a long-acting agent if the patient's pain is constant

true/false: patients have to have chronic pain to be prescribed a long-acting agent

FALSE: it has to be constant, but not chronic

true/false: patient has to be opioid tolerant to be prescribed a long acting agent

FALSE

how do you initiate a long-acting agent?

1. calculate total daily dose used in PRNs and use 2/3 of that dose towards long acting 2. PRN dose is 10-15% of long-acting regimen, every 4 hours PRN 3. do not titrate up for at least 3 days for PO, and 7 days for TD

true/false: it is necessary to reduce for cross tolerance when switching from a different opioid to a fentanyl patch

FALSE the conversion on the package insert is conservative already

true/false: the equianalgesic table applies to both IV and transdermal fentanyl

FALSE it only applies to IV fentanyl NOT transdermal: use package insert

what is the 5 step approach to opioid conversions

1. assess the patient (PQRSTUV) 2. determine total daily usage of current opioid in the last 24 hours: long acting and breakthrough 3. set up ratio 4. adjust for cross tolerance (reduce by 33%) 5. follow up

______ cannot be used in opioid-naive patients

transdermal fentanyl, methadone

which drugs are specifically problematic that Dr. Lowry hates

Tramadol: it lowers seizure threshold, risk of serotonin syndrome is high codeine is problematic because ultra rapid metabolizers have a higher risk of respiratory depression

when is transdermal fentanyl (duragesic) indicated

constant (non-acute) pain for opioid-tolerant patients: meaning they require at least 60 mg OME per day x 1 week

onset, peak, duration of transdermal fentanyl

onset: 12 hours peak: 24 hours duration: 72 hours

how is fentanyl able to be absorbed transdermally

it is highly lipophilic so it can absorb through SC fat/tissue

true/false: you can cut fentanyl patches

false

how do you convert TO versus FROM fentanyl patch

TO: use the package insert FROM: fentanyl dose (mcg/h) x 2 = oral morphine equivalent per day (mg)

how do you calculate a PRN regimen for transdermal fentanyl

calculate OME take 10-15% of that total OME for each PRN dose