cancer pain Flashcards
what are the 3 physical pain syndromes
somatic (nociceptive)
visceral (nociceptive)
neuropathic
what is somatic pain
pain arising from damage to muscle, bone, skin: well localized
sharp, intense, throbbing, localized
what is visceral pain
pain arising from damage to organs; not well localized- can be referred
gnawing, cramping, squeezing, diffuse, distant
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
what is the PQRSTUV of pain assessment
Precipitating/palliating
Quality
Region/radiating
Severity
Timing/temporal
Utilization
Values
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
how to treat bone metastasis pain
APAP, NSAID, OPIOID, corticosteroid, bisphosphonates, radation, surgery
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
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
which non-pharm therapies have a higher level of evidence in cancer pain
massage and acupuncture
bisphosphonates are indicated for ____
bone pain
cannabinoids are indicated for ____
opioid-refractory cases of cancer pain
though evidence is NOT strong for its use with cancer pain
corticosteroids are indicated for _____
cancer pain related to inflammation (bone pain, lymphedema, increased intracranial pressure)
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
ADRs specific to CODEINE
ultra-rapid metabolizers have higher risk of respiratory depression
ADRs specific to methadone
QTc prolongation
ADRs specific to morphine
higher rates of itching, hypotension due to histamine release upon binding
ADRs specific to tramadol/tapentadol
lower seizure threshold and increased risk of serotonin syndrome
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
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
M1
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?
- increase the dose (by 25-50% if mild-moderate pain <6, by 50-100% if severe pain >7)
- 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?
- calculate total daily dose used in PRNs and use 2/3 of that dose towards long acting
- PRN dose is 10-15% of long-acting regimen, every 4 hours PRN
- 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
- assess the patient (PQRSTUV)
- determine total daily usage of current opioid in the last 24 hours: long acting and breakthrough
- set up ratio
- adjust for cross tolerance (reduce by 33%)
- 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
