Chronic Malignant and Non-Malignant Pain Flashcards by Nicole Gaudreau

What is the definition of chronic malignant pain?

Pain associated with potentially life-threatening conditions

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What are the causes of cancer pain?

Pain associated with tumor or metastasis
Pain associated with treatment
Pain unrelated to either

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What are the types of cancer pain?

Nociceptive (surgical procedures, tumor, bone metastasis)
Neuropathic (chemotherapy, radiation therapy, surgical injury to nerves, tumor/metastasis-related
Mixed

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What are complications from chronic malignant pain?

Anxiety
Depression
Wt loss
Sleep disturbance
Decreased QoL

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What are medication options for chronic malignant pain?

Morphine
Fentanyl
Hydrocodone
Oxycodone
Hydromorphone
Oxymorphone
Methadone
Tramadol

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What types of medications are most commonly used in cancer pain?

Pure agonists (morphine, oxycodone, hydromorphone, and fentanyl)

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Which opioid is considered the standard starting drug of choice in opioid naive patients?

Morphine

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How is morphine eliminated?

Renally

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When is fentanyl used in cancer pain?

Transdermal patches when opioid tolerant patients are in need of around the clock pain relief

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Which routes of fentanyl are used for breakthrough pain in opioid tolerant patients?

Transmucosal
Buccal
Intranasal

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How is hydrocodone used in cancer pain?

Limited to mild, initial use

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Which medication can be used for cancer pain in morphine intolerant patients?

Oxycodone

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How can methadone be initiated?

By physicians

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How does tramadol compare to morphine?

1/10 potency of morphine

Higher doses lead to increased AEs

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What do adjuvant analgesics treat?

Bone pain
Neuropathic pain
Bowel obstruction

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What is the cause of bone pain?

Tumor metastasis to bone

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What are tx options for bone pain?

Radiation/surgery
NSAIDs/APAP
Corticosteroids
Bisphosphonates
Denosumab
Calcitonin
Radioisotopes

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For what conditions are corticosteroids used?

Bone pain
Compression of neural structures
HA d/t increased intracranial pressure
Arthralgia
Metastatic spinal cord compression

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What are positive SE of corticosteroid use?

Improve appetite, nausea and malaise

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Which corticosteroid is commonly used and why?

Dexamethasone, low mineralcorticoid effects

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What is the MOa of bisphosphonates?

Inhibit osteoclast activity
Reduce bone resorption
Reduce tumor associated osteolysis
Delayed skeletal events

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Which bisphosphonates are administered IV?

Zoledronic acid

Pamidronate

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What are AEs associated with bisphosphonates?

Flu like reaction (treated with APAP)
Impaired renal function
Hypocalcemia
Osteonecrosis of the jaw (IV)

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When should bisphosphonates be avoided?

CrCl < 30

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What is the MOA of denosumab?

Monoclonal antibody that binds to and inhibits RANKL leading to prevention of osteoclast formation and decreased bone resorption

What are the AEs of denosumab?

Hypocalcemia Osteonecrosis of the jaw Fatigue HA

What agent can be used for bone pain if all others fail?

Calcitonin

Where are radioisotopes absorbed?

Areas of high bone turnover

What are the causes of neuropathic pain?

Tumor Surgery Chrmotherapy Radiation

What are the pharmacologic options for neuropathic pain?

``` TCAs Gabapentin Pregabalin SNRIs Corticosteroids*** ```

What is the first line option of bowel obstruction?

Surgery

What are tx options if bowel obstruction surgery is not an option?

Octreotide and anticholinergics decrease intraluminal secretions and peristaltic movements Corticosteroids decrease edema in the area

When is a patient considered opioid tolerant?

Those who have taken opioids for at least one week

What is the treatment recommendation for opioid-naive patients with moderate to severe pain (4+)?

For acute, severe pain or pain crisis, consider hospital or inpatient hospice admission Start and rapidly titrate short-acting opioid

What is the treatment recommendation for opioid-naive patients with mild pain (1-3)?

Consider non-opioids and adjuvant analgesics first, then short-acting opioids

What is the first step for uncontrolled pain 4+ in opioid naive patients?

Give morphine IR 5-15 mg PO or 2-5 mg IV (or PCA)

What is the second step for uncontrolled pain 4+ in opioid naive patients?

Reassess efficacy and AE in 60 minutes (PO) or 15 minutes (IV)

What do we do if the pain is unchanged or increased in opioid naive patients?

Increase dose by 50-100%

What do we do if the pain is decreased but inadequately controlled in an opioid naive patient?

Repeat same dose

What do we do if the pain is decreased but adequately controlled in an opioid naive patient?

Continue at current effective dose as needed over initial 24 hours

What is the first step for uncontrolled pain 4+ in opioid tolerant patients?

Administer a "rescue" dose (PO or IV) equivalent to 10-20% of total opioid taken in previous 24 hours

What is the subsequent pain management for mild pain?

Reassess and modify regimen to minimize AEs | Taper opioids and other treatments when no longer needed

What is the subsequent pain management for moderate-severe pain?

Re-evaluate opioid titrate and diagnosis if needed Consider pain specialty consultation Consider opioid rotation if dose limiting AE occur Consider adding/adjusting adjuvant analgesics

When should a long acting opioid be started?

After stabilized on short-acting opioids

How are long-acting opioids dosed?

q12h (some q8h)

If a patient has adequate analgesia and intolerable AEs, how do we adjust the medication?

Reduce dose by 10-25%

If a patient is well controlled with stable disease and never needs breakthrough medications, completion of acute pain event, or improvement of pain control with non-opioids, how do we adjust the dose?

Reduce dose by 10-20%

What is the dose of breakthrough pain?

10% TDD

What is Breakthrough pain?

Pain that fails to be controlled by regularly scheduled opioids

How frequently can short-acting pain medications be dosed?

Combination - 4-6 hours | Pure opioids - as short as every 1 hour, but usually every 4-6 hours

If a patient is opioid-tolerant, how do we increase dosages?

Increase both scheduled and PRN opioids

How do we prophylax for constipation?

Stimulant laxative +/- stool softener (senna-s) Propylene glycol twice daily Adequate fluid intake if possible

How do we treat constipation if it develops?

Titrate bowel regimen to produce 1 non-forced BM every 1-2 days Consider adding Mg-based products, bisacodyl, lactulose, sorbitol

If there is no adequate response to constipation treatment, what is the next therapy option?

Methylnaltrexone | Naloxegol

Why do methylnaltrexone and naloxegol not affected opioid analgesic effects?

Do not cross BBB

What are other second line agents for constipation?

Injectable methylnaltrexone (Relistor) Lubiprostone Linaclotide

What are the options for pain relief that is inadequate but sedation is interfering with dose titration?

Decrease opioid dose if possible Add non-opioid analgesic to reduce opioid dose Use a lower dose of opioid more frequently to reduce peak concentration

What are options to tx sedation?

Methylphenidate Dextroamphetamine Modafinil Caffeine

How do we adjust opioid doses in delirium?

Lowering dose or changing to a different opioid

How do we treat delirium d/t opioids?

Haloperidol Olanzapine Risperidone

What do we do if the patient has nausea?

Ensure patient is having bowel movements | Should resolve with continued opioid exposure

What are prophylaxis/treatments for nausea?

``` Metoclopramide Prochlopramide Haloperidol Olanzapine Serotonin antagonists are options but may cause constipation Opioid rotations ```

How do we treat respiratory depression?

Cautiously administer naloxone

How do we treat pruritus?

Antihistamines | Change to another opioid

What is the last line for pruritus?

Small doses of a mixed agonist-antagonist (nalbuphine) as needed or continuous infusion of naloxone

When does palliative care begin?

At diagnosis

When are patients placed in hospice?

Less than 6 months prognosis

How do we determine d/cing medications?

Determine utility of medication - How would the patient benefit from this medication - Remaining life expectancy vs time until benefit of drug is seen - Consider goals of care when analyzing medication utility

Can morphine be used to treat dyspnea?

Yes

How do we treat increased secretions?

Atropine eye drops administered SL Scopolamine patch Glycopyrrolate

What is chronic non-malignant pain?

Pain lasting longer than 3 months or beyond the expected period of healing of tissue pathology

What is the pathophysiology of chronic non-malignant pain?

Damage to the peripheral or CNS