Pain Management In Cancer Flashcards
General principals for symptom management in oncology?
see Pain and prescribing analgesia LEC on BB
Epidemiology of pain in cancer patients
- 30-40% patients with early disease
- 75-90% with advanced cancer
- 65% dying from non-malignant disease
- 1/3 with >2 different pains
- Pain can be controlled in 80% using stepwise approach
What do you need to include in your pain assessment?
BB LEC:
* the impact of the pain on all areas of the patient’s life
* Their understanding of the pain what does it mean to them?
* Any concerns they may have about treatment of the pain
From ox handbook
* detailed history and examination to understand cause i.e. nervre pain doesnt respond to opiods as well
* severity
* nature
* functional deficit
* psychological state
Pain in advanced disease: nature, cause, how it effects the patient
Example of a pain asessment : what are some possible causes of his pain? (think cancer, iatrogenic, other)
Possible causes for his pain would include:
CANCER related:
* chest wall invasion, bone metastases, MSCC
TREATMENT related:
* oesophagitis, local reaction to RT
OTHER:
* CAP, PE pneumothorax, MI, anxiety, musculoskeletal
AR neuro anatomy of pain pathway
What are some different types of pain?
just names for now
- Nociceptive
* somatic
* visceral - Neuropathic
- Mixed (40%)
- Incident
Define nociceptive pain
Nociceptive pain= normal nervous system, identifiable lesion causing tissue damage.
2 types:
Somatic and Visceral
Somatic pain :
Where does it originate from?
how might it be described?
Origin:
* from skin/muscles/bone
Described as:
* sharp, throbbing, well localised
Visceral pain :
Where does it originate from?
how might it be described?
Origin:
* hollows viscus or solids organ
Described as:
* diffuse ache, hard to localise
Define neuropathic pain
How might it be described?
define:
* malfunctioning nervous system; nerve structure is damaged
Described as:
* stabbing, shooting, burning, stinging, allodynia, numbness, hypersensitivity
What is mixed pain
(about 40% pts get)
mixture of Nociceptive and neuropathic pain
What is incident pain?
Pain due to a certain event such as movement, coughing, dressing change
Using analgesics effecitvely. What 3 classes of pain relief do we have?
What are adjuvant / co-analgesics?
what? who should you use for? benefits? cautions?
- Drugs whose primary indications is not for pain
- Consider for pain that is only partially responsive to opioid analgesia
- Can have a significant opioid sparing effect
- be careful as can have some adverse effects e.g. CNS symptoms
What are some examples of adjuvant / co-analgesics?
- Antidepressants:
amitriptyline, duloxetine - Anti-convulsants;
gabapentin, pregabalin - Benzodiazepines:
diazepam, clonazepam - Steroids:
dexamethasone - Bisphosphonates:
for bony pain
What are some drugs indicated for neuropathic pain?
give examples, doses and some SE (BB LEC)
- Amitriptyline:
dose: start 10-25 mg
SE: confusion, hypotensions, caution in CVS disease - Gabapentin
dose: 300 mg TDS over 3/7 - Pregabablin:
dose: 75 mg BD
SE: sedation, tremor, confusions, dizziness, caution in renal impairment)
How long can it take for analgesics for neuropathic pain to work ?
Full beneift can take at least 5/7
may need to be titrated
WHO analgesic 5 principals for effective pain management :
p532 ox hanbook + BB Lec
- By the mouth—give orally whenever possible.
- By the clock—give at fixed intervals to offer continuous relief.
- By the ladder—following the WHO stepwise approach
- For the individual—there are no standard doses for opioids, needs vary. (inidividual dose titration and use adjuvants at any step)
- Attention to detail—communicate, set times carefully, warn of side-effects
WHO pain ladder
Stage 1 (Non-opioids)
- Paracetamol
- Ibuprofen
- Paracetamol + Ibuprogren
Step 2
- Non-Opioids +
- Weak opioid (dihydrocodeine, codeine phosphate, tramadol, co-codamol)
Stage 3
- Non- opioid +
- Opioid (Oxycodone, morphine, fentanyl, diamorphine)
What are some key points to remember when using the WHO pain ladder to manage a pts pain?
(CLUE: reasons to go up and down, drugs that can be opiate sparing, other drugs to help with SE, adjuvants)
pg 532 in oxford handbook of clinical medicine
- Persisting/increasing pain and side-effects inform the decision to step up and step down. Take one step at a time to achieve pain relief without toxicity (except in new, severe pain when step 2 may be omitted).
- Paracetamol (PO/PR/IV) at step 1 may have an opiate-sparing effect, and should ben continued at steps 2 and 3. Stop step 2 opioids if moving to step 3.
- Use laxatives and anti-emetics with strong opioids.
- Adjuvants which can be added at all steps include: NSAIDS, amitriptyline, pregabalin, corticosteroids, nerve block, transcutaneous electrical nerve stimulation (TENs) radiotherapy
What are examples of non-opiod pain relief?
- Paracetemol
- NSAIDS
- COX-2s
Table from BB LEC:
For each type of pain think of:
1. key features
2. response to opiods
Managing pain:
Bone mets often respond to….?
- NSAIDS
- RT (radiotherapy)
- Surgery
Pain management: Liver pain may improve with…?
drug names from BB LEC
Steroids
NSAIDs
Side effects of strong opiods
Lecture: stepping up from maximum dose codeine to morphine
how much equates to?
TDD?
What generally prescribe?
Options for oral morphine?
opiod dose:
how work out TDD
The SR dose?
The Breakthrough dose?
Titration example
Patient taking oramorph 5mg PRN
need 8 PRNS to achieve pain relief
no side effect
titration : patient taking zomorph 30mg BS but still in pain
Need 3 PRN dose a day of oramorph 10 mg
work out TDD, New BD, and new PRN
Titration : patient taking zomorph 120mg BD, still in pain, needing 3 PRN doses of oramorph 40mg with good effect
what is TDD, new BD dose and new PRN
fentanyl: how use?
how long for steady state?
dose?
syringe driver: pt taking morphine 40 mg / 24 hours
they are ALSO needing 5mg SC PRN x 4/24hours
what is new dose for syringe driver to step up?
