Cancer Pain Juliana Howes RN, BNSc, MN Clinical Nurse Specialist, Palliative Care.

Cancer Pain

Juliana Howes RN, BNSc, MN

Clinical Nurse Specialist, Palliative Care

OutlineOutline

Examine classifications of cancer painExamine classifications of cancer pain Barriers to pain managementBarriers to pain management Tolerance, Dependence, AddictionTolerance, Dependence, Addiction Pain AssessmentPain Assessment

– Tools (ESAS)Tools (ESAS)– Special PopulationsSpecial Populations

Common MedicationsCommon Medications– Opioids, Non-Opioids & AdjuvantsOpioids, Non-Opioids & Adjuvants

Outline Cont.Outline Cont.

Treatments to reduce painTreatments to reduce pain– Radiation Therapy & ChemotherapyRadiation Therapy & Chemotherapy

Guidelines for Use of OpioidsGuidelines for Use of Opioids Managing common side effectsManaging common side effects

– Constipation, dry mouth, N&V, sedationConstipation, dry mouth, N&V, sedation Case StudiesCase Studies

Definition of PainDefinition of Pain ““an unpleasant sensory and emotional an unpleasant sensory and emotional

experience associated with actual or experience associated with actual or potential damage, or described in terms of potential damage, or described in terms of such damage”such damage”

(IASP, 1979)(IASP, 1979)

““whatever the experiencing person says it whatever the experiencing person says it is, existing whenever the experiencing is, existing whenever the experiencing person says it does”person says it does”

(McCaffrey (McCaffrey & Pasero, 1999)& Pasero, 1999)

Cancer PainCancer Pain

35% experience pain at diagnosis35% experience pain at diagnosis 74% in advanced cancer (40-50% 74% in advanced cancer (40-50%

moderate to severe pain)moderate to severe pain) 85% at end of life85% at end of life

Cancer pain CAN be managed safely Cancer pain CAN be managed safely & effectively & effectively

Despite available options, up to 70% Despite available options, up to 70% do not experience adequate reliefdo not experience adequate relief

Total Pain Total Pain

Classification of PainClassification of Pain

Duration:Duration: Quality:Quality:

* Acute* Acute * Nociceptive* Nociceptive* Chronic * Chronic - Visceral- Visceral

* Breakthrough* Breakthrough - Somatic- Somatic

* Incident* Incident * Neuropathic* Neuropathic

NociceptiveNociceptive

Direct stimulation of afferent nerves Direct stimulation of afferent nerves in skin, soft tissue, viscerain skin, soft tissue, viscera

Nociceptive: SomaticNociceptive: Somatic

Skin, joints, muscle, bone, connective Skin, joints, muscle, bone, connective tissuetissue

Well localized Well localized Deep - aching, throbbingDeep - aching, throbbing Surface – sharpSurface – sharp Often worse with movementOften worse with movement May be tender on palpationMay be tender on palpation i.e. surgical incisions, bone metsi.e. surgical incisions, bone mets

Nociceptive: VisceralNociceptive: Visceral

Visceral organs Visceral organs Poorly localizedPoorly localized Gnawing, deep, pressure, stretching, Gnawing, deep, pressure, stretching,

squeezing, crampingsqueezing, cramping Referred pain (i.e. left arm with MI, Referred pain (i.e. left arm with MI,

epigastric and back with pancreatic)epigastric and back with pancreatic) i.e. bowel obstruction, liver metsi.e. bowel obstruction, liver mets

NeuropathicNeuropathic

Abnormal processing of sensory Abnormal processing of sensory input due to nerve damage/changesinput due to nerve damage/changes

Allodynia:Allodynia: pain from stimulus that does not pain from stimulus that does not normally provoke painnormally provoke pain

Hyperalgesia:Hyperalgesia: increased response to painful increased response to painful stimulistimuli

Burning, stabbing, itching, numbing, Burning, stabbing, itching, numbing, shooting, tingling, electrifyingshooting, tingling, electrifying

i.e. brachial plexopathy, cord compressioni.e. brachial plexopathy, cord compression

Barriers to Pain ManagementBarriers to Pain Management

Health Care ProfessionalsHealth Care Professionals– Lack of knowledgeLack of knowledge– Lack of assessmentLack of assessment– Concern abut side effectsConcern abut side effects– Concern about tolerance and addictionConcern about tolerance and addiction

Health Care SystemHealth Care System– Not a priority, issues with availabilityNot a priority, issues with availability

PatientsPatients– Fear (condition worsening, addiction)Fear (condition worsening, addiction)– Not wanting to burden HCPsNot wanting to burden HCPs

AddictionAddiction

Chronic neurobiological disease with Chronic neurobiological disease with genetic, psychosocial and genetic, psychosocial and environmental factorsenvironmental factors

3 C’s3 C’s– Impaired Control over drug useImpaired Control over drug use– Craving/Compulsive useCraving/Compulsive use– Continued use despite consequencesContinued use despite consequences

DependenceDependence

State of adaptation manifested by State of adaptation manifested by withdrawal syndrome fromwithdrawal syndrome from– Abrupt cessationAbrupt cessation– Rapid dose reductionRapid dose reduction– Administration of Administration of

an antagonistan antagonist

ToleranceTolerance

State of adaptation where exposure State of adaptation where exposure to drug causes decrease in its effect to drug causes decrease in its effect over timeover time

PseudosPseudos

Pseudo addictionPseudo addiction– Mistaken assumption of addiction in Mistaken assumption of addiction in

patient seeking relief from painpatient seeking relief from pain Pseudo tolerancePseudo tolerance

– Misconception that need for increasing Misconception that need for increasing dose is due to tolerance rather than dose is due to tolerance rather than disease progressiondisease progression

Assessment - ESASAssessment - ESAS

Initial and routine assessment of pain Initial and routine assessment of pain & other symptoms& other symptoms

Body diagram to show location of Body diagram to show location of painpain

Assessment – Nonverbal or Assessment – Nonverbal or Cognitively Impaired PatientsCognitively Impaired Patients

Gold Standard is self-reportGold Standard is self-report High potential for unrelieved & High potential for unrelieved &

unrecognized painunrecognized pain Non-verbal CuesNon-verbal Cues

– Facial ExpressionsFacial Expressions– Body MovementsBody Movements– Protective MechanismsProtective Mechanisms– VerbalizationsVerbalizations– VocalizationsVocalizations

Family observations/perceptionsFamily observations/perceptions

Commonly Used OpioidsCommonly Used Opioids

MorphineMorphine HydromorphoneHydromorphone CodeineCodeine OxycodoneOxycodone FentanylFentanyl

MorphineMorphine

Moderate to severe painModerate to severe pain Gold Standard - affordable & Gold Standard - affordable &

availableavailable Measure for dose equivalenceMeasure for dose equivalence Active metabolites – toxicity in Active metabolites – toxicity in

elderly & renal impairmentelderly & renal impairment Oral (IR/CR/Elixir), Parenteral, Rectal, Oral (IR/CR/Elixir), Parenteral, Rectal,

IntraspinalIntraspinal

HydromorphoneHydromorphone

5x more potent than morphine5x more potent than morphine Oral (IR/CR/Elixir), Parental, Rectal, Oral (IR/CR/Elixir), Parental, Rectal,

IntraspinalIntraspinal Better tolerated in elderlyBetter tolerated in elderly

CodeineCodeine

Mild to moderate painMild to moderate pain 10x weaker than morphine10x weaker than morphine Usually in combination with TylenolUsually in combination with Tylenol Ceiling effect at 600mg/24 hrs, max Ceiling effect at 600mg/24 hrs, max

360mg/d if Tylenol #3360mg/d if Tylenol #3 Metabolized into active form (morphine) Metabolized into active form (morphine)

by liverby liver Up to 10% of population unable to convert Up to 10% of population unable to convert

to active form – no pain reliefto active form – no pain relief Oral (IR/Elixir), ParenteralOral (IR/Elixir), Parenteral

OxycodoneOxycodone

1.5-2x more potent than morphine1.5-2x more potent than morphine Oral (IR/CR)Oral (IR/CR) Often combined with Tylenol Often combined with Tylenol

(Percocet)(Percocet) ?more issues with addiction?more issues with addiction

Fentanyl Fentanyl

Not for opioid naïve patientsNot for opioid naïve patients Difficult to convert as 25 mcg patch Difficult to convert as 25 mcg patch

= 45-135 mg PO morphine= 45-135 mg PO morphine

*Tip: Duragesic 25mcg/hr patch = *Tip: Duragesic 25mcg/hr patch = Morphine 25 mg SC/24hrsMorphine 25 mg SC/24hrs

Patch difficult to titrate as it takes Patch difficult to titrate as it takes 12-24 hours to see effect of change12-24 hours to see effect of change

Transdermal, Sublingual, ParenteralTransdermal, Sublingual, Parenteral

Non-OpioidsNon-Opioids

Mild to moderate painMild to moderate pain Inflammation, Bony painInflammation, Bony pain Used as adjuvant with opioidsUsed as adjuvant with opioids Acetaminophen: Acetaminophen: max 4g/d, 3 g/d in frail max 4g/d, 3 g/d in frail

elderly, Liver toxicityelderly, Liver toxicity NSAIDs: NSAIDs: inhibit synthesis of prostaglandins inhibit synthesis of prostaglandins

preventing contribution to sensitization of preventing contribution to sensitization of nociceptorsnociceptors– i.e. Ibuprofen, Naproxen, COX2 (celebrex)i.e. Ibuprofen, Naproxen, COX2 (celebrex)– Adverse effects: GI bleed, increased BP, decreased renal Adverse effects: GI bleed, increased BP, decreased renal

function, impaired platelet functionfunction, impaired platelet function

AdjuvantsAdjuvants

AntidepressantsAntidepressants AnticonvulsantsAnticonvulsants CorticosteroidsCorticosteroids Local AnestheticsLocal Anesthetics Anticancer therapiesAnticancer therapies

AntidepressantsAntidepressants

TCAs i.e. amitriptyline, nortriptyline TCAs i.e. amitriptyline, nortriptyline for neuropathic (burning) painfor neuropathic (burning) pain

Anticholinergic effects – sedation, Anticholinergic effects – sedation, constipation, dry mouthconstipation, dry mouth

Start low and titrate as needed q2-3 Start low and titrate as needed q2-3 daysdays

AnticonvulsantsAnticonvulsants

Neuropathic (shooting) painNeuropathic (shooting) pain i.e. Gabapentin – start at 100mg TID i.e. Gabapentin – start at 100mg TID

or 300mg OD and titrate up to or 300mg OD and titrate up to 3600mg/day3600mg/day

Decreased dose in elderly/renal Decreased dose in elderly/renal impairmentimpairment

Side effects can include sedation & Side effects can include sedation & dizzinessdizziness

CorticosteroidsCorticosteroids

Pain due to spinal cord compression, Pain due to spinal cord compression, headache due to increased ICP, bone headache due to increased ICP, bone metsmets

Can be used to stimulate appetiteCan be used to stimulate appetite i.e. Decadron 4mg to 16mg/dayi.e. Decadron 4mg to 16mg/day Side effects include hyperglycemia, Side effects include hyperglycemia,

psychosis, insomniapsychosis, insomnia

Anticancer TherapyAnticancer Therapy

Palliative Radiation: bone pain, Palliative Radiation: bone pain, reduce tumour size to decrease pain reduce tumour size to decrease pain (i.e. chest pain in lung ca) (i.e. chest pain in lung ca)

Palliative Chemotherapy: reduce Palliative Chemotherapy: reduce tumour size if adequate tumour size if adequate

performance status and performance status and

not significant impact not significant impact

on QOLon QOL

Guidelines for UseGuidelines for Use Constant or frequent pain requires regular Constant or frequent pain requires regular

medicationmedication– Oral route preferredOral route preferred– Start with IR to allow for titrationStart with IR to allow for titration– Use opioid with best analgesia and fewest side effectsUse opioid with best analgesia and fewest side effects

A breakthrough dose should be available as A breakthrough dose should be available as neededneeded– 10% of daily total or 50% of q4h dose10% of daily total or 50% of q4h dose– CMAX: PO 1h, SC 20-30 min, IV 5-10 min CMAX: PO 1h, SC 20-30 min, IV 5-10 min

Treat opioid side effects from the startTreat opioid side effects from the start– Regular laxative order, PRN antiemeticRegular laxative order, PRN antiemetic

Adjuvants are often essential for adequate pain Adjuvants are often essential for adequate pain controlcontrol

Guidelines Cont.Guidelines Cont.

Is patient opioid naïve?Is patient opioid naïve?– Opioid still required if moderate to severe pain, Opioid still required if moderate to severe pain,

start low and titrate start low and titrate Choose route of administrationChoose route of administration

– Ability to swallow, absorption, compliance, pt. Ability to swallow, absorption, compliance, pt. preferencepreference

Determine dosing scheduleDetermine dosing schedule– IR q4h with BT doses q1h until reliefIR q4h with BT doses q1h until relief– Based on BT usage, titrate upBased on BT usage, titrate up– When adequate dosage found, can switch to When adequate dosage found, can switch to

long acting medicationlong acting medication

Titration Titration

If requiring more than 3-4 If requiring more than 3-4 breakthrough in 24 hours:breakthrough in 24 hours:– Look at pattern and reassess painLook at pattern and reassess pain– Increase q4h dose and BT accordinglyIncrease q4h dose and BT accordingly

Add BTs to q4h dose or increase by Add BTs to q4h dose or increase by 1/3 1/3

i.e. Morphine 5mg PO q4h and 2.5mg PO i.e. Morphine 5mg PO q4h and 2.5mg PO q1h, pt used 6 BTs = 15mgq1h, pt used 6 BTs = 15mg

30mg + 15mg = 45mg /6 doses30mg + 15mg = 45mg /6 dosesNew dose would be 7.5 mg PO q4hNew dose would be 7.5 mg PO q4h

ConvertingConverting

Once stabilized, can switch to long acting Once stabilized, can switch to long acting BIDBID– Take total daily dose and divide for BIDTake total daily dose and divide for BID– i.e. Morphine 10mg PO q4h = MS Contin 30 mg i.e. Morphine 10mg PO q4h = MS Contin 30 mg

PO q12hPO q12h If switching to a new opioid, need to If switching to a new opioid, need to

consider incomplete cross-toleranceconsider incomplete cross-tolerance– Tolerance to new opioid may be less and so Tolerance to new opioid may be less and so

can achieve pain relief with lower dosecan achieve pain relief with lower dose– Thus need to reduce dose of new opioid by 25-Thus need to reduce dose of new opioid by 25-

50% (usu. cut by ~ 1/3)50% (usu. cut by ~ 1/3)

PumpsPumps

Allows for self-administration of Allows for self-administration of parenteral BTsparenteral BTs

More consistent dosing as continuousMore consistent dosing as continuous CADD pump CADD pump

Equianalgesic TableEquianalgesic TablePOPO SC/IVSC/IV

CodeineCodeine 100mg100mg ------

MorphineMorphine 10mg10mg 5mg5mg

OxycodoneOxycodone 5mg5mg ------

HydromorphoneHydromorphone 2mg2mg 1mg1mg

Using the TableUsing the Table

Convert Percocet 2 tab PO q4h to MorphineConvert Percocet 2 tab PO q4h to Morphine

(1 Percocet = Oxycodone 5mg + Tylenol 325mg)(1 Percocet = Oxycodone 5mg + Tylenol 325mg)

Oxycodone 10mg x 6 doses = 60mgOxycodone 10mg x 6 doses = 60mg

From Table Oxydone 5mg = Morphine 10mgFrom Table Oxydone 5mg = Morphine 10mg

Thus, Oxycodone 60mg = Morphine 120mg Thus, Oxycodone 60mg = Morphine 120mg

This would be Morphine 20mg PO q4h, but consider This would be Morphine 20mg PO q4h, but consider incomplete cross-tolerance incomplete cross-tolerance

Therefore, Morphine 15mg PO q4h with 7.5mg q1h PRNTherefore, Morphine 15mg PO q4h with 7.5mg q1h PRN

SuggestionsSuggestions

Initial dosage of strong opioid in opioid Initial dosage of strong opioid in opioid naïve patientnaïve patient

Fit: Morphine 5-10mg PO q4h or equivalentFit: Morphine 5-10mg PO q4h or equivalent Frail: Morphine 2.5-5mg PO q4h or equivalentFrail: Morphine 2.5-5mg PO q4h or equivalent

Dosage of strong opioid in patients already Dosage of strong opioid in patients already on opioidson opioids

If on weak opioid (i.e. Tylenol #3), not opioid naïve!If on weak opioid (i.e. Tylenol #3), not opioid naïve! Determine starting dose by using equianalgesic tableDetermine starting dose by using equianalgesic table

Side Effects of OpioidsSide Effects of Opioids

Common: constipation, dry mouth, Common: constipation, dry mouth, nausea, vomiting, sedationnausea, vomiting, sedation

Less Common: confusion, pruritis, Less Common: confusion, pruritis, myoclonus, hallucinations, urinary myoclonus, hallucinations, urinary retentionretention

Rare: respiratory Rare: respiratory

depressiondepression

ConstipationConstipation

Opioids inhibit peristalsis and Opioids inhibit peristalsis and increase re-absorption of fluids in the increase re-absorption of fluids in the lining of the gutlining of the gut

Standing order if on opioidsStanding order if on opioids– Senokot 1-6 tab BID Senokot 1-6 tab BID + + Stool softener Stool softener – Lactulose 15-45 cc OD to TIDLactulose 15-45 cc OD to TID

Sedation and N&VSedation and N&V

Commonly experienced in first few days of Commonly experienced in first few days of taking opioids or after increasing dosetaking opioids or after increasing dose

Body will adjust and these symptoms will Body will adjust and these symptoms will improveimprove

Minimize other meds that contribute to Minimize other meds that contribute to drowsiness (i.e. Benzodiazepines)drowsiness (i.e. Benzodiazepines)

PRN anti-emetic (i.e. haldol 1mg PO/SC/IV, PRN anti-emetic (i.e. haldol 1mg PO/SC/IV, stemetil 10mg PO/IV/PR, maxeran 10 mg stemetil 10mg PO/IV/PR, maxeran 10 mg QID)QID)

Dry MouthDry Mouth

Difficult to avoidDifficult to avoid Strategies to minimize include:Strategies to minimize include:

Frequent mouthcareFrequent mouthcareFluids/Ice ChipsFluids/Ice ChipsSugarless gumsSugarless gumsArtificial saliva Artificial saliva

(i.e. Moi-Stir)(i.e. Moi-Stir)

SummarySummary

Pain Orders should include:Pain Orders should include:

1.1. Regular AnalgesicRegular Analgesic

2.2. PRN AnalgesicPRN Analgesic

3.3. Standing LaxativeStanding Laxative

4.4. PRN Anti-emeticPRN Anti-emetic Treat side effects from the beginningTreat side effects from the beginning Consider type of pain & use adjuvantsConsider type of pain & use adjuvants Ongoing re-evaluationOngoing re-evaluation

Case Study #1Case Study #1

Mr.R, 46 yrs, met. lung ca., currently Mr.R, 46 yrs, met. lung ca., currently taking Tylenol #3 2 tab q4h and taking Tylenol #3 2 tab q4h and using 9 extra tablets/day for using 9 extra tablets/day for breakthrough. He has no difficulty breakthrough. He has no difficulty swallowing the Tylenol #3.swallowing the Tylenol #3.

What is the problem with this What is the problem with this amount of Tylenol #3?amount of Tylenol #3?

What are your recommendations? What are your recommendations? Calculate and provide new ordersCalculate and provide new orders

Case Study #1 Cont.Case Study #1 Cont.

After titrating his medication, Mr.R was After titrating his medication, Mr.R was comfortable for a time. However, he has comfortable for a time. However, he has begun to complain of right arm weakness begun to complain of right arm weakness and shoulder pain causing shooting pain and shoulder pain causing shooting pain down his arm.down his arm.

What type of pain do you suspect he is What type of pain do you suspect he is experiencing?experiencing?

What medication and dose would you What medication and dose would you recommend?recommend?

Case Study #2Case Study #2

Ms.Q, 63 yr old, met. breast ca., has been Ms.Q, 63 yr old, met. breast ca., has been taking MS Contin 30mg q12h and has taking MS Contin 30mg q12h and has morphine 5mg tablets available for BT. morphine 5mg tablets available for BT. She is using about 4 tab/day, but still She is using about 4 tab/day, but still having uncontrolled painhaving uncontrolled pain

Main pain to low back that radiates along Main pain to low back that radiates along the left side, an MRI confirms bone met to the left side, an MRI confirms bone met to L4 (no cord compression)L4 (no cord compression)

Case Study #2Case Study #2

What changes would you make to What changes would you make to her pain medication?her pain medication?

What other treatments might be What other treatments might be considered?considered?

Ms.Q’s condition deteriorates and Ms.Q’s condition deteriorates and she is no longer able to swallow her she is no longer able to swallow her medications – What would be the medications – What would be the SC/IV dose?SC/IV dose?