Flashcards in Chronic Malignant and Non-Malignant Pain Deck (72):
What is the definition of chronic malignant pain?
Pain associated with potentially life-threatening conditions
What are the causes of cancer pain?
Pain associated with tumor or metastasis
Pain associated with treatment
Pain unrelated to either
What are the types of cancer pain?
Nociceptive (surgical procedures, tumor, bone metastasis)
Neuropathic (chemotherapy, radiation therapy, surgical injury to nerves, tumor/metastasis-related
What are complications from chronic malignant pain?
What are medication options for chronic malignant pain?
What types of medications are most commonly used in cancer pain?
Pure agonists (morphine, oxycodone, hydromorphone, and fentanyl)
Which opioid is considered the standard starting drug of choice in opioid naive patients?
How is morphine eliminated?
When is fentanyl used in cancer pain?
Transdermal patches when opioid tolerant patients are in need of around the clock pain relief
Which routes of fentanyl are used for breakthrough pain in opioid tolerant patients?
How is hydrocodone used in cancer pain?
Limited to mild, initial use
Which medication can be used for cancer pain in morphine intolerant patients?
How can methadone be initiated?
How does tramadol compare to morphine?
1/10 potency of morphine
Higher doses lead to increased AEs
What do adjuvant analgesics treat?
What is the cause of bone pain?
Tumor metastasis to bone
What are tx options for bone pain?
For what conditions are corticosteroids used?
Compression of neural structures
HA d/t increased intracranial pressure
Metastatic spinal cord compression
What are positive SE of corticosteroid use?
Improve appetite, nausea and malaise
Which corticosteroid is commonly used and why?
Dexamethasone, low mineralcorticoid effects
What is the MOa of bisphosphonates?
Inhibit osteoclast activity
Reduce bone resorption
Reduce tumor associated osteolysis
Delayed skeletal events
Which bisphosphonates are administered IV?
What are AEs associated with bisphosphonates?
Flu like reaction (treated with APAP)
Impaired renal function
Osteonecrosis of the jaw (IV)
When should bisphosphonates be avoided?
CrCl < 30
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?
Osteonecrosis of the jaw
What agent can be used for bone pain if all others fail?
Where are radioisotopes absorbed?
Areas of high bone turnover
What are the causes of neuropathic pain?
What are the pharmacologic options for neuropathic pain?
What is the first line option of bowel obstruction?
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?
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?
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)
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?
How do we adjust opioid doses in delirium?
Lowering dose or changing to a different opioid
How do we treat delirium d/t opioids?
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?
Serotonin antagonists are options but may cause constipation
How do we treat respiratory depression?
Cautiously administer naloxone
How do we treat pruritus?
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?
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?
How do we treat increased secretions?
Atropine eye drops administered SL
What is chronic non-malignant pain?
Pain lasting longer than 3 months or beyond the expected period of healing of tissue pathology