CANCER PAIN

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CANCER PAIN

• Kathy Coulson, RN, MScN, ACNP, CHPCN(C)
• Advanced Practice Nurse Palliative Care

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PALLIATIVE CARE
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PAIN

• Pain is whatever the experiencing person says it
  is, existing whenever he/she says it does
• M. McCaffery, R.N., M.S., F.A.A.N.

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TOTAL PAIN

• Visible Pain
• Hidden Pain

EMOTIONAL SPIRITUAL SOCIAL SUFFERING
PHYSICAL
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CANCER PAIN

• VISCERAL
• SOMATIC
• NEUROPATHIC

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CANCER PAIN

• Visceral poorly localized, stretching, deep
  aching, distention, cramping
• examples liver capsule pain
• bowel obstruction

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CANCER PAIN

• Somatic localized, throbbing, aching
• example bone pain (metastasis)

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CANCER PAIN

• Neuropathic burning, shooting, stabbing,
  numbness, tingling
• examples nerve damage
• cord compression

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VISCERAL PAIN

• PHARMACOLOGIC
• opioids
• anti-spasmodics (baclofen, Buscopan)
• dexamethasone

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BONE PAIN

• PHARMACOLOGIC
• NSAIDs
• opioids
• bisphosphonates
• calcitonin
• chemotherapy
• dexamethasone

• OTHER MODALITIES
• radiotherapy
• splints/braces
• surgical fixation
• positioning /- support surfaces

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NEUROPATHIC PAIN

• PHARMACOLOGIC
• TCA (amytriptilline)
• anticonvulsants (valproic acid, carbamazepine,
  gabapentin)
• dexamethasone
• opioids

• OTHER MODALITIES
• acupuncture
• nerve blocks (intercostal, celiac plexus)
• TENS

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PAIN ASSESSMENT

• Onset and pattern
• Location
• Description (in pts own words)
• Intensity (use pain score 0-10, validated pain
  assessment tools)
• Aggravating Factors
• Previous Treatment
• Effect

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MANAGEMENT

• By the mouth
• By the clock
• By the ladder

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W.H.O. LADDER

• STEP 3
• STEP 2
• STEP 1

Strong Opioids /- adjuvant
Weak Opioids /- adjuvant
Non -Opioids /- adjuvant
WHO Analgesic Ladder , 1990
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W.H.O. LADDER
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CHOOSING AN OPIOID

• Strength depends on severity of pain
• DO NOT initiate patients on long acting
  preparations (MS Contin, M Eslon, Hydromorph
  Contin) or the fentanyl patch (Duragesic)
  until opioid requirements have been determined
  

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INITIATING OPIOIDS

• regular dosing is essential
• 5 to 10 mg of po morphine q4h (or equivalent)
  starting dose, less in elderly or renal/liver
  impairment
• breakthrough doses of same agent available q2h
  (10 of total 24 hour dose)

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MONITORING EFFICACY

• Use of 3 or more prns in 24 hours indicates need
  to reassess and possible increase regular dose
• to titrate dose, calculate total mgs used in 24
  hours and divide by number of doses in a day

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ANTICIPATE SIDE EFFECTS

• constipation - permanent
• drowsiness - transient
• nausea/vomiting - transient
• delirium - especially in elderly, or patients
  with liver/renal impairment

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CHANGING OPIOIDS

• Some Indications
• change in pain severity
• intolerable side effects
• alternate method of delivery needed
• opioid toxicity

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OPIOID EQUIVALENCIES
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OPIOID TOXICITY

• decreased level of consciousness (LOC)
• myoclonus
• delirium - fluctuating LOC, impaired
  memory/attention, altered perception
• symptoms correspond with increase in dose or
  decreased need for medication

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• Patient Management
• pain
• reassess
  listen/believe
• Quality of
  assess
• life
  
• 
  involve
• establish
• management

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CASE STUDY

• Mr. P. G.
• 72 year old man recently admitted to hospital for
  investigation of a lung mass noted on CXR,
  suggestive of ca lung.
• bronchoscopy-confirmed non-small cell ca lung
  with mets to liver, ribs, thoracic spine, and
  brain.
• palliative radiotherapy to ribs for pain
  management.

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CASE STUDY

• Concurrent history includes heart disease, type
  II diabetes, mild chronic renal failure (cr.
  135).
• Discharged home with family, CCAC and community
  nursing.
• To be followed by FD.

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Comment on these orders

• OPIOID ORDERS
• morphine 2.5-5mg PO, IM, SC q3-4h PRN
• using morphine 5mg q3h 5-6/day
• ESAS 5/10 (for pain)

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Telephone Call

• Has mucousy cough,
• Increased rib cage pain
• ESAS 7/10 (for pain)
• Using morphine 5mg q4h PO with 6 breakthrough
  doses in past 24 hours
• Wife indicates he was twitchy as he slept and
  again this morning

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Orders Changed

• OPIOID ORDERS
• Hydromorphone 1 mg q4h PO and 0.5mg PO q2h prn
• Naprosyn 500mg PO bid prn

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Telephone Call

• more comfortable (used b/t twice in past 24
  hours)
• less twitchy
• ESAS 3/10 (for pain)