Download Bone Pain: A Practical Approach to Management — Dr

Bone Pain: A Practical Approach to
Management
Dr Rowan Hearn, Consultant in Palliative Medicine
University College London Hospital
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The patient with myeloma
Challenging patients, challenging pain
• Age
• Co-morbidities
• Multiple causes of pain
• Cancer pain vs chronic pain
• Setting realistic expectations
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Assessing pain
The (very, very) basics….
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Site
Radiation
Onset
Time intensity
Character
Severity
Aggravating factors
Relieving factors
Associated factors
Assessing pain
0-10 pain score
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What does it mean?
“My 2 is your 10”
What’s a good reduction?
What is acceptable?
What are we measuring?
• Functional ability
• Other scoring systems
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Management options
• Bisphosphonates, radiotherapy and balloon kyphoplasty/vertebroplasty
• Pharmacological options
• Paracetamol
• Opioids
• Calcium channel modulators (gabapentin, pregabalin)
• (NSAIDs)
• Non-Pharmacological options
• Exercise
• Psychological support
• Complimentary therapies
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Opioids: Counsel, titrate, negotiate
• “I don't want to become addicted to it”
• “I might overdose if take too much”
• Drug driving legislation, March 2015
• Morphine, codeine, diamorphine, benzodiazepines
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Opioids: Counsel, titrate, negotiate
• Low and slow!
• Rapid escalation of pain = rapid escalation of analgesia!
• How much pain is acceptable?
• Follow-up and side effects
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Which opioid?
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Weak opioids
Daily oral equivalent
Codeine
15-60mg
6 hourly
24mg morphine
Tramadol
50-100mg
6 hourly
12 hourly and 24 hourly preparations
Buprenorphine
5-20mcg/hr
35-70mcg/hr
35-70mcg/hr
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7 days
3 days
4 days
BuTrans
Hapoctasin
Transtec
20-40mg morphine
10-55mg morphine
75-190mg morphine
75-190mg morphine
Strong opioids
Morphine
2.5-5mg
4 hourly
Oramorph liquid
Oxycodone (twice as strong as morphine)
1-2.5mg
4 hourly
Oxynorm liquid
Fentanyl patches
12mcg/hr = 35-70mg oral morphine
Pain management plan:
“Take one dose and wait one hour.
If still in pain, take a second dose and wait another hour.
If still in pain, take a third dose and wait another hour.
If still in pain, call for advice.”
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Beware…..
• Rapidly absorbed fentanyl
• Constipation
• Sedation
• Nausea
• Hypogonadic hypogonadism!
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Take home points
• One size does not fit all
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Decide on a standard assessment for pain in your service
Assess functional ability as well as a pain score
Set realistic expectations of pain relief
Opioid selection is individual, based on science
Consider endocrine suppression as a cause of fatigue
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References
Snowden J, Ahmedzai S, et al, “Guidelines for supportive care in multiple myeloma”, British Journal of
Haematology, (Blackell Publishing Ltd, 2011, 154;76-103)
Picture accessed 11/3/16: http://www.rmgnetworks.com/blog/bid/365859/Internal-communications-isnot-one-size-fits-all
Picture accessed 12/3/16:
http://www.practicalpainmanagement.com/treatments/interventional/injections/perioperative-pain-planwhy-it-needed
Picture accessed
12/3/16:http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hematologyoncology/cancer-pain/
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