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Bone Pain: A Practical Approach to Management Dr Rowan Hearn, Consultant in Palliative Medicine University College London Hospital 2 3 4 5 The patient with myeloma Challenging patients, challenging pain • Age • Co-morbidities • Multiple causes of pain • Cancer pain vs chronic pain • Setting realistic expectations 6 Assessing pain The (very, very) basics…. • • • • • • • • • 7 Site Radiation Onset Time intensity Character Severity Aggravating factors Relieving factors Associated factors Assessing pain 0-10 pain score • • • • • 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 8 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 9 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 10 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 11 Which opioid? 12 13 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 14 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.” 15 Beware….. • Rapidly absorbed fentanyl • Constipation • Sedation • Nausea • Hypogonadic hypogonadism! 16 Take home points • One size does not fit all • • • • • 17 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 18 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/ 19