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Bone Pain: A Practical Approach to Management

Bone Pain: A Practical Approach to Management. Dr Rowan Hearn, Consultant in Palliative Medicine University College London Hospital. The patient with myeloma. Challenging patients, challenging pain. Age Co-morbidities Multiple causes of pain Cancer pain vs chronic pain

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Bone Pain: A Practical Approach to Management

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  1. Bone Pain: A Practical Approach to Management • Dr Rowan Hearn, Consultant in Palliative Medicine • University College London Hospital

  2. The patient with myeloma • Challenging patients, challenging pain • Age • Co-morbidities • Multiple causes of pain • Cancer pain vs chronic pain • Setting realistic expectations

  3. Assessing pain • The (very, very) basics…. • Site • Radiation • Onset • Time intensity • Character • Severity • Aggravating factors • Relieving factors • Associated factors

  4. 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

  5. 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

  6. 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

  7. 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

  8. Which opioid?

  9. Weak opioids • Daily oral equivalent • Codeine • 15-60mg 6 hourly 24mg morphine • Tramadol • 50-100mg 6 hourly 20-40mg morphine • 12 hourly and 24 hourly preparations • Buprenorphine • 5-20mcg/hr 7 days BuTrans 10-55mg morphine • 35-70mcg/hr 3 days Hapoctasin 75-190mg morphine • 35-70mcg/hr 4 days Transtec 75-190mg morphine

  10. 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.”

  11. Beware….. • Rapidly absorbed fentanyl • Constipation • Sedation • Nausea • Hypogonadichypogonadism!

  12. Take home points • One size does not fit all • 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

  13. 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-is-not-one-size-fits-all • Picture accessed 12/3/16: http://www.practicalpainmanagement.com/treatments/interventional/injections/perioperative-pain-plan-why-it-needed • Picture accessed 12/3/16:http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hematology-oncology/cancer-pain/

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