Basic Cancer Pain Management: Case Studies For Medical Students, Medical Residents, and HematologyOn

1
Basic Cancer Pain Management Case StudiesFor
Medical Students, Medical Residents, and
Hematology/Oncology Fellows

• This work was produced by the University of
  Maryland Palliative Care Educational Initiative,
  funded by an R25E grant (R25CA 66940) from the
  National Cancer Institute.

2
Learning Objectives BATS

• BARRIERS
• Recognize patient, healthcare professional, and
  healthcare and legal system-related barriers to
  good pain management
• ASSESSMENT
• Properly assess pain across a broad range of
  patient types and quantify its severity
• Distinguish between pain types nociceptive
  (e.g., bone, visceral, other somatic) and
  neuropathic
• Incorporate the 5th vital sign into patient
  care/treatment plans.
• Define and recognize the opioid pseudoaddiction
  syndrome in pain assessment. For the original
  case report, see Pain 1989 3363-6.
• Recognize opioid abuse and drug-abusive behavior
• TREATMENT
• Institute proper pain management based on the
  severity and type of pain
• Recognize severe somatic nociceptive pain and
  titrate opioid medications appropriately
• Recognize severe nociceptive bone pain and treat
  with opioids and appropriate adjuvant medications
• Recognize neuropathic pain and treat with
  appropriate adjuvant medications.
• Calculate appropriate equianalgesic doses for
  switching from one opioid to another, or
  switching routes of administration
• Prescribe appropriate breakthrough pain
  medications for patients with chronic pain taking
  long acting opioids
• Titrate opioids to control worsening pain caused
  by progressive cancer in a patient already taking
  pain medications
• SIDE EFFECTS
• Recognize, pre-empt or treat opioid side effects
  (e.g., constipation, sedation, respiratory
  depression, nausea, pruritis, delirium,
  myoclonus, urinary retention).

3
Case studies

• Ms. YL is 43-year-old inpatient on day 14 of a
  high-dose, timed-sequential induction regimen for
  AML. Her nurse reports that Ms. YL did not sleep
  at all the previous night, and complained of
  mouth numbness (tingling) and pain. Her pain
  scores have been 6 to 10/10 throughout the night.
  Ms. YL refused the PO or IV PRN pain meds
  offered.
• Ms. YL was born and raised in China, but has
  lived in the U.S. since she was 20 years old.
• On exam, you see evidence of early mucositis.
• She seems reluctant to talk about her mouth and
  discomfort, and attributes her sleepless night to
  things other than pain. She rates her pain only 4
  or 5/10 when you ask her.
• You suggest titration with potent pain
  medications, but the she says she does not need
  pain medications now, and assures you that she
  will be OK. But your overall assessment is that
  she appears to be in considerable discomfort.

Objective Recognize patient, healthcare
professional, and healthcare and legal
system-related barriers to good pain management.
4
Case studies

• A 45-year-old man is admitted for salvage
  chemotherapy for advanced non-small cell lung
  cancer. PRN hydromorphone (Dilaudid), 2 to 4 mg
  Q3h, IV is ordered for pain gt5/10.
• His nurse informs you that he reports pain scores
  of 8/10, and has been requesting this med every
  three hours, yet he appears to be in pain only
  when she enters the room. Surreptitiously, she
  observed the patient laughing, telling jokes with
  visitors in his room.
• She asks if she could try a saline placebo at his
  next pain med request to see if his pain is
  real.
• What should you do?

Objective Recognize patient, healthcare
professional, and healthcare and legal
system-related barriers to good pain management.
5
Case studies

• You are reviewing the case of an inpatient now
  under your care on 9 West. You notice that the
  most recent vital signs are
• Temperature 98.8
• B/P 138/85
• Pulse 92, regular
• Respirations 25
• Pain 6/10.
• What should you do?

Objective Incorporate the 5th vital sign into
patient care/treatment plans.
6
Case studies

• DH is a 28-year-old woman with diffuse large
  B-cell lymphoma and bulky adenopathy receiving
  inpatient chemotherapy. She complained of pain on
  admission, and was prescribed hydromorphone
  (Dilaudid), 2 mg IV, Q6H, PRN pain.
• Her nurse calls you to inform you that he thinks
  the patient is displaying drug seeking
  behavior, and is concerned with opioid addiction
  in this patient. He says the patient seems
  preoccupied with receiving pain meds, and asks
  for more medication as early as one hour after
  receiving a dose of hydromor-phone. Furthermore,
  he says that the patient does not look like she
  is in pain.
• What should you do?

Objective Define and recognize the opioid
pseudoaddiction syndrome in pain assessment.
7
Case studies

• You are assigned to care for a 55 year old man
  who wishes to transfer his care from an
  oncologist in Anne Arundel county for follow-up
  of Burketts lymphoma. He was diagnosed and
  treated 3 years ago, and is currently in
  remission however he had bony involvement that
  left him with chronic pain requiring opioids. He
  brings his medical records, which document his
  diagnosis and treat-ment. Recent CT scans show
  considerable but stable sclerosis in multiple
  bones.
• His current meds include long-acting oxycodone
  (Oxycontin) 40 mg PO, BID, and hydromorphone
  (Dilaudid), 4 mg PO, Q4H PRN. He asks you for
  refills of the pain meds, and you write him for a
  4-week supply.
• Two days later he calls and says that his
  granddaughter wrote on the Dilaudid script, so
  the pharmacist wouldnt accept it, and could he
  have another. You comply, but a week later he is
  asking for another prescription, saying he
  inadvertently threw out the pills.
• What should you do?

Objective Recognize opioid abuse and
drug-abusive behavior .
8
Case studies

• A 17-year-old man with acute leukemia and no
  prior history of drug or alcohol abuse was
  hospitalized with fevers and treatment-induced
  bone-marrow aplasia. Several days into his
  hospital course he began complaining of
  continuous chest-wall pain directly over a new
  pulmonary infiltrate associated with a pulmonary
  friction rub. Intravenous morphine, 5 mg every
  4-6 hours PRN was prescribed for the pain. During
  this time he was also receiving 50 mg of IV
  meperidine PRN to control shaking chills from
  amphoterecin administration. Over the next
  several days he made repeated requests for pain
  medication prior to the 4-6 hour dosing schedule.
  This prompted repeated one-time orders for
  additional IV morphine or meperidine. After 1
  week of continued chest pain he began requesting
  meperidine for relief of chills unrelated to
  fever, amphoterecin or blood product
  administration. He also began to complain of a
  variety of aches and pains for which there was no
  objective pathology, but for which he requested
  additional pain medication. At this point, the
  healthcare team asks for your advice in managing
  this patients opioid addiction.

Objective Define and recognize the opioid
pseudoaddiction syndrome in pain assessment. This
is the original case report (Pain 1989 3363-6)
9
Case studies

• Ms. YL is a 43-year-old inpatient on day 14 of a
  high-dose, timed-sequential induction regimen for
  AML. Her nurse reports that Ms. YL did not sleep
  well last night, complaining of mouth numbness
  (tingling) and pain. The patient had a standing
  order written for morphine, 2-4 mg IV Q4H PRN
  pain. In the past 12 hours, Ms. YL was given a
  total of 12 mg of morphine IV however, she
  experienced relief of pain for only about 2 hours
  after a PRN morphine dose. As a consequence, her
  pain scores have been 6 to 10/10 throughout the
  night. Her current pain score is 9/10. On exam,
  you see evidence of early mucositis. How do you
  manage this patients pain?

Objective Recognize somatic nociceptive pain and
titrate opioid medications appropriately.
10
Case studies

• The pain of a hospitalized patient is well
  controlled on a continuous infusion of morphine
  at 10 mg. per hour. You want to convert to an
  equianalgesic oral regimen of hydromorphone
  (Dilaudid) for home use. What is the q4h dose of
  hydromorphone (Dilaudid) that you would
  prescribe, PO?

Objective Calculate appropriate equianalgesic
doses for switching from one opioid to another,
or switching routes of administration.
11
Case studies

• A patient is taking oral hydromorphone (Dilaudid)
  8 mg Q4H. Recent events require you to switch to
  a parenteral morphine infusion. What is the
  equianalgesic IV dose of morphine sulfate per
  hour?

Objective Calculate appropriate equianalgesic
doses for switching from one opioid to another,
or switching routes of administration .
12
Case studies

• Mr. AZ is a 68-year-old man with hormone
  refractory prostate cancer with low back and
  shoulder pain due to metastases. The pain has
  been well controlled by long-acting morphine, 100
  mg PO BID. He now complains of an increase of
  this pain to severe levels (6/10 to 10/10),
  accompanied by severe paresthesias and pain in
  his right leg and foot. A CT myelogram reveals no
  cord compression, but other scans show an
  increase in metastases in the left scapula, and
  lumbar-sacral vertebrae, with a new right-sided
  lumbar-sacral soft tissue mass encompassing the
  vertebral foramina and nerve roots. Two days ago
  you increased the long-acting morphine to 200 mg
  PO BID, but Mr. AZ reports that this dose, while
  partially relieving the pain, makes him feel
  drowsy and in outer space. How would you manage
  this case now?

Objective Recognize nociceptive bone pain and
treat with opioids and appropriate adjuvant
medications. Objective Recognize neuropathic
pain and treat with appropriate adjuvant
medications.
13
Case studies

• Mr. MT is a 63-year-old man with non-small cell
  carcinoma of the right lung with extension to the
  mediastinum and chest wall. He had severe chest
  pain and is currently prescribed a fentanyl
  transdermal patch, 125 ug/hr to be changed every
  3 days, and Percocet, one to two tablets Q4H PRN
  for breakthrough pain. This regimen does not
  cause sedation, and the fentanyl patch generally
  relieves the pain. However, a few times each week
  the pain flares up to severe levels, and it
  takes a day or two to subside despite use of the
  Percocet every 4 hours. How would you manage this
  case?

Objective Prescribe appropriate breakthrough
pain medications for patients with chronic pain
taking long acting opioids .
14
Case studies

• Mr. MT is a 63-year-old man with non-small cell
  carcinoma of the right lung with extension to the
  mediastinum and chest wall. He had severe chest
  pain and is currently taking long-acting morphine
  60 mg PO Q12H, which controls the pain for about
  8 hours after a dose, but the pain returns to
  severe levels by 12 hours. He experienced no
  sedation from the long-acting morphine. How would
  you manage this case?

Objective Prescribe appropriate breakthrough
pain medications for patients with chronic pain
taking long acting opioids.
15
Case studies

• Mr. MT is a 63-year-old man with non-small cell
  carcinoma of the right lung with extension to the
  mediastinum and chest wall. He had severe chest
  pain which until recently had been well
  controlled by transdermal fentanyl, 125 ug/hr to
  be changed every 3 days, and immediate-acting
  morphine, 30 mg PO Q2H PRN pain which he took on
  rare occasions for breakthrough pain. In the past
  week he has experienced a progressive increase in
  his pain, and had trouble sleeping the last few
  nights. Yesterday he says he took 8 doses of his
  breakthrough med. He does not appear sedated on
  your exam. A chest CT scan shows progression of
  his intrathoracic cancer. How would you manage
  this case?

Objective Titrate opioids to control worsening
pain caused by progressive cancer in a patient
already taking pain medications.
16
Case studies

• Mr. MT is a 63-year-old man with non-small cell
  carcinoma of the right lung with extension to the
  mediastinum and chest wall. He had severe chest
  pain as a result of this, but one week ago one of
  your colleagues prescribed long-acting morphine,
  60 mg PO BID for pain, which greatly relieved the
  chest discomfort. Over the past 3 days, however,
  Mr. MT noted a sensation of bloating, nausea, and
  increased abdominal distension. He has not had a
  bowel movement for the past 6 days. His current
  meds are morphine (as above), and docusate sodium
  (Colace), 50 mg PO BID. On exam his abdomen is
  distended, mildly tender without rebound, bowel
  sounds are quiet. How would you manage this case?
  

Objective Recognize, pre-empt or treat opioid
side effects (e.g., constipation, sedation,
respiratory depression, nausea, pruritis,
delirium, myoclonus, urinary retention).
17
Final message

• Pain management is an essential component of
  comprehensive cancer care