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Basic Cancer Pain Management: Case Studies For Medical Students, Medical Residents, and Hematology/Oncology Fellows

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Title: Basic Cancer Pain Management: Case Studies For Medical Students, Medical Residents, and Hematology/Oncology Fellows


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
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