Bone Pain

[RNSUEIA]

I have a new patient that I am seeing who is having a hard time adjusting to any new pain meds being added to her current dosages.

I have her on oxycontin 120 mg bid and hydrocodone 7.5\325 2 every 4 hours and oxycodone 5 mg 2 every 2 hours for breakthrough (tho its difficult to get her to take it). She continues to have breakthrough hip pain due to bone mets. Seems like every time I do|try to change something it really gets her anxious. I tried a medi planner she did not like that at all. now I have made a written list of everything she is to take and at what time.

My main trouble is getting this bone pain managed. Any suggestions? By the way if you couldnt tell. I have case managed exactly 1 week and I really want to do my very best for this patient.

Welcome all suggestions.

Thank you

[introspectiveRN]

I would recommend scheduled doses of an NSAID 'round the clock (ibuprofen is now the gold standard for bone met pain...go figure). If this gives "decent" relief but leaves wiggle room- I would also add a steroid. In addition, since pain can be perpetuated by anxiety, I would probably also start with something milder like 0.25 of Ativan QHS scheduled and B to T ID prn. How goes the response to narcs so far?

[mc3, ASN, RN]

Agree c Leslie and 206Bones...has worked very well for me. Have also used methadone but lots of docs are afraid of it...

mc3

[206bones]

You know, I've not had much experience using methadone. It's cheaper, works well I hear, but I've also heard it's difficult to titrate. I guess I've just always stuck with what I know. What's your call on methadone?

[CANRN, MSN, RN]

You know, I've not had much experience using methadone. It's cheaper, works well I hear, but I've also heard it's difficult to titrate. I guess I've just always stuck with what I know. What's your call on methadone?

We use Methadone almost exclusively in our hospice. Our pharmacy is great at helping us with titration and we all know how to titrate it and how often etc. Follow up on Methadone is very important. Once we get them at the proper dose, our patients are VERY comfortable and do very welll with it. It's a great medication when used properly and with proper education.

[leslie :-D]

we use a ton of methadone also.

but esp during the titration period, continuous monitoring is essential.

it has a very slow onset with a long duration.

and many meds change its absorption, metabolisma and distribution...

esp when given with the benzos.

be very, very careful with this combo.

but still, it's one of the most effective narcotics around.

leslie

[saribeth]

We have had really good results with Dexamethasone 4mg bid..it increases appetite and gives them a feeling of "well being" (oxymoron I know)! What about a fentanyl patch starting with 75-100 mcg and the percocet for BTP...maybe with the patch she will not feel as if she is taking so many oral meds???? All the best

[206bones]

What would you say the benefit of methadone is over Morphine LA, oxycontin etc??.

[Em1995]

I have found that adding motrin to a long-acting pain med is very effective for bone mets. And, adding prednisone or decadron is an added plus. Can someone explain why methadone works better? We rarely use methadone. I used it once for a man who had terrible neuropathic pain and it worked beautifully. It was my understanding that methadone is more effective for neuropathic pain.

Thanks!

[introspectiveRN]

There are more potent (and more effective) NSAIDS available at minimal cost for bridging the bone pain gap, such as Voltaren. A one month supply of this medication is available at Walmart/Sam's Club for $4/per 30 day supply.

Ultram and Naprosyn are also more potent than Ibuprofen.

When I am dying and in pain of any kind including bone, please do not give me Ibuprofen. It will not help.

hmmm.....well, ibuprofen has been very effective for the majority of my pts c bone mets/pain, esp when combined c dexamethasone.

[Em1995]

I've found ultram useless. All of my patients who used it complained that it didn't help them. And, Naprosyn has caused more stomach upset than Motrin. I still think that an anti-inflammatory combined with a long-acting pain med works the best.And, my patients also love how prednisone helps. So far, no one has complained about stomach upset from prednisone.I'm still curious about the methadone. Can anyone tell me the rationale for methadone used for bone pain? If it's more effective, I'd certainly consider it.

Thanks!

[leslie :-D]

I'm still curious about the methadone. Can anyone tell me the rationale for methadone used for bone pain? If it's more effective, I'd certainly consider it.

Thanks!

methadone is effective and inexpensive.

but for bone pain, it's not practical.

duration of action is too long to allow easy changing of doses.

and there are too many other intermediate-acting narcotics, making it much more practical.

we use methadone a lot, for neuralgias...

only because this is the hardest type of pain to treat.

methadone works beautifully w/this type of pain.

but it's a last resort, usually.

titrating takes too much time:

not good, for someone that has immediate needs.

leslie

[Em1995]

Leslie and all....that's what I thought! I've found methadone to be very effective in neuropathic pain, but NEVER with bone pain. I thought maybe I had missed some new study! Whew!

Thanks!