Pain medicine and bone mets

Specialties Hospice

Published

I have a patient with lung cancer that has spread to spine. Pain is horrendous, any suggestions. Currently on Fentanly 100mcg, Percocet 10 (2) every 4hrs and Roxanol every hr as needed.

Thanks for any help.

OK, I posted this in the hospice section, because I am now a hospice nurse and this is a hospice patient. She recently moved from another state to be with her daughter and was transferred to our agency. The doctor is very much aware of her pain. I was just wanting to know about pain control for bone pain in cancer patients, like if anyone knew of a combination of drugs that worked really well. Bone pain is the worst type of pain to help manage. Thank you for all your

Hope you've seen something here that helps. Bone pain in cancer is tough to manage. I used to see docs write various combinations of meds for different patients. It really just depends on what works for each individual, and that varies from person to person and is subject to change with the disease process. The key is persistence and, of course, supporting your patient until you get a winning combination.

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Specializes in Hospice.

Havd you tried Methadone? I have had very good results with methadone for bone mets pain. It takes 3 days to build up in the system so you have to wait before titrating. For my patients with bone mets, I talk to the doc early about getting methadone started.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
OP made no mention of contacting a physician. I don't assume anything. For a nurse to ask about pain meds makes me suspicious, more so with the lack of stating that a physician was first consulted. This is not a place to ask medical questions.

As far as knowing doctors that don't care about a patient suffering, I suppose maybe I've been fortunate. But maybe it's also my approach, since like I said- I have never seen such a thing happen.

And I do in fact check a poster's profile in AN before I decide whether to post my opinions, to rule out the Spam. But to suggest OP's stated history of 22 years, or even that OP IS a nurse, when none of that has been verified, is naive. I joined this forum only recently, and I can assure you that nobody asked me to verify whether or not I am a nurse, or even who I am. In fact? You continue to reply to this post, knowing nothing about me- so tit for tat.

If a nurse has a patient that is suffering, and has to resort to an anonymous online forum for advice- trust me- I will find myself a new nurse. There is no excuse.

While you are correct there is no way of "knowing" whether or not a member is really a nurse. You are right...for all I know you are Charles Manson in prison....if he has a computer. I will tell you from experience here... those who are not nurses/medical professionals are quickly discovered by the membership. Many of the seasoned members, like Soldier Nurse, have a pretty good eye for reading the truth in a post.

Nurses come here all the time for advice about their patients. Is someone in another part of the country have better success at one treatment or med versus another. Many nurses who have recently changed specialties will come here and ask questions about treatment and meds they encounter while at work. It is one of the strengths of this forum. I personally have had MD's say...I'm out of ideas..you have any?

While I am very cautious in how I answer many questions here...I don't find the OP's question untoward in any way.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Hope you've seen something here that helps. Bone pain in cancer is tough to manage. I used to see docs write various combinations of meds for different patients. It really just depends on what works for each individual, and that varies from person to person and is subject to change with the disease process. The key is persistence and, of course, supporting your patient until you get a winning combination.
My BIL had bone mets....and he suffered. I was frustrated with the hospital RN's and their attitude at times about his pain. My sisters who are also nurses made it clear...give him his meds...he will die of the cancer long before "addiction" becomes a problem. What is it with newer nurses (my experience only) who have this issue with pain meds and judgement that any chronic pain is a crock and those who ask for meds are addicts baffles me...:down:
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Specializes in Hospice.

Have you tried NSAIDs? Bone pain typically responds poorly to opioids. My hospice used to use ibuprofen fairly regularly for bone pain. Toradol can be helpful in a pain crisis, but is not recommended for long-term use.

From a handbood on palliative care, the citation for which I lost - will try to find it again:

A Bone pain

1 Consider early referral for palliative radiotherapy - usually a single fraction is

effective. Radioactive isotope treatment may be used for multiple sclerotic

metastases.

2 NSAIDs may be effective but beware side effects: discontinue if not helping.

Gastro-protective agents should usually be prescribed.

3 IV infusions of bisphosphonates may reduce pain in patients with bone

metastases, especially from breast and prostate cancer and myeloma: drugs

and doses as per hypercalcaemia (see p51).

4 Consider referral to an orthopaedic surgeon for internal fixation for metastases

in long bones at risk of fracture.

5 Vertebroplasty or cement fixation may be appropriate for isolated vertebral

collapse in selected patients.

A helpful article:The Management of Pain in Metastatic Bone Disease moffitt.org/File%20Library/.../154.pdf‎H. Lee Moffitt Cancer Cen... (found in a quick google search):

Background: Metastatic bone disease is a common cause of pain in cancer patients. A multidisciplinary approach to treatment is often necessary because simplified analgesic regimens may fail in the face of complex pain generators, especially those involved in the genesis of neuropathic pain. From the origins of formalized guidelines by the World Health Organization (WHO) to recent developments in implantable therapies, great strides have been made to meet the needs of these patients.

... Analgesic strategies can be developed with specific targets in mind to complement the classic, opioid-centered WHO analgesic ladder obtaining improved outcomes and quality of life. Unfortunately, high-quality evidence is difficult to produce in pain medicine, and these concepts are evolving slowly.

Conclusions: Treatment options are expanding for the challenging clinical problem of painful metastatic bone disease. Efforts are concentrated on developing alternative nonopioid approaches that appear to increase the success rate and improve patients' quality of life.

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My BIL had bone mets....and he suffered. I was frustrated with the hospital RN's and their attitude at times about his pain. My sisters who are also nurses made it clear...give him his meds...he will die of the cancer long before "addiction" becomes a problem. What is it with newer nurses (my experience only) who have this issue with pain meds and judgement that any chronic pain is a crock and those who ask for meds are addicts baffles me...:down:

Same here. One of the most disgusting displays I've ever seen to this day was a neurologist who refused to medicate a patient dying of a retinoblastoma. The patient's family was sitting in his room crying, wearing noise-cancelling headphones so they didn't have to listen to his screams.

His nurse called me from the floor, frantic for assistance. I was charge on my unit at the time, and the patient's nurse was brand new. We talked back and forth for hours until she sent this clueless young neurologist to my ward where we had a frank discussion about pain control. As you can imagine, this discussion attracted attention, and I was quickly surrounded in support by the voices of my coworkers, many of them with 10+ years experience in oncology. It was their combined insistence that eventually convinced this young doc that he wasn't going to kill the patient by putting him on a basal PCA--that it was, in fact, the only ethical thing to do.

I couldn't believe we were even having the conversation the entire time we were talking, especially as this doc considerably outranked me. But that just goes to show that many, many docs don't have near adequate training when it comes to controlling pain, especially something as complex and poorly understood as pain caused by cancer.

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Specializes in Hospice.

Sadly, we as a society have become addicted to the quick fix: a magic pill or one-shot strategy to get rid of the problem. It's a combination of lack of training and the tendancy to throw opioids at everything. Then, if that doesn't work, we dismiss the patient as a drug-seeker.

The problem is just as bad among nurses as it is among docs.

What is frustrating is that good information has been out there for forty years and we're still struggling to teach the basics.

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Specializes in Hospice, Geriatrics, Wounds.

You need to be more specific regarding his pain. How does he describe it? This will give you the knowledge to know how to suggest to manage. Seems most people on this lost are assuming his pain is r/t bone Mets. If so, an opiate, steroid, ibuprofen regimen is good.

If nerve pain....see below:

Methadone

I'm sure the pain is due to tumor pressing on spine/nerves (this is common with lung ca) . You are fighting a losing battle treating with somatic/visceral pain medications. The most you can hope for with current regimen is that it sedates him, therefore he's not in pain. Changing morphine to a different route isn't gonna help (pca) you have to treat neuropathic pain with pain medication designed to manage neuropathic pain.

Start him on methadone.

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Specializes in Acute Care, Rehab, Palliative.

So HAS the OP talked to a doctor?

Have they tried a PCA? Pretty much all of our palliatives go on one.

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So HAS the OP talked to a doctor?

OP has not only NOT indicated that OP has talked to a doctor, OP also has since clarified that OP 'has become a hospice nurse' and further, went on to ask about 'combination drugs' to treat bone pain? I'm even more suspicious. That said:

1. I'm not taking this to an extreme. It's my view of what I am reading.

2. The TOS of this very forum preclude giving medical advice. And as far I know, offering drug information (to an unkown poster, even worse?) IS offering medical advice.

Peace.

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Specializes in Adult Internal Medicine.
OP has not only NOT indicated that OP has talked to a doctor OP also has since clarified that OP 'has become a hospice nurse' and further, went on to ask about 'combination drugs' to treat bone pain? I'm even more suspicious. That said: 1. I'm not taking this to an extreme. It's my view of what I am reading. 2. The TOS of this very forum preclude giving medical advice. And as far I know, offering drug information (to an unkown poster, even worse?) IS offering medical advice. Peace.[/quote']

Actually the OP posted that has HAS talked with the attending.

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All I saw was the comment 'the doctor is very much aware of her pain', without OP specifying just how the OP would know 'the doctor is very much aware of her pain'. I don't see where OP has discussed anything, with any physician.

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