Pain medicine and bone mets

[esrun00]

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.

[softrbreeze]

Many physicians know very little about adequate pain control and will ask OUR opinions on the matter since we actually spend more time bedside and (in many cases) know what will work better for the patient. We have come across several doctors that have ordered MS Contin THREE times a day (hello- half life anyone?) or doctors that will order fentanyl patches for cachexic patients. Or something ridiculously ineffective like Norco q 6 hrs. Asking a nurse first is not a bad idea as long as the patient is not suffering a long time while the nurse is gathering opinions. BTW, methadone works very well for bone mets as long as the patient is not opioid nave.

[BostonFNP, APRN]

Many physicians know very little about adequate pain control and will ask OUR opinions on the matter since we actually spend more time bedside and (in many cases) know what will work better for the patient. We have come across several doctors that have ordered MS Contin THREE times a day (hello- half life anyone?) or doctors that will order fentanyl patches for cachexic patients. Or something ridiculously ineffective like Norco q 6 hrs. Asking a nurse first is not a bad idea as long as the patient is not suffering a long time while the nurse is gathering opinions. BTW methadone works very well for bone mets as long as the patient is not opioid nave.[/quote']

MS Contin can be dosed q8h per guidelines.

[QuiltDog]

Or my personal favorite, MS Contin 15 mg q4h prn!

[TammyG]

We often go up to MS Contin q8 hours if the patient is having end-of-dose failure at q12 hours. I think that is pretty common. I have never seen MS Contin ordered q4 hours though.

[NC29mom, ASN, LPN, RN]

I'm pretty sure the poster meant morphine sulfate IMMEDIATE RELEASE Q4H PRN. ....bc we certainly wouldn't be dosing an extended release morphine tablet PRN......

[NRSKarenRN, BSN, RN]

Kudos to you wanting more knowledge/advice to seek effective pain relief for your patient. Each patient needs a personal plan to control cancer pain as each person's diagnosis, cancer stage, response to pain, and personal likes and dislikes are different. Type of cancer/site origin + metastatic area greatly influences metastatic pain management.

The Management of Pain in Metastatic Bone Disease - Medscape

Step 1 consists of nonopioid analgesics when pain is mild. Nonsteroidal anti-inflammatory drugs (NSAIDs) and COX-2 inhibitors, acetaminophen, adjuvants, and topical analgesic compounds comprise this group. Much controversy has revolved around the safety of NSAIDs; currently, their use is advised with caution, particularly in the elderly. ^[26] Adjuvants typically refer to drugs that, although are not analgesics per se, can be used for this indication in special circumstances. Several antiepileptics and antidepressants are first-line therapies in the management of neuropathic pain. The most commonly used agents include gabapentin, pregabalin, and tricyclic antidepressants (eg, amitriptyline, nortriptyline).

Step 2 introduces weak opioids such as hydrocodone, codeine, and low-dose oxycodone for pain that is mild to moderate. Other μ receptor agonists with dual mechanisms of action include tramadol and, most recently, tapentadol. These drugs reduce much of the side effects profile of pure opioids and have added effects on neuropathic pain. Propoxyphene (Darvocet, Darvon) has been taken off the market due to concerns of cardiac arrhythmias.

Step 3 consists of stronger opioids such as morphine, hydromorphone, fentanyl, high-dose oxycodone, meperidine, and methadone.

For patients with chronic cancer pain, a combination of long- and short-acting opioids is recommended. The long-acting opioids, whether they are pharmacologically long-acting (such as methadone or levorphanol) or pharmaceutically long-acting (a slow-release delivery system such as extended-release morphine, oxycodone, oxymorphone or hydromorphone), are used for the chronic baseline cancer pain. The shortacting opioids that require repetitive dosing are used for the acute pain.

Regarding breakthrough pain, which is defined as an abrupt, short-lived, and intense flare of pain in the setting of chronic stable pain managed with opioids, ^[27] there is an increasing trend to the use of transmucosal lipophilic drugs (eg, oral transmucosal fentanyl citrate, fentanyl buccal tablets, sublingual fentanyl, intranasal fentanyl spray, fentanyl pectin nasal spray, fentanyl buccal soluble film) due to the rapid effect of these drugs, which is clinically observable 10 to 15 minutes after administration. ^[28,29] Breakthrough pain has been reported to occur in 50% to 70% of cancer patients. ^[30] Patients with pain located in the spine, back, and pelvis may be at risk for resistant breakthrough pain. ^[31] Breakthrough pain can be categorized as somatic, visceral, or mixed, and also as idiopathic (spontaneous), incidental, and end-of-dose failure (when the pharmacokinetics of the analgesic do not match the patient's dosing schedule)... ^[32]

...Tumors in which hormonal therapy is of proven benefit include breast, prostate, and endometrial cancers. ^[35–37] ...

Interventional radiology can provide radiofrequency ablation and cryoablation--- desensitizing the bone by killing the nerve endings in the vicinity of the metastasis.

I've seen breast CA with mets to bones respond to this along with palliative radiation.

Nonsurgical Treatments for Metastatic Cancer in Bones - SIR

Further info

Pain Management at the End of Life - Medscape Education

Therapy of Metastatic Bone Pain* - Journal of Nuclear Medicine

[NRSKarenRN, BSN, RN]

Closing thread per OP as advice received.