Cancer associated pain

 Brief pain inventory:

BPI

Assess pain at every visit. Rate the pain ( worst, best, current, average). How does it interfere with ADL and social life?

Create a personalized treatment plan

Create a monitoring plan.

Duloxetine is the only adjunct agent with data supporting treatment of chemotherapy induced neuropathy. However a recent BMJ article challenges this.

Consult an interventional pain specialist if considering nerve blocks, trigger point injections, cryoablation, radiation ( rad onc).

Calculate total daily opioid use= convert to long acting form. Then calculate 10-20percent of this and give another prescription for breakthrough pain.

If patient needs more than 4 breakthrough pain medication dose, then pain is typically not controlled.

If pain is controlled and you want to taper the opioids:

1. If patient has been on it for over a year, taper by 10 percent per month

2. If patient has been on opiates for weeks to months, taper by 10% per week

Specific types of cancer related pain

Bone pain: Is this an oncologic emergency? If not ok to use NSAID, Acetaminophen, steroids and topical agents ( voltaren) along with opiates

Neuropathic pain: antidepressants, anticonvulsants, topical patches ( lidocaine)

Bowel obstruction pain: opiates ok

Mucositis/Esophagitis/ stomatitis pain: opiates, non opiates, gabapentin