This case examines the challenges of managing pain in the prostate cancer patient.

PainEDU.orgImproving Pain Treatment Through Education

https://www.painedu.org/case_selection.asp?CaseType=16

Learning Objectives

Upon completion of this exercise, the participant should be able to:

• 1.Recognize the importance of assessment and reassessment of pain

• 2.Select appropriate diagnostic tests for metastasis of cancer to bone

• 3.Manage side effects of opioid treatment• 4.Describe the World Health Organization (WHO) analgesic

ladder of cancer pain treatment

Case History• This is the case of a 73-year-old male with a history of hormone

refractory prostate cancer, with no known metastases, who presents with pain in the low back, buttock and hips.

• Patient: “I have a little pain in the back and when I walk, my hip hurts. It’s not too bad. I don’t think it’s necessary to do anything about it.”

• Wife: “He never says he’s in pain but I can see it. He limps when he walks and I notice that he doesn’t like sitting too long either.”

• Physical Examination: A physical examination reveals pain on palpation at the mid lumbar-sacral level of the back. Achilles tendon reflexes are diminished, but the neurological examination is otherwise normal. The straight leg test is negative. Significant back pain is experienced with all range of motion.

• Would you like to assess this patient or move directly to the treatment plan without assessment?

A.Assess B.Treat Directly

• Psychosocial

The patient has been married for 50 years. He has a stoic style of expression.

• Laboratory and Diagnostic Tests

No information is available at this time.

The most critical factor reported by the patient or his wife that should trigger a thorough assessment and diagnostic work-up is:

• A.His stoic style of expression• B.His pain intensity ratings• C.His report of new patterns of pain• D.His report of hip pain

CORRECT • The patient reports new pain. Changes in pain

patterns should trigger thorough assessment and diagnostic work-up. New pain may signal infection, fracture, or new metastatic processes.

All of the following imaging studies could be helpful in diagnosing the etiology of pain except:

A.Magnetic resonance imaging (MRI)B.Dual-energy x-ray absorptiometry (DXA or DEXA

Scan)C.Plain filmsD.Bone scintigraphy

CORRECT • DEXA scanning shows the mineralization of bone and

can help detect vertebral body fractures in osteoporosis. The procedure measures bone mineral density, which is usually performed on the wrist, lower spine, and hips. It is not used in the evaluation for metastatic disease.

[REF] American College of Radiologists. Bone Density Scan. Available at: http://www.radiologyinfo.org/en/info.cfm?pg=dexa&bhcp=1. Radiological Society of North America Web Site. Accessed on November 3, 2011.

The patient reports a prior history of constipation with a short-acting opioid. In the event that you decided to use an opioid for pain treatment, what could be done to address this side effect?

A.Prescribe a different opioidB.Recommend acupunctureC.Avoid opioidsD.Recommend a bowel regimen

CORRECT • Prophylactic use of a bowel regimen is

appropriate for this patient. Most physicians recommend a prophylactic regimen to all patients with cancer-related pain taking opioids. Increasing dietary fiber or using mild laxatives can counteract mild constipation. Cathartic agents (e.g., bisacodyl, senna concentrate, or hyperosmotic agents) can be used for more persistent constipation.

What is the most appropriate term for the component of the patient’s pain that is induced by walking?

A.Breakthrough pain B.Rest painC.Neuropathic painD.Incident pain

CORRECT• Incident pain refers to breakthrough pain that

is provoked by specific types of activity (e.g., walking).

• You prescribe controlled-release morphine every 12 hours and immediate release morphine every 4-6 hours as needed for breakthrough pain. The patient says he takes 5 rescue doses per day. He reports continued difficulty walking due to pain. How can his pain control be improved?

• A.Prescribe a non-steroidal anti-inflammatory drug (NSAID)• B.Increase the opioid dose• C.Add an antiepileptic• D.Refer for an intrathecal morphine pump

CORRECT The World Health Organization (WHO) analgesic ladder

for cancer pain recommends NSAIDs as a first step in treating cancer pain. NSAIDs

• 1) may be dose sparing for opioids, • 2) may therefore reduce opioid side-effects, and • 3) may be more effective for incident pain than

opioids. The side effects of NSAIDs can appear at any time and

should be closely monitored, especially when prescribing for older individuals.

• [REF] WHO's Pain Relief Ladder. World Health Organization. Available at http://www.who.int/cancer/palliative/painladder/en/. Accessed November 3, 2011.

• You prescribe the maximum recommended dose of a cyclo-oxygenase Type 2 inhibitor (COX-2) and titrate morphine to a controlled-release formulation morphine every 12 hours, and an immediate release formulation of morphine every 3 hours as needed of which the patient is taking 5 doses per day. He reports adequate pain relief if he follows this regimen faithfully, but since increasing the opioid he also experiences excessive daytime sedation. You can:

• A.Decrease opioid dose• B.Double the COX-2 inhibitor dose• C.Switch to another opioid• D.Add a psycho-stimulant medication

CORRECT • Opioid rotation can be helpful, by taking

advantage of individual differences in opioid responses.

This case explores pain management in a patient with ovarian cancer.

Learning Objectives

Upon completion of this exercise, the participant should be able to:

• 1.Identify different routes of opioid administration

• 2.Formulate an effective treatment of nausea and vomiting as an opioid therapy side effect

• 3.Formulate an attainable treatment goal for cancer pain

Case History

A 40-year-old female presents with diffuse abdominal pain and a history of ovarian cancer. She complains of increasing abdominal pain, nausea, vomiting and inability to tolerate liquids and solids since starting chemotherapy 3 weeks ago.

The patient has been treated with sustained release oxycodone each evening, in addition to oxycodone/acetaminophen once or twice orally every 4-6 hours for breakthrough pain

• Would you like to assess this patient, or move directly to the treatment plan without assessment?

A.AssessB.Treat Directly

Pain Assessment

• How does the pain feel? (sharp, dull, aching, burning, squeezing, pressure, cramping, etc.)

• The patient describes intermittent severe cramping, constant aching, with occasional radiating pain.

• Where is the pain? Is it in more than one site? • The patient states that her pain is located in the abdomen with

diffuse tenderness to palpation with intermittent radiating pain into her back. There is localized exquisite tenderness over three distinct 3 cm palpable nodules located in the epigastric region just above what appears to be a well-healed incision.

• What is the present and past intensity of the pain, at its worst and at its best? How often does it occur? Is it consistent or intermittent? When did it begin?

Numerical Rating Scale:

Current Pain Current Pain: 7/10 Pain Over Past Week • Average Pain: 8/10

Least Pain: 7/10Greatest Pain: 10/10

• What makes the pain worse? • The patient states that coughing, gagging, retching,

and vomiting exacerbate her pain.

• What makes the pain better? What pharmacological and non-pharmacological approaches (including complementary or alternative therapies) have been and are being used for the treatment of pain? Were they and are they effective?

• The patient had been prescribed sustained release oxycodone every 12 hours in addition to one to two oral oxycodone/acetaminophen every 6 hours for breakthrough pain. She reports that her pain was relatively well controlled at a level of 3-4/10 before receiving her last chemotherapy treatment.

• What side effects were/are experienced from past and present analgesics? How does pain affect quality of life - physical, psychological and social functioning?

• Since she has been taking the opioids, she reports having constipation, which has been fairly successfully managed with docusate sodium and frequent fruit consumption. The patient has been having increased difficulty with everyday activities because of the increasing pain.

BRIEF SCREENING PSYCHOLOGICAL ASSESSMENT

• How has your mood (depression or anxiety) affected your daily functioning?

• The patient states that she cannot tolerate the pain and even has difficulty getting out of bed.

• Do you have enough energy to accomplish things during the day?

• The patient responds, “I just feel totally drained because of the pain and the nausea.”

• Do you ever feel like giving up? • The patient says, “No. I have to be here to take

care of my son.” • How have others around you reacted to your

pain? • The patient says, “My mother has been very

helpful and supportive, but I can’t put this burden on her."

• Psychosocial

The patient is now unable to tend to her household chores. She has an 8-year-old son who lives with her and her mother.

• Laboratory and Diagnostic Tests

No information is available at this time.

• What routes of administration are commonly available for opioids?

A.Subcutaneous/transdermal B.Rectal/oral/transmucosal C.Intravenous/intramuscularD.Intrathecal/epiduralE.All of the above

CORRECT• There are numerous options available for

opioid administration, which is highly effective in alleviating cancer pain. Opioids may be administered by subcutaneous, transdermal, rectal, oral, oral transmucosal, intravenous, intramuscular, intrathecal, or epidural routes. The choice will be dictated by a variety of factors, including the patient’s clinical condition.

• Of the available routes of opioid administration, which is most appropriate for this patient at this time?

• A.Oral• B.Intravenous• C.Intrathecal• D.Transdermal

CORRECT• The oral route of opioid administration is often

preferred because it is the most convenient, painless, and cost-effective. However, because this patient is experiencing nausea and vomiting, additional therapy with an antiemetic, or even rotation to another opioid, may be necessary.

• [REF] Inturrisi CE, Lipman AG. Opioid analgesics. In: Fishman SM, Ballantyne JC, Rathmell JP, eds. Bonica's Management of Pain. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:1172–87.

Follow-up• Despite a month of alternating opioids and

antiemetics, the patient continues to have increasing pain. She was then admitted for pain control, and treated with transdermal fentanyl as well as morphine patient-controlled analgesia (PCA) for breakthrough pain. Her pain is now well controlled. She received another course of chemotherapy during this admission. Ondansetron relieved her nausea. She is subsequently discharged with transdermal fentanyl for pain control, oral oxycodone for breakthrough pain, and with ondansetron for nausea/vomiting as needed.

• Which of the following is most important when attempting to successfully treat cancer-related pain?

• A.Formulating goals of treatment along with the patient as soon as therapy is initiated

• B.Total pain relief• C.Avoiding all side effects of treatment• D.Being able to use an oral route of administration• E.All of the above

CORRECT • Formulation of treatment goals with the patient

is arguably the most important step in treatment of any kind of pain. When treating a chronic pain condition such as cancer-related pain, understanding the wishes and desires of the patient are critical. Often, the most important treatment goal from the patient’s perspective is the ability to perform activities of daily living, along with some significant decrease in their pain.

• [REF] Hagen NA. Epidemiology, prevalence, and cancer pain syndromes. In: Fishman SM, Ballantyne JC, Rathmell JP, eds. Bonica's Management of Pain. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:1172–87.

• The patient is encouraged to continue a preventative bowel regimen for constipation. The patient is also instructed about other possible side effects of opioids such as sedation, pruritus, respiratory depression, nausea and vomiting, urinary retention, amenorrhea, and sexual dysfunction. If the pain continues despite effective delivery of opioid medications, which options may be appropriate for this patient?

• A.Increasing systemic doses of opioids, multimodal treatment with non-opioid analgesics, and non-pharmacologic treatments

• B.Further surgical intervention• C.Regional neurolytic blocks• D.Intrathecal delivery of opioids• E.All of the above

CORRECT • All of the above choices are possible

treatment options for this patient.

This case highlights the importance of understanding effective cancer pain

management in a patient with aggressive pancreatic cancer.

Learning Objectives

Upon completion of this exercise, the participant should be able to:

1.Identify available treatments in cancer pain therapy2.Recognize the role of opioids in cancer pain therapy3.Identify the goal of cancer pain therapy4.Recognize indications for nerve blocks in cancer

pain therapy5.Recognize the role of celiac plexus block in cancer

pain therapy

Case History

• A 54-year-old male presents with epigastric abdominal pain. Computerized tomography (CT) shows a large mass centered in the tail of the pancreas, which is presumably responsible for his abdominal pain.

Would you like to assess this patient, or move directly to the treatment plan without assessment?

A.AssessB.Treat Directly

• How does the pain feel? (sharp, dull, aching, burning, squeezing, pressure, cramping, etc.)

• The patient describes constant sharp epigastric pain with occasional “stabbing” pain.

• Where is the pain? Is it in more than one site? • The patient states that his pain is located in mid-

epigastric region with radiation to the back.

• What is the present and past intensity of the pain, at its worst and at its best? How often does it occur? Is it consistent or intermittent? When did it begin?

Numerical Rating Scale

Current Pain Current Pain: 7/10 Pain Over Past Week • Average Pain: 8/10

Least Pain: 7/10Greatest Pain: 9/10

• What makes the pain worse? • The patient reports that the pain is constant, and

exacerbated with eating, coughing, or any movement of the abdominal muscles.

• What makes the pain better? What pharmacological and non-pharmacological approaches (including complementary or alternative therapies) have been and are being used for the treatment of pain? Were they and are they effective?

• The patient reports minimal relief with the use of a combination of opioid and non-opioid analgesics.

• What side effects were/are experienced from past and present analgesics? How does pain affect quality of life - physical, psychological and social functioning?

• The patient reports mild constipation correlating with the use of the opioid analgesic, and loss of appetite secondary to pain associated with eating.

BRIEF SCREENING PSYCHOLOGICAL ASSESSMENT

• How has your mood (depression or anxiety) affected your daily functioning?

• The patient says, “I don’t feel like doing anything.”

• Do you have enough energy to accomplish things during the day?

• The patient answers, “Nothing takes the pain away.”

• Do you ever feel like giving up? • The patient responds, “Sometimes.” • How have others around you reacted to your

pain? • The patient responds, “My family is supportive

– and scared at the same time. I don’t know how they will survive if something happens to me.”

• Psychosocial

The patient is a self-employed electrician. However, he has been unable to work with the development of his illness over the last three months.

• Laboratory and Diagnostic Tests

CT scan of the abdomen revealed a 3 cm mass located in the tail of the pancreas.

• Diagnosis and Treatment

There is no definitive diagnosis at this time, though pancreatic cancer is the presumptive diagnosis.

Thin needle biopsy confirms the diagnosis of pancreatic cancer. What therapies are appropriate for treating this patient?

• A.Analgesics• B.Radiation therapy• C.Surgery• D.Nerve blocks• E.All of the above

CORRECT • Analgesics, radiation therapy, surgery, nerve

blocks, radiation therapy, and psychosocial interventions may all be valuable adjuncts for treating cancer pain.

• The patient is scheduled to undergo pancreatectomy and subsequent radiation therapy. During the laparotomy, extensive metastatic disease is found with seeding throughout the abdominal cavity. The primary concern in treating a terminally ill patient with cancer pain with opioid analgesics is:

• A.Addiction• B.Dependence• C.Tolerance• D.Comfort

CORRECT • The overall goal of cancer pain therapy is to

keep the patient as comfortable as possible enabling the patient to function independently, and have the best quality of life that is possible.

• The purpose of interventional nerve blocks with regard to cancer pain is:

• A.Diagnostic• B.Therapeutic• C.Prognostic• D.Preemptive• E.All of the above

CORRECT • Nerve blocks may be used diagnostically,

therapeutically, prognostically or preemptively in treating cancer related pain.

• The decision is made to provide analgesia through a celiac plexus block. A celiac plexus block:

• A.Provides pain relief from pelvic cancers• B.Provides relief of pain in 100% of patients• C.Is not associated with any side effects• D.May allow opioid dosage to be reduced

CORRECT • Celiac plexus block may potentially allow the

reduction of opioid dosages in treating pain from upper abdominal cancer.

• [REF] Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni PA. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database Syst Rev. 2011 Mar 16;(3):CD007519.

• Follow-up

There is no pertinent information available.