Management

management of cancer induced bone pain

The main aim of management is maintenance of function together with pain relief.

The following simple measures can be initiated at non specialist centers but specialist referral should be considered for patients with

• persistent pain despite these initial steps
• rapidly increasing pain despite treatment or evidence of toxicity from opioids
• suspected pathological fracture or spinal cord compression (1)

Non drug interventions:

• it is important to encourage patients to manage pain through use of non-drug interventions
  • an observational study of 1000 patients in Europe revealed that those who had pain on movement (many of whom had bone metastasis)
    • 43% experienced consistent pain relief with the use of non drug measures
    • either rest or sleep was the frequent measure which helped pain
• behavioural modifications such as avoiding strenuous movement, and referring patients for any appropriate movement aids (walking stick, Zimmer frame) or home adaptations (bath rails) may help in improving quality of life

Pharmacological approach

• The "standard" or "traditional" approach has been the World Health Organization’s analgesic stepladder guidelines for pain relief
  
  
  • step 1 - non opioid analgesics e.g. - paracetamol and non-steroidal anti-inflammatory drugs
    • several systemic reviews found out that paracetamol although well tolerated, had no significant benefit particularly when added to strong opioids
    • although it is widely known that non-steroidal anti-inflammatory drugs are more efficacious in cancer induced bone pain than in other pain states, there is very limited evidence to support this theory
      
      
  • step 2 - weak opioids e.g. - tramadol and codeine
    • has only shown marginal benefits in cancer patients
    • this step is commonly overlooked and moved on to treatment with low dose strong opioids if non-opioid analgesia is ineffective
      
      
  • step 3 - strong opioids
    • mainstay of treatment for background pain in CIBP
    • NICE recommends morphine as the preferred opioid for patients who can take oral drugs.
      • there was no difference in pain intensity or adverse effects with morphine and oxycodone
      • transdermal opioids such as fentanyl or buprenophine may have less constipation as a side effect compared to morphine or oxycodone.
      • treatment failure or inadequate pain control after the initial titration of opioid analgesia should prompt referral for specialist advice
    • management of incident pain is challenging since it manifests within five minutes, is often movement related, and subsides within 15 minutes in about half of patients
      • immediate release morphine preparations are currently recommended as the preferred treatment method
      • fast acting fentanyl preparation can be used if immediate release morphine preparations fails
      • laxative should be given with the initiation of opioid treatment to avoid constipation
        
        
  • other drugs
    • antidepressants and anticonvulsants may be beneficial in enhancing analgesia from strong opioids
    • there is no evidence to support the use steroids and lidocaine (lignocaine) in CIBP

Further treatment options

• the following methods can be used after initial treatment has been started
  • radiotherapy
    • is the most effective treatment and is associated with significant reduction in CIBP
    • hence confirmed CIBP cases should be referred to a clinical oncologist should as soon as possible
  • radioisotopes
    • there is some evidence that radioisotopes may result in complete reduction in pain over a period of one to six months but severe adverse effects (leucocytopenia and thrombocytopenia) may occur commonly with this treatment
  • bisphosphonates
    • used for reducing pain in breast, prostate, and lung cancer as well as multiple myeloma and to prevent skeletal related events seen in bony metastasis
    • NICE recommends bisphosphonates for
      • early treatment of bone pain associated with breast cancer
      • lung and prostate cancer once palliative measures and radiotherapy have been given
  • denosumab
    • act by inhibiting RANK-ligand
  • interventional procedures
    • should be considered for patients who continue to have pain despite receiving opioids, radiotherapy, or bisphosphonates
    • implantable intrathecal devices have shown to reduce pain and increase the survival in patients taking high dose opiates for refractory pain
  • surgery

Note:

• when starting strong opioids, clinicians should remember the following
  • to discuss with the patients about
    • addiction, tolerance, and side effect
    • taking strong opioids does not mean that they are in the last stage of life
  • verbal and written instruction on how opioids should be used for both background and breakthrough pain
  • educate about
    • the possible impairment of the patients’ ability to drive during initiation of treatment or when doses are increased
    • signs of toxicity, such as drowsiness, twitching, and hallucinations and what should be done if they occur out of hours
  • address the side effects such as constipation at the start of treatment
  • importance of regular review (1)

Reference:

• (1) Kane CM, Hoskin P, Bennett MI. Cancer induced bone pain. BMJ. 2015;350:h315