So I’m writing this piece about a hypothetical patient with terminal lung cancer who has metastases in his vertebrae. He suffers a pathological fracture while his hospice aides are turning him over, and the fracture impinges the nerve.
Now, then. Here is what I know about treatment.
First line treatment for bone mets is radiotherapy and biphosphonates (e.g. Fosamax). I will assume that he has had those.
How would the pain be treated? What drugs would be prescribed? I’m assuming that any surgical procedure would be contraindicated because of his condition, so this is management with medication, only.
Is this even plausible? The audience is nurses, so this has to be decently accurate, but very specific details aren’t really necessary, if that makes sense.
Fosamax wouldn’t be indicated as this patient is terminal. On occasion radiation can be used to reduce pain in terminal patients, but sometimes just the act of getting them to a cancer center to do the treatment is too painful and cruel.
I’ve patients similar to this one at present, and I manage their pain. Long-acting morphine is quite useful as a fixed dose medication to provide constant levels of analgesia around the clock. Short-acting morphine can be given every 2- 3 hours, or even more often if needed for breakthrough pain. Oxycodone, it its long and short-acting forms could be used instead of morphine.
Fentanyl patches can also provide the constant analgesia once the patient is already habituated to opioids, and is especially useful if the patient has trouble swallowing pills. The long-acting pills must be swallowed whole to be effective, while the short-acting ones do have forms that dissolve on the tongue and are absorbed. Fentanyl even comes in ‘lollipops’ which are quickly absorbed in the mouth.
Other opioids could be employed too. Methadone and dilaudid are both effective. Codeine and hydrocodone would likely be insufficiently potent to treat this sort of end of life pain.
We try to avoid IVs and IM injections in end of life care, as it just adds more discomfort in order to give comfort. But if the patient needs rapid pain relief and isn’t getting it by other means, we’ll use it. And then try to figure out how to give better pain relief without needles.
Use of benzodiazepines to relieve anxiety is also helpful. Xanax and ativan are particularly effective.
My dad had lung cancer that metastasized in his vertebrae (among other places). His extreme back pain was how they found out he had cancer. The tumors cracked the vertebrae on their own, though.
They treated him with fentanyl patches for the pain and Xanax for the anxiety. They also tried morphine and methadone.
Surgery was never an option, although he did both chemo and radiation. He had extensive small cell lung cancer, and the doctors had told him he had 12-18 months to live from when he was diagnosed. He died six months ago, which was almost exactly 18 months from his diagnosis.
Sometimes, as an “adjunct” to meds like morphine and other narcotic analgesics, and especially when there may be a component of neuropathic pain, drugs like gabapentin and pregabalin are also given.
However, in addition to their (modest) benefit in this regard, they often cause a lot of sedation (possibly desirable) and even delirium (definitely not a good thing).
ETA: “Sometimes” above may be an understatement. Where I work, it seems every patient with any type of pain has had gabapentin or pregabalin administered.
I agree treatment would be conservative and not surgical but I would think an epidural steroid injection of some sort to take down the inflammation and be better help than pain pills. (IANAD)
An epidural steroid for metastatic bone pain?! Unless there’s a specific nerve root being directly affected, I don’t seeing such an approach helping much.
A regional block might work for intractable pain due to one very, very localized lesion, but if the mets are widespread, one would have to block a lot of regions with a long-lasting agent, which would mean multiple moderately deep injections done in some sort of office setting.
I still vote for a good oral or topical analgesic agent as outlined in my earlier post.
