Cancer pain consult

[gasgasgas]

Hey guys,

Was consulted on this pt in-house yesterday. Young pt in her 30s with recurrence of Ewing's sarcoma. Has had multiple surgeries in the past and more aggressive recurrence, currently undergoing chemotx. Had IT pump placed since initial dx over 8 yrs ago (revised last fall). Lives in a different city about 4 hours away but comes back for oncology f/u. Pump initially managed by doc in town and was on various combinations (she doesn't really remember) but has had Prialt, Baclofen, Dilaudid all in her pump at some point. Currently, she's on Dilaudid (35 MG/DAY!!!), Bupivacaine, Clonidine. ADDITIONALLY, (sorry for the yelling, just want to make a point) Methadone 80mg TID, Actiq 1200mcg (last prescription was for ONE HUNDRED AND TWENTY), Dilaudid 8mg PO, Gabapentin 1800mg a day and God knows what else. This is all being managed by the pain doc in her city. Her oncologist here does not agree w his management of her pain.

We were consulted while she is in house on what else we can do for her. She is still on Methadone po but on a Dilaudid PCA as well as Ativan prn. When she is awake and alert, she is in pain. But she is also drowsy. Her survival expectancy is anywhere from several months to up to a year as her cancer is not compromising any vital organs and her lungs/heart are healthy.

I am a little bit caught in the middle here. What are your thoughts on what we should do? I thought about her case all night and just feel at a loss.

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[PainDrain]

Explain that all of her receptors are blocked. She may well have opioid induced hyperplasia, I would almost guarantee it considering those doses. I would only consider adding ketamine to an IV regimen via a picc line. Nothing else.

 

[lobelsteve]

Increase methadone to 1000mg per day over 5 days. Problem solved. What are the euthanasia laws like in your state?
Call the pain doc in the other state and tell him to provide input. Do a dye study. Turf to hospice.

 

[101N]

Hey guys,

Was consulted on this pt in-house yesterday. Young pt in her 30s with recurrence of Ewing's sarcoma. Has had multiple surgeries in the past and more aggressive recurrence, currently undergoing chemotx. Had IT pump placed since initial dx over 8 yrs ago (revised last fall). Lives in a different city about 4 hours away but comes back for oncology f/u. Pump initially managed by doc in town and was on various combinations (she doesn't really remember) but has had Prialt, Baclofen, Dilaudid all in her pump at some point. Currently, she's on Dilaudid (35 MG/DAY!!!), Bupivacaine, Clonidine. ADDITIONALLY, (sorry for the yelling, just want to make a point) Methadone 80mg TID, Actiq 1200mcg (last prescription was for ONE HUNDRED AND TWENTY), Dilaudid 8mg PO, Gabapentin 1800mg a day and God knows what else. This is all being managed by the pain doc in her city. Her oncologist here does not agree w his management of her pain.

We were consulted while she is in house on what else we can do for her. She is still on Methadone po but on a Dilaudid PCA as well as Ativan prn. When she is awake and alert, she is in pain. But she is also drowsy. Her survival expectancy is anywhere from several months to up to a year as her cancer is not compromising any vital organs and her lungs/heart are healthy.

I am a little bit caught in the middle here. What are your thoughts on what we should do? I thought about her case all night and just feel at a loss.

Say it, this is duel diagnosis: addiction and pain.

 

[drusso]

Agree with OIH. Agree with Ketamine.

 

[lobelsteve]

Say it, this is duel diagnosis: addiction and pain.

Which 4 of the C's did you gather from his post. Unacceptable jump to conclusions. Of course she is likely an addict on top of a hospice patient.

 

[gasgasgas]

So many hoops to jump to administer Ketamine in this hospital. Have any of you had experience with doing this? I've read about it, but the only time I've used ketamine was a long time ago during fellowship for CRPS... but of course, the institution where I trained was very good about that. I feel like my hands are tied because she will be discharged to go back to her pain doc to do what then? Manage her the same way. Sigh. I feel bad for these types of patients.

 

[emd123]

Agree with turf to hospice & palliative care or to the original prescribing doc


This also shows the problem of throwing all caution to the wind with opiates in cancer pain. What if they live 2, 10 or 20 years? Aren't the concerns then identical to any "non-cancer pain" patient?

 

[101N]

Which 4 of the C's did you gather from his post. Unacceptable jump to conclusions. Of course she is likely an addict on top of a hospice patient.

Addicts get cancer and die as well.

There is no helping this patient, she and her previous pain doctor are so far down the path of no return that nothing more can be done.
The only thing to be learned here is not to make the same mistake yourself.

 

[gasgasgas]

This depresses me. I feel for this patient and so many others. Wish there was something that can be done to help her as she is clearly dying.

 

[emd123]

This depresses me. I feel for this patient and so many others. Wish there was something that can be done to help her as she is clearly dying.

There is something that can be done for this dying patient. Get her care with a doctor that specializes in helping dying patients, ie. Hospice and palliative.

 

[PainDrain]

I totally agree to get hospice/pal med involved. You may be dealing with her fear of death more than actual pain in this case. That's for them to uncover.

I was peripherally involved with one case when I was in training where we sent a cancer patient to hospice on a ketamine PCA. It worked very well and she was remarkably lucid considering until the end. I have used ketamine for crps also, but those doses over several hours, not months as would be the case here.

 

[gasgasgas]

Thanks. Her oncologist is vehemently against hospice/palliative care, and it is a completely appropriately consult. So many politics involved at this hospital.

 

[lobelsteve]

Addicts get cancer and die as well.

There is no helping this patient, she and her previous pain doctor are so far down the path of no return that nothing more can be done.
The only thing to be learned here is not to make the same mistake yourself.

What was your answer to her having an addiction problem? Was it her failure to read the literature you provided on the forum? Maybe she is faking the Ewing's.
Besides unpalatable regimen that is excessive and ineffective, what say you?

I am of the opinion that most people die with far less pain and far less narcotic on board. If I was seeing her in hospital I would not believe that she was taking the meds and that giving the doses she says she is on would OD her and kill her.

 

[drrosenrosen]

Thanks. Her oncologist is vehemently against hospice/palliative care, and it is a completely appropriately consult. So many politics involved at this hospital.

I have one of those in my area. Unfortunately he's the medical director at a major cancer center. So, so frustrating...

 

[101N]

Thanks. Her oncologist is vehemently against hospice/palliative care, and it is a completely appropriately consult. So many politics involved at this hospital.

You might try persuading the oncologist with "Ya know, getting palliative care involved might get her local- idiot -pain doctor out of the picture."

 

[Agast]

Any change you want to make is a moot point if she's not on board with following with you regularly. At those doses and meds I would want to see the patient back once a week. If she isn't amenable to that I wouldn't start something I would not be able to finish.


Where exactly is her pain? If it's unilateral limb, I say consult neurosurgery for cordotomy. I would block and ablate whatever I can. I would do a dye study and make sure she's actually getting those meds intrathecally. I doubt she actually needs that much gabapentin unless imaging shows me neuro involvement. I would have her choose between the Actiq and Dilaudid for her breakthrough med and stick to one. Later on I would consider starting Cymbalta. But I would have to see her regularly to keep her compliant and make sure she doesn't run home to her other doc.

 

[deleted472101]

What state did that physician work in?

 

[emd123]

Thanks. Her oncologist is vehemently against hospice/palliative care, and it is a completely appropriately consult. So many politics involved at this hospital.

Completely against? Why?

Either way, if he's putting personal politics/grudges before patient care then ---- him, and if he knows better than you, then he can put his pen to paper and sign the scripts, himself. People that consult a specialist, then want to dictate what the consultant recommends can go solo without dragging someone else into the mix. Sounding like a classic "I think treatment is outrageous and crazy but as long as you endorse it and take the liability off my shoulders, then I'll look the other way."

I call BS.


As a side note, I did have a terminal brain cancer patient referred to me a couple of years ago, who's wife was found to be stealing his opiates, and selling them to buy heroin. The PCP supposedly didn't know this, but out of the blue refers to me for no apparent reason and I discover this, fortunately before any rx was filled by me. When I called the guy to tell hi this, he says, "Oh, that wouldn't surprise me." What a !#=£?"&?&,$,@

These people will do almost anything to avoid telling a patient, "No," and definitely won't hesitate to put your license on the line if you take the bait.

 

[EtherBunny]

Hey guys,

Was consulted on this pt in-house yesterday. Young pt in her 30s with recurrence of Ewing's sarcoma. Has had multiple surgeries in the past and more aggressive recurrence, currently undergoing chemotx. Had IT pump placed since initial dx over 8 yrs ago (revised last fall). Lives in a different city about 4 hours away but comes back for oncology f/u. Pump initially managed by doc in town and was on various combinations (she doesn't really remember) but has had Prialt, Baclofen, Dilaudid all in her pump at some point. Currently, she's on Dilaudid (35 MG/DAY!!!), Bupivacaine, Clonidine. ADDITIONALLY, (sorry for the yelling, just want to make a point) Methadone 80mg TID, Actiq 1200mcg (last prescription was for ONE HUNDRED AND TWENTY), Dilaudid 8mg PO, Gabapentin 1800mg a day and God knows what else. This is all being managed by the pain doc in her city. Her oncologist here does not agree w his management of her pain.

We were consulted while she is in house on what else we can do for her. She is still on Methadone po but on a Dilaudid PCA as well as Ativan prn. When she is awake and alert, she is in pain. But she is also drowsy. Her survival expectancy is anywhere from several months to up to a year as her cancer is not compromising any vital organs and her lungs/heart are healthy.

I am a little bit caught in the middle here. What are your thoughts on what we should do? I thought about her case all night and just feel at a loss.

1. Catheter dye study to confirm intrathecal positioning of catheter and patency
2. Pulsed radiofrequency, radiofrequency ablation, or chemical ablation of pertinent nerves to the affected areas (if possible). Consider tunneled plexus or peripheral nerve catheter for short term control. Consider SCS trial.
3. Limit IT pump drugs to just dilaudid and bupivacaine
4. Eliminate all other systemic opioids, leaving just methadone 10 mg PO tid
5. Initiate treatment for suspected opioid induced hyperalgesia (ketamine, centrally acting alpha 2 adrenergic agonist, etc and aggressive de-escalation in total opioid consumption)
6. Implement balanced, multimodal therapy (Lyrica or Cymbalta for any underlying undiagnosed centralized pain state or neuropathic component of neoplasm related pain, COX 2 selective, APAP, topicals)
7. Consult rad onc for possible palliative XRT
8. Consult psych
9. Send pt to well trained Chinese accupuncurist

We have a special protocol at my institution for patients like this (I get these train wrecks in my clinic every few months) that works extremely well. It involves admission to the hospital for a variety of drug infusions. I'm working on publishing the results later this year.

Good luck with this case!

 

[joshmir]

EtherBunny, sorry if I misunderstood you, but why would you stop the IT clonidine and simultaneously advocate for a central acting Alpha-2 agonist?

Would a dye study rule out an IT granuloma? consider imaging for that if pain is in the right place

Nucs/Rads can maybe give strontium-89 (not sure if thats the right isotope) if its bone pain for which the isotope is indicated for (I forget if its lytic or blastic)

You can get around the ketamine situation in 2 ways; 1) take her to the OR for a diagnostic ketamine infusion/trial, maybe they will let you do this in the PACU, then transfer to ICU on a ketamine drip (5-15mg/hour) 2) get an outside compounding pharmacy to mix the IV stufff with cherry syrup 5mg/teaspoon, and give 40mg PO q2hours prn pain, increase to 80mg PO q2 if partial effect

Consider lidocaine infusion especially if nerve involvement, and check lido levels periodically

If she is willing to go to the NIH hospital in Bethesda, PM me and I can give you details on how she can trial IT resferinatoxin, which has a good record in these cases

Agree with duloxetine, titrating gabapentinoid/swithing to lyrica (1800mg a day is a low dose), stopping PO dilaudid, adding NSAID vs dexamethasone if nausea, consider marinol, anything to get her PO opioid intake down; if she is asleep all day, substituting some sedating neuropathic analgesic for some of the methadone wont make a difference likely; she will be unlikely to show withdrawal physiology; anything to get her offf the PO dilaudid and reduce the sublingual fentanyl dose

check her teeth for undiagnosed cavity/rot from the Actiq, especially if neutropenic, consider switching to Subsys if so

Steve may have been kidding about euthanasia laws in different states but in other countries someone would have brought this up a long time ago; tough to politically do this especially if they are blocking the hospice/palliative care consult; but when the Ewings starts spreading aggressively that may be the best option for her with saturated receptors; I was going to say prescribe her a narcan injector for her family to use but then I realized it would be counterproductive in this situation

check clinicaltrials.gov for other options


I recognize the main point is that all this is moot unless she has a good pain doc but I thought bringing up these ideas would be good for discussion

 

[lobelsteve]

EtherBunny, sorry if I misunderstood you, but why would you stop the IT clonidine and simultaneously advocate for a central acting Alpha-2 agonist?

Would a dye study rule out an IT granuloma? consider imaging for that if pain is in the right place

Nucs/Rads can maybe give strontium-89 (not sure if thats the right isotope) if its bone pain for which the isotope is indicated for (I forget if its lytic or blastic)

You can get around the ketamine situation in 2 ways; 1) take her to the OR for a diagnostic ketamine infusion/trial, maybe they will let you do this in the PACU, then transfer to ICU on a ketamine drip (5-15mg/hour) 2) get an outside compounding pharmacy to mix the IV stufff with cherry syrup 5mg/teaspoon, and give 40mg PO q2hours prn pain, increase to 80mg PO q2 if partial effect

Consider lidocaine infusion especially if nerve involvement, and check lido levels periodically

If she is willing to go to the NIH hospital in Bethesda, PM me and I can give you details on how she can trial IT resferinatoxin, which has a good record in these cases

Agree with duloxetine, titrating gabapentinoid/swithing to lyrica (1800mg a day is a low dose), stopping PO dilaudid, adding NSAID vs dexamethasone if nausea, consider marinol, anything to get her PO opioid intake down; if she is asleep all day, substituting some sedating neuropathic analgesic for some of the methadone wont make a difference likely; she will be unlikely to show withdrawal physiology; anything to get her offf the PO dilaudid and reduce the sublingual fentanyl dose

check her teeth for undiagnosed cavity/rot from the Actiq, especially if neutropenic, consider switching to Subsys if so

Steve may have been kidding about euthanasia laws in different states but in other countries someone would have brought this up a long time ago; tough to politically do this especially if they are blocking the hospice/palliative care consult; but when the Ewings starts spreading aggressively that may be the best option for her with saturated receptors; I was going to say prescribe her a narcan injector for her family to use but then I realized it would be counterproductive in this situation

check clinicaltrials.gov for other options


I recognize the main point is that all this is moot unless she has a good pain doc but I thought bringing up these ideas would be good for discussion

Agree with above. But most of this needs research based university setting.

Dye study is to see if she has broken catheter and if meds are going IT or just around the ribs.

 

[Ducttape]

id first ask the patient if she is going to go back to her old pain doc. if she is, then tell her that the hospital can only provide her with her standard outpatient meds, and only consider adding non-opioid based meds to her pain regimen (ie NSAID, radiation, tylenol.), set up outpatient services, and anticipate she will essentially self-discharge.

if the patient she says she is transferring care, then a contract might be considered, for x number of days/doses post surgery etc. and fall back on chronic meds as soon as that period is complete.

if she is interested and there is an inpatient facility around, maybe she might be one of the very few people that should consider anesthesia assisted rapid opioid detoxification, turn off all the opioids, and after an appropriate washout period, restart at low dose opioids.

i do use ketamine, one of the few on this board who does, but honestly, with the patient already on 240 mg daily of methadone, i am not sure you are going to get much NMDA antagonism with the ketamine, only increased cognitive effects...

 

[gasgasgas]

Great info, guys. I did end up talking to her pain doc. Funny how one-sided things are and how important it is to get all the information. Apparently her oncologist put her on that high dose methadone and just a few months ago her Dilaudid dosage was about 7mg/day. Sounds like it was a lot of back and forth which is par for the course. She left over the weekend to go back home, and that morning, when my NP came to see her she hadn't taken any of her meds yet. She was very alert, lucid, still in pain of course but mentally clear/sound. I just hope she gets the right care. It is sometimes difficult having a frank conversation w these patients. Thanks for your input.

 

[Ducttape]

posted a similar case in the pain physicians forum (because there are other "concerns"). similar case.

 

[gasgasgas]

Funny I was looking for another thread and found this old one. This patient ended up passing away about 2 months after I originally posted this after being sent home with home hospice care. She was comfortable when she passed with IV pain medications.