Cancer Education Series: Cancer Medications

good evening ladies and gentlemen this is the third in the series of the cancer education lecture series and tonight we are delighted to bring two speakers for you this evening they are dr. Cindy so and Jennifer Daly Morris the first speaker is Jennifer Daly Morris who is the coordinator of pharmacy for the Stronach regional cancer center here at southlake during her six years in the profession jennifer has had experience with a number of different programs which has been invaluable in the startup of the Regional Cancer Program in newmarket in her current role jennifer has been instrumental in the setup of the cancer center processes building electronic charts and leading a number of safety initiatives Jennifer’s oncology specific interests lie in research and development as well as patient and safety for the staff and patients she was at the forefront in the design and development of the southlake pharmacy area please welcome Jennifer Daly Morris do you mean everyone when I thank you very much for having me here this evening I’m I was asked to see me to talk a bit about um medication safety and what we can do for ourselves when coming to see our physician so it’s a little more broad than oncology but hopefully I’ll be able to expand on that with oncology specific examples so that you can understand from our perspective why it’s so important that we have a good medication history from our patients and clients when they come in and as as I’ve said before I’m a pharmacy coordinator here at the Stronach regional cancer center so we’ll start off with what is a best possible medication history you may hear me now call that BP mhm and I will try to say that nice and slowly it is a medication history obtained by clinician which is systemic using a number of different sources of information it’s typically different and more comprehensive than the traditional routine medication history that you might go through with your physician and it’s different for everyone and it changes constantly so these BPM H’s include current and recently prescribed medications and we often we forget about creams ointments patches eyedrops inhalers as well as the ads native medication so pain medications that you might only use every now and then previous allergies are drug reactions and the details to this reaction they include over-the-counter medications including complementary alternative medicines and these include vitamins herbal medicines and homeopathic medicines recreational drugs and we also need to find out how when you use the medication sometimes just because it’s on the label and how you take it doesn’t necessarily mean that’s really what you’re doing at home because you might have a conversation with the physician and adjust your medications on your own so why is it considered best possible because it’s the best we can do with the time at the time that we have at hand so the other sources that we include our medication vials labels booster packs we often ask our patients to bring in their bag of vials with them because it’s very helpful to read the label for us the community pharmacy list I know a lot of people in the back of the receipt gets a list of all the medications they’re on that’s often very helpful hospital discharge summary provincial electronic record client database referrals medication calendars are very helpful for us because it tells us actually when you’re taking it and the patient interview of course cannot be forgotten actually speaking with the patient and their family members to find out exactly when and how they’re taking their medication so why do we bother well the patient’s kind of at the center of evolving care especially now with all these specialty medicines coming out the oncology cardiology so it’s a very dynamic process and it always changes so you have the hospital you have what’s going on the community at your at your community pharmacy when you’re buying cough and cold medications or ginseng and you got your outpatient clinics like us in the Cancer Center so many errors with prescriptions happen when the health care team isn’t aware of the complete medication history so one of the things that we’re trying to do here the Cancer Center is prevent these by knowing exactly what the patient’s taking so we’re going to start over the next 12 months is a a project where patients are going to be interviewed by our pharmacy technicians so we can get a complete list before you can go and see the doctor so it’s all there so he has everything at hand when he goes to write that prescription so we can do all the

important checking so the important checking includes drug drug interactions there’s a lot of oral chemotherapy happening in the world right now and so there’s a lot of interactions with other medications drug herbal interactions it’s an ever-growing thing especially now that people are going more and more towards homeopathic and herbal type medications they may not be obvious to everybody but sometimes some of these herbal medications can cause side effects to be worsened by the chemotherapy nausea and vomiting for one example everyone it was chemotherapy can cause a lot of nausea and vomiting sometimes some of the herbal medications can make that nausea and vomiting work so it’s good for us to know so that we can help manage all the side effects appropriately management of side effects so if we know it you’re on just as I said before help us kind of make our game plan so we know what we’re doing is right for you and monitoring outcomes of treatment so sometimes we like to know what you’re on just so that we fear a diabetic so we know if you’re an insulin we can see your Sugar’s aren’t rising while we’re giving you your treatment so who’s involved well first and foremost is the patient the family they’re the center of this anyone can do a BP mhm the physician informal caregivers nurse the pharmacy teen other healthcare members you might have radiation therapists collecting this or dietitian might be interested in what you’re on so we’re all dynamically collecting these lists so our goal here at the cancer center is to eventually just have one person taking the list for you so you don’t have to repeat it over and over with every appointment because we acknowledge the fact that you see multiple people in one day so how can the patient or the family help always carrying up to date medication list of all your health to all your health related appointments and to remember to include the over-the-counter medications the complementary medications the as needed medications because these could be important whether you’re seeing your eye doctor doctor so in the palliative clinic or one of our medical oncologists try to use only one community pharmacy this way that they have a complete accurate list so if we write a prescription they can also do some screening on there and it’s often helpful technology that sometimes you can’t always in the middle of the night get to your pharmacy but it’s helpful provide the contact information of your pharmacy and always notify the clinician if there’s any changes even if we forget to ask sometimes we forget in our busy days and we’re so focused on the chemotherapy or the pain that we sometimes forget to ask so we ask that people remind us to about the changes in their medication list there are a couple of resources in the community that people are aware of that are very very helpful especially for those people with three or more medications one is a program called meds check which the Ontario government launched I think about four years ago and what it is it’s one-on-one interviews between the pharmacists and patient to review the patient’s prescription and non-prescription medications and it’s offered to anybody with a valid OHIP in ontario they do require that you’re on at least three medications for chronic disease so it’s more for those people who are on medications all the time diabetics hi people with high blood pressure but sometimes there are some other indications that we don’t realize that you need some help with there are four different programs is just the regular meds check there’s one specifically for people living with diabetes so anybody with diabetes week some of this they’ve acknowledged that sometimes people can’t get out of the home so they’ve now started doing the meds check at the home and in long-term home residents so there’s a big push on having everyone understand that when you go for your interview they will give you a complete list of everything you’re on and that’s invaluable for us it really helps us on our end know what’s going on and that someone on the other end has also taken a look at it there’s also a resource through the Community Care Access Center CCAC it’s called the medication management support services you must be a client of CCAC to be eligible you have to take three or more medications and again it’s face-to-face interviews for these patients and it’s a nurse or pharmacist will come in to explain how to take the medications and the best way to take them so they’ll take their time they’ll sit down I know they do medication calendars the help organize blister packs if people need that if you bar just the labels the font is really tiny so if we have an elderly patient can’t read the font they’ll help organize getting bigger labels for them they do also check for drug interactions they’ll discuss high alert medicines that have to be watched closely so things like if you’re a blood thinner they’ll help the patient understand when they should go for monitoring chemotherapy I know that they’ve started to talk to patients in the community about chemotherapy and how to handle the chemotherapy don’t crush because we don’t want the they harder to be in the air those sorts of things I I do know that they’re starting to enter those conversations as well find easier ways to take them they’ll develop schedules they’ll check the pain patient pay level and SS medication options and they will follow up with your home with your team your health care team so I know we’ve received recommendations from

pharmacists in the community saying what they recommend for our physicians so that they can help manage better the patient’s medications at home and how do you refer it for this particular program it can be a self referral so if you’re just a patient that has CCAC and want help that can they’ll take your your own referral a physician can do it another family member caregiver someone who provides you with regular services or your local pharmacist so it’s really easy program to tap into I do believe unfortunately there’s a bit of a waiting list because it’s such an excellent program but it is out there so if you have any loved ones who need a little bit of help there there it’s a short and sweet talk serve I references I know it was very general I didn’t really know what to speak about so we can answer entertain whatever questions going to have yes a medication calendar is um we take a calendar and you write what time of day you’re taking your medication and on what day and these are really helpful especially if patients are only taking medications sometimes once a week or once a month it helps people remember when to take them and if people bring that in it it just gives us the dates and the times so people find that very helpful I know we’ve started with our patients that have a lot of medicines to help prevent nausea and vomiting we’ve started doing that so we’ll be so specific to say 8 am-3 of these pills and will sometimes draw the shape and then at 10pm you take this one and so just defining the times on right on the calendar and they can post it and just go there they’re homemade yeah they’re homemade um yes I know some of the pharmacies the community pharmacies I do have that service if you ask for it I know the pharmacy that I do some local work with we we can do take the computer and do a little bit of typing out and they we can produce those for you so there is that access to I know if the meds check program often patients will walk away with that a calendar as well anything else anything specific to oncology and medicine and errors anyone sometimes it can be hard especially if you’ve got patients that are on a long list of notifications because they have lots of different things going on with them um often though the family is a good help they’ll know why patients are on something usually it’s obvious not all the times but most often in your blood pressure medications we can kind of help isolate that sometimes we use medications for things that they’re not necessarily designed for because we’re doing something a little what we call label but that’s very rare so often what we do is rely on the caregiver with the patient or sometimes we will call the community pharmacy and they tend to know have a really good sense of what that patients on so that’s about using multiple resources and there’s no I’ve been known to call the family physician and ask to so it’s just it’s about being that sleuth in problem solving and finding out exactly the reason behind it it’s a little bit more challenging now with the naturopathic medicine because it’s a little bit more gray because we don’t know as much information about those so that’s a new sort of avenue we’re all learning about here at the Cancer Center and so we’re really starting to tap into calling the naturopathic physician and finding out exactly why they prescribe certain items I was like over-the-counter medications just like would you list extra strength tylenol yep Julis gravel you know you would yes yes if you would all take it we we do want to know about it because sometimes what will happen is you’re going along you haven’t had town a couple months but if all of a sudden you’re starting to take tunnel you know three to four times a day on a regular basis there might be something there we can help you manage maybe your pain medications aren’t working or so yeah we even want to know that stuff it’s a lot of something like cold medicines do it get six that’s like–that’s that gets a little dynamic so maybe if you’re taking it within the last month or so we would want to know about it if it’s the summarized yeah yeah medications like it’s a it’s a mixture so it’s about how that so what we’re concerned with is how the medication breaks down in your body a lot of them go through the liver but a lot of them also go through the kidney so what we do is when we’re reviewing these things we we actually look at this one goes to the liver so does this one and are they going to cause harm so we do look at it from that that type of level and if we’re worried about your kidney function and and the drugs going through your kidney we do look at the blood test so we work with the doctors to say oh I think we should you know back off on that dose because they have these other medications that are also clear through the kidneys and we’re getting concerned so we kind of work as a as a team to help and I we often make recommendations to the physicians so

what we do now is that we have a physician and nurse team so they work really great together the pharmacist is it kind of after the fact luckily we’ll the IV chemotherapy it works okay because we review we review the chart completely before the patient’s hooked up to the chemotherapy so where we are a double check is just not you know at the time with the oral medications because the patient gets to walk away and go to another pharmacy often what happens is the physician or nurse if they notice the patients on a lot of stuff they’ll call us and they’ll say you know I’m a little concerned about mrs. Jones she’s on like 10 different things I’m worried about you know the interactions and I’m worried the community pharmacy may not have a complete list and so will them that way the computer system although I was having computer technical difficulties today is actually a great research for them as well because the computer system will also show them the drug interactions and they often call and say this is what I got do we need to be worried so we’re a little bit after the fact but we do ad hoc um some of them it’s just some of the the that’s an excellent question actually it’s just the nature of the beast unfortunately with those anthracyclines there they’re just toxic there they they’re not specific when I say not specific is we can’t guide them to any particular place in the body and they just tend to to make the heart work potentially less effective that doesn’t affect the other organs yes no so you can’t have other effect I mean your your blood counts do go down so with those chemotherapies and it can I guess they can affect your liver and but they affect mostly the heart that’s what we’re most fearsome of is the heart because we don’t want to do permanent damage so we’re that’s why we’re so cautious with all the extra monitoring because we we know with history that if we are not careful you know we can get ourselves into trouble so it’s just it’s they’re just very specific they just like that heart tissue whereas it I know the newest one on their market that causes problems the harvest the Herceptin her trust Susan map and the heart actually has so we say it’s specific to the cancer cells but the heart actually has those risks has been noted yeah so but it’s reversible so we but that’s what we’re just being really really careful because past has taught us a lot it’s a lot of these things we learn we learn through trial and error the one class of the drugs the anthracyclines can affect your heart but we watch very very carefully for that and they do regular and there’s we do put a maximum how much we let the body see so in that maximum is different per person based because we do or all of our chemotherapy don’t see none wait so and they follow up with regular echoes to to make sure we don’t we don’t go too far that would be mostly a judgment call by the physician it’s that would be very difficult for me to say and in this type of venue only because it’s that we’re getting a little bit more complicated and more doctor type questions but in terms of the drug be metabolized by the liver if my basic understanding is a pharmacist if the stent is in there and working properly there should be no problem the what therefore the liver should be able to break down that drug so that you can you can get rid of it from your body there’s so it’s an interesting question because right now a lot of the hospitals have established it for their impatience so when you come in through the emergency room so we have that established now the challenge has always been for outpatient clinics how to get that started it’s often a resource issue because you know that’s with anything I guess we’ll throw the big money thing out there but it’s also how often do you how often should we be doing these interviews because some of our patients come every day sometimes I radiation they come every day for a month so we shouldn’t we wouldn’t want to take up all your time we could be doing these lists all the time so it’s about finding our process so we’re all actually most of us in Ontario cancer centers specifically we’re all starting this new right now we’re all entering this water because we finally have realized this is a very important thing especially with all the oral chemotherapies so that we can really understand before the patient you know gets the chemo what we can do to adjust so it’s we’re all kind of in the same boat so we’re all going to learn from the journey together but we do often a lot of us talk to talk often and share share our stories and often a kind of say okay this didn’t work so what next so we do talk to each other our second speaker is dr. Cindy so dr so completed her medical school training family medicine residency and fellowship in palliative care through the University of Toronto she is on the Leadership Council for the division of palliative care in a Department of Family and Community Medicine and is also the medical director for palliative care supportive care at southlake please

welcome dr. Sol okay thank you very much so I’m dr. Sol and I am the medical director for palliative and supportive care here at Southwick as well as the Stronach regional cancer center and thank you for having me to speak today and I was asked to speak specifically on this topic in terms of medication safety regarding pain medication management and really there’s a lot of fears a lot of myths about pain medications so I thought it would be a good chance to really talk to you guys today and and maybe dispel some of those myths so we’re not so afraid of using these medications so before I talk about the pain medication specifically I want to talk about the concept of pain and a lot of us when we think about pain we think of physical pain but pain is much more than that there’s certainly functional effects of pain so how does it affect our day-to-day living are we able to do the activities that we used to do on a day-to-day basis or we’re very much limited because of pain there’s certainly spiritual aspects of pain especially with cancer people start to kind of question kind of psycho existential questions and then psychosocial factors and cultural influences can all affect pain so when we in paladin supportive care when we assess pain we’re looking at all these different dimensions of pain but today we’re probably going to focus more on the physical aspect of pain so this is quite a complicated diagram in terms of the pathophysiology and how do we experience pain but just to simplify it imagine we just cut ourselves we have a cut on our thumb essentially what happens is from your thumb there will be peripheral peripheral nerves that travel and transmit the signal of pain first so through this this nerve into the spinal cord that signal travels up into the brain and into the cortex and that’s where you perceive pain so pain is a perception okay now what you see here is a complicated diagram of the basically the transmission of that signal from one nerve to another as you travel up into the brain and essentially there’s a lot of receptors in these nerves and what we try and do with the pain medication is blocked these receptors and hence you’re blocking that transmission of signal of pain so when you go to your doctor and you tell that him or her that you have pain they’re going to go and do an entire pain assessment and these are the kind of questions that they’re going to ask you and I always find that pain is something very difficult to necessarily describe so these are ways that you can think of how you can prepare yourself to describe the pain that you’re experiencing with your doctor so they’re going to want to know when did it begin when’s the onset and how long does it last for is it’s just a couple of seconds this kind of pain or is it lasting for hours what what brings it on what makes it better what makes it worse anything that you’ve tried before and then try your best to describe the pain and pain is very difficult described but you can kind of contrast is it a dull aching pain or more of a sharp stabbing pain certain teams are throbbing in nature like certain migraine pain and then there’s certain types of pains that are burning shooting electric shock type so try your best to use your vocabulary to describe your pain because your description the pain really helps us delineate what the cause of that pain actually is does it spread anywhere is it a pain just in your shoulder or does it sometimes shoot all the way down into your arm that’s important for us to know as well and certainly the severity of pain how bad does the pain gap let us know if there’s any treatments that you’ve used in the past and if you’ve had a side effects to those pain medications because it’s important for us not to repeat those and then again as I alluded to in the beginning in terms of the concept of total paid what is your understanding of the pain what do you think is causing that pain how is it impacting your life possibly even your family life and what does our expectations for the pain if it’s related to cancer sometimes we can’t necessarily take the pain all the way down to zero but we can control it to a one to two to the point that you can still function in your day-to-day life this is something for those who have attended the Cancer Center probably very familiar with and probably fill out at nauseam essentially so this is the ESS or the Edmonton symptom assessment scale or system and essentially as you guys know we ask you to fill out 0 to 10 what D what are you feeling on that particular day in terms of pain in terms of nausea in terms of all these other symptoms I know it’s very difficult and I sometimes have patients just come and have it blank and say I don’t know how to fill this out it’s too subjective how do I do this and I really say to them that’s actually the point it’s meant to be subjective because it’s your personal experience of these symptoms and we you we actually take these scales quite seriously we record them on our computer every time and it’s a marker for us to tell us how you’re feeling how you’re dealing with the chemotherapy or the

radiation if more help needs to be given and our physicians particularly use this scale to decide whether they need to make a referral to our team the palliative and supportive care team so we’re seeing a lot of numbers on this right side on the tent that’s possibly when they make a referral to our team and I want it just to use this to take a moment to dispel a bit of myths about palliative care itself because a lot of people think that they would only come to see a doctor like myself if they’re really in their final days or hours type of thing and that’s traditionally what people think of as palliative care but really recently in the last 10-15 years or so health care spectrum has really expanded and we really try and get involved with patients and families early on even at the beginning of their diagnosis because a lot of people who have cancer do experience some sort of symptoms rather be pain or nausea or difficulty breathing and we can get involved early on and we hope and through this journey we hope and pray with you that things go well but if things don’t go about you already have an established relationship with us we already know the medications you’ve you’ve been on or that you’ve tried and then we can appropriately treat you when that time when or if that time comes so just thought i’d add in my little plug for palliative care and on the back of of your SS and you may or may not have noticed it there’s always a body diagram and this actually gets missed a lot and this is specific in terms of pain and for you to draw in you can shade it in you can circle you can cross off exactly where you have the pain because like i said the more information we can gather about your pain the more likely we’re going to be treating it effectively so if alluded to kind of different types of pain and that the words here are not important to remember really what I wanted to get across is there are different types of pain and when we’re taking these descriptions from you we’re trying to figure out what type of pain do we think it is going on the main two categories are nociceptors pain or better or easier way to understand that is inflammatory pain so this is a pin you would typically get if you cut yourself and it’s if it again getting very red inflamed and whatnot this is pain that you usually get in the bones and the muscles and the skin type of thing you can get around the organs as well and that’s the difference between somatic and visceral pain but that difference is not as important the contrast is neuropathic pain so this is pain that’s originating from the nerves and the irritation of the nerves so if you have a tumor in your axillary you’re under your arm that’s pressing on some major nerves in your arm under your arm you’re going to get paint you possibly could get pain that travels all the way down the arm and that pain is going to usually be you’re going to say burning like an electric shock you can get numbness and tingling so getting that description tells us oh this is probably nerve pain and we would actually use different medications to treat that so when your doctor asked you about your pain they’re going to first get a very detailed pain history they’re going to do a physical exam that’s appropriate and then they may look at any imaging that they’ve done x-ray CT MRI just to kind of have a better idea of where this pain is coming from so now we have an idea of what we think the pain is how do we treat it so this is something that you’ll find all over the Internet the wh 0 pain ladder and essentially the wh 0 have come up with guidelines for how you would treat pain and it is a step by step ladder from kind of mild to severe pain so the first step is we try to avoid opioid medications or some people may hear the word narcotic medications and just because they tend to have a little bit more side effects so we try to use non opiate medications first step 1 if that doesn’t work then we go to the second step which is kind of more week opioid and then third step would be stronger opioids the last step in something that we don’t do as often is we get our anesthetist evolved and involved in they can do nerve blocks or epidurals if the pain really is that severe usually we can manage with medications so that first step what are the non opiate medications well the most common one as one of them we mention already is tylenol and so it is important to know how much time well that you’re using and and nsaids are basically anti-inflammatory medications so something as simple as advil is an anti-inflammatory medication other people may be using celebrex or arthrotec for their arthritis so those are all anti-inflammatory medications that are non opioids there’s also bisphosphonates which some of you may or may not be familiar with their medications that we use for bone bone pain essentially for people who have cancer seating their bones and it can actually prevent you from having the risk of fractures as well if cancer has

seeded your bone so that’s something that we may or may not use if it’s appropriate and there’s another list that I’m going to go to and a little bit then we go to our weak opioids so these are probably these two are probably the most common week opioids you have your coding which most of you have heard of and tramadol which is not as common coding medication is what you find in in the tunnel twos and threes okay so when your doctors giving you twos and threes what they are are there’s some codeine in it a small amount of coding and some some tylenol component and the combination pill the important thing to remember about tunnel number threes or anything that has tylenol in it is that there’s a maximum amount of town mall that your body can take before it’s toxic to your liver so the very maximum amount of tunnel number 3s or tunnel number two’s you would ever want to take would be 12 two tablets okay usually with my patients by the time they’re getting to eight to 10 tablets I’m saying this medication isn’t the right one for you anymore we should switch it because of the toxicity to your liver and particularly if you have any sort of cancer spread all ready to deliver I probably would take you off it all together from the beginning even if you’re only taking a couple of tablets the big thing to remember with all coding medications and all opioid medications is these are very constipating medications that’s one of the side effects that unfortunately we have to deal with and so it’s important for you to get from your physician a bowel routine medications whether it’s stool softeners or stimulants or laxatives that you’re using on a regular basis if you’re going to be using these opioid medications on a regular basis now so those were the weak opioids these are what would be considered kind of the stronger opioids so oxycodone is a common one other people you guys may have heard of oxycontin or percocet a lot of people get that after surgery and and again percocet is important to keep in mind that is a combination of the oxycodone as well as a tunnel so again a combination pill and that’s why again there’s a maximum of 12 that you can use per day the advantage of these other medications morphine which most people have heard of hydromorphone and fentanyl all of them are all really opioid medications all in the same family i like to call them kind of cousins of each other the the thing about those medications are they don’t they don’t necessarily have a ceiling effect meaning you can keep using and using it to a limitation with the with the vice of your physician but there’s no maximum that you can necessarily take and every one is different compared to as I mentioned the percocet and the Town Hall number three you don’t want exceed 12 one thing in one myth that I get a lot from people is oh if you’re on morphine that’s it you’re done you’re must be at the end of the rope but that’s not true we have a lot of people on morphine or its cousins for a very long period of time doing quite well and controlling their pain well and I put again a note to remind myself to remind you guys about the bowel regimen so all these medications are constipating make sure taking something for your bowels so what are the different ways you can get pain medications and the main one that we’ve been focusing on and the one you’re most familiar with is oral medications and in terms of oral medications there’s different types there’s long-acting oral medications and short acting and the clue about long-acting is usually it’ll end with the word content so this is oxycontin MS contin hydromorphone content that’s the sign that it’s long-acting and another son that’s long acting is usually it’ll come in a capsule form because what happens is you take the capsule and slowly it’s releasing over the next eight hours over the next 12 hours some medication in your system this compares to or contrast with short-acting medication where you take it and it’s to give you immediate relief so usually within 30 minutes or an hour you’re getting that mix that that that peak effect and then it starts to kind of Wayne over time so with short acting you’re kind of getting more hills and valleys with long-acting you’re getting a more slow and steady pain medication in your system and other ways you can get pain medication transdermal meaning a patch on the skin the most common one that people will have heard of is fentanyl patches and certainly we can give injections so the injections can be under the skin which we call subcutaneous or obviously through an IV and sometimes I even need to put patients on what we call a pain pump so they have a continuous infusion of pain medications going through them either on a nap or under their skin or through an IV port I just listed some less common

ways that you may get pain medication transmucosal where there’s actually a new product that just came out in the last six months or so where’s a pain medication that actually dissolves under the tongue or a patch that actually you can apply to the to your cheek and it absorbs that way and that probably over time will be more commonly used for these extra breakthrough pain episodes you can if you have a feeding tube of the immense your pain medications through there and as I mentioned anesthetist would give nerve blocks or epidurals to people to give them pain medication so these next few slides are probably what I wanted to impress on people the most so when you’re your physician starts you on pain medication they’re going to start you on short acting pain medication to begin with and short acting medication another way to call it is breakthrough pain medication okay and so you’re going to start with breakthrough pain medication and you’re going to be told to use it as needed and there will be different instructions if it’s percocet or tomm well you’re probably going to be told you can use it every four to six hours as needed if it’s something like morphine Oh hydromorphone I typically write prescriptions that say you can use them every one to two hours as needed okay again any oral form of medication usually starts to peak around 30 minutes to an hour so by that one hour mark you really should start to feel that effect of the pain medication now if you don’t that may mean that that dose wasn’t adequate and that’s why it’s safe and okay to take that second dose and that’s why i dosed my medication every one to two hours as needed because it allows you to take more injectable medications work a little faster and that’s why if you come into the emergency room will give you an injection and you find that works a lot quicker because that’s how that’s how it works but the important thing to remember and I can’t stress this enough is really to record the amount of breakthrough medications that you’re using this is really really important so whether it’s Tom well threes percocets a morphine hydromorphone please put keep a record of how often you’re using it because this really helps us titrate your next dose of pain medication and a pain diary similar to a medication diary but it’s for you to record for us what time you’re using that extra pain medication and sometimes people even record other details like how quickly that pain medication worked or if you had any side effects that sort of thing record that for sets again useful information this is a question I get when do I use this breakthrough medication a lot of people like to wait their pain is eight out of ten or wait nine out of ten then it’s ten out of ten and that’s when they use it the difficulty is then you’re already dealing with a pain level at this level using maybe a small amount of medication and only brings it down a little bit you should really use the pain medication when you really start to become uncomfortable and that’s going to be different for every person usually i would say once paynes hitting a 4 to 5 out of 10 it’s probably a time to you should start to think about using your pain medication don’t wait until it gets bad and think about your activities a lot of people start to get pain if they’re more active one day they know where they’re going to go for outing and that day they know they’re going to really suffer with pain so think about using it before you go out just as a preventative measure same thing with physiotherapy and exercises it’s a good idea to take a break through pain medication before you before you and go for your exercise so this is I just this is just a copy and paste of a calendar of january two thousand twelve and this is just to say this is probably the easiest way for you to record your breakthrough pain medication use just print out a calendar from from the internet and every time you use a morphine tablet just put a one and that way you’re recording exactly how many times are using it and it’s not taking up too much of your time and then bring that calendar into your physician so he or she has a very clear record of how often you’re using it so what happened so let’s say you did this calendar you brought in this brought it into your position and he’s looking and seeing you’re using five or six breakthroughs a day what they’re going to do that or they’re going to consider starting you on that long-acting medication so then you’ll get a capsule probably once in the morning and once at night that is slowly giving you that pain medication dose that you have told us is what’s adequate for you for your pain control over time and the goal would be that you can still use their breakthrough medications in between but the goal is to cut it down so maybe some people don’t need to take any extra pain medication in between sometimes you need one or two extra because we know that pain isn’t static pain is always waxing and waning and sometimes you need an extra but we’re trying to avoid you from

needing extra five or six times a day so that long-acting medication is typically given every 12 hours so 10 am-10 p.m. or 8 am-8 p.m. sometimes for some people we do it three times a day so every eight hours again keep using the breakthrough pain medication just because you’re a long-acting doesn’t mean that’s it you can’t use anything else you can still use the breakthrough but again record it for us so we know how much you’re using and if you’re using a lot make sure you book that follow-up appointment with your physician because they’ll probably need to do the next step in terms of increasing your medications and one of the common questions that you get is what’s the side effects of these medications so generally they all have very similar side effects number one like I mentioned before is constipation dry mouth can be a common one as well not that much we can do for that other than kind of keeping yourself hydrated and and then these two I’ve start them nausea vomiting and sedation those two are side effects of pain medications but generally tolerance develops to those side effects so usually within 48 to 72 hours of starting the new medication or getting a major bump in your medication that side effect will actually go away as your body gets used to it some of the less common side effects or itch or a rash some people have what we call urinary retention where they actually have difficulty urinating and other people have a true allergic reaction although having a chew allergic and a full active reaction is quite rare to this class of medications so I put on here just to remind us again about the constipation different medications and most of these are over-the-counter that you may use to help with your bowel routine the first one is a stool softener the main one that you’ll see out there is colace or so flax it’s a red jelly pill and you probably want to use that on a regular basis to keep your stool soft the second type of medication are what I call still stimulants so these are things that stimulate the bow to keep moving because these medications actually slow the gut down a little bit the big ones that usually that we give our son a club or dulcolax and again both of those are over the enter and then lastly even if you’re using the stool softeners already you’re using the stimulants but you’re still having difficulty that’s when we use kind of more rescue laxatives so there will be certain very sweet drinks that you may use you may take like lactose or milk of magnesia and then certainly suppositories and enemas can be ordered through your physician and some of them are over-the-counter as well but to get your bowel routine to figure out what’s best for you that’s something you should consult with your family doctor or your oncologist or certainly palliative care physician so this is a long list of medications and we call them adjuvant so these are all medications that we can use along with the opioid medications to help pain and there’s no need to go into all these specific ones because it really is used on a case-by-case basis but I wanted to show you that there’s a lot other pain medications that we use as well but the baseline usually is some sort of opioid medication antidepressants can be used and even anticonvulsants can be used and these two are very good for nerve pain probably something that most people fear is about addiction they think they’re good they’re going to take one percocet and they’re going to be addicted the important thing really to distinguish in this chart distinguishes well is what is the definition of an addiction so an addiction is when you have no control over your use of the medication or the drug that you crave it you have compulsions to use it and you’ll use it whether you have pain or not you keep using it and whether it’s causing you harm or not you keep using it that’s the definition of an addiction that is different from what happens in the normal physiological way what we call dependence or tolerance tolerance would be you’re using a small amount of medication one day and that seems to work well then a couple days later you notice you’re using a little bit more not a couple is usually it would be much longer than that that phenomenon can be many things can be causing that phenomenon the first could be the source of the pain could be getting worse to begin with especially if you have cancer if your cancer is spreading you may need more pain medication just because of that over weeks sometimes your pay your body gets used to the medication a little bit and that’s why you need an increased dose or you need a switch of the medication but that’s not an addiction that’s a normal physiological response of the body and and then obviously diversion which would be taking the medication then selling them on the street that’s certainly

illegal and we wouldn’t condone that opioid toxicity so this is another big fear people think they’ll take one percocet of one morphine and then this is the kind of your at the end you’re going to die it’s going to look really horrible and it’s true there is such thing as Opio toxicity these medications can be dangerous if not used correctly but if you use it the way that I had just described extremely unlikely that you would have any of these issues so Opio toxicity essentially is an overdose of pain medications what you would see is all of these kind of symptoms altogether so we’re not just talking a little bit of sedation but you’re talking about someone who’s extremely drowsy you can barely arouse them and they can be confused they might be having visual or auditory hallucinations seeing things and hearing things neurotoxicity is they kind of feel this pain all over their body it’s like this fiery pain that spreads throughout they can get seizures myoclonus would be kind of a jerking sensation that they get in their body and then last but not least respiratory depression meaning they’re they’re breathing slows down so I can’t say that it’s not possible so it’s certainly possibly can get these but it used in the right way this would not happen okay the causes of it the major cause is going to be medication errors so whether there was a conversion error or you’re using it much too much compared to what you’re supposed to or if your dose was changed much too quickly that’s possible that you could get a toxic another important thing to think about is if we’re adding those adjuvants if we’re adding extra chemo or extra radiation that’s shrinking your disease you may as a result get less pain and as a result you may not need to be on that same dose of long-acting medication your doctors originally prescribed and if if that was truly a case and there was a really big difference technically you could become toxic so it’s really important to have regular follow-ups with your physician to find out so that they can figure out if you’re not using any breakthroughs anymore at all and you’re finding yourself a little bit sleepy probably it’s time to go down on the medications and not up so it’s important to have very regular follow-up with your physicians especially if you’re getting chemotherapy and radiation a few other ones i listed there’s infection and dehydration that can certainly affect the medication toxicity so we’ve been through a lot on this talk I just wanted to conclude with kind of some take-home points so like I said in the beginning pain is multi-dimensional it’s not just the physical effect but there’s the entire total pain syndrome it’s extremely rare to be addicted to pain medication especially if you’re using it appropriate for cancer related pain the biggest point is recording your breakthrough use because it’s really vital for us to use that record to titrate up your pain medications in a safe stepwise manner and lastly get those frequent reassessment from your physician because we really were doing that assessment frequently for your own safety okay so that’s my talk but I’m happy to entertain any questions you guys may have yeah go ahead is so that’s a good question and we’re always trying to make sure we communicate with each other as much as possible I’m call just their main role is to take care of the chemotherapy medication certainly have skills and helping with pain and symptoms but when things get tricky first of all they would probably refer to us but we always like to keep the family doctor in the loop your family doctor would probably the appropriate person to be getting these frequent reassessments that I’m alluding to in my my talk about in terms of the pain medication but obviously it’s important to update your oncologist as well but their main role is really to monitor how your how your cancer is doing how it’s responding to the actual chemotherapy or the radiation and they certainly have a side wall and can help expedite getting new medications when you’re waiting for your family doctor but your family doctor should be in the loop the entire time so for me my clinic i use the dictation system so I every time I see a patient I’ve always dictate the note and a note gets sent either a fax store or mail to the family doctor and that’s how most of the oncologist would work here as well 44 grams its programs around before so the tunnel 3 is 3 if I get a regular shrink okay sometimes are strict sometimes regular strengthen that fold out so no more than eight extra strength no more than so it’s more grateful Andy back they might be lowering it to my think

thirty two hundred milligrams Oh boobs at the free tonight all these check your other medicines there’s tylenol acetaminophen again allergy medication [ __ ] but all kinds of things you’re tracking anti-mafia where’s it’s in a lot thank you for that that’s a good point so just think about anything anything that you think is going to really trigger that pain really it’s best to prevent it from happening to begin with and I mentioned exercises just because I find for our patients who really want exercise their pain is limiting them and they can’t do as much as they want to do but their pain is better control they can walk that extra however many steps or do that much more stairs and then they’re getting the physical benefits of the exercise rather than just suffering through and then giving up yeah and unfortunately I think that’s human nature no one really likes to be on medication so you try and avoid and avoid it but if you use it and it’s because a lot of people have these fears that I talked about about these pain and medications but if you use it in the correct way it’s it’s certainly really really effective and safe and I think those are all very valid good treatments for pain and I’m glad you brought that up because it brings me back to that very first slide when I talk about total pain and one of the things on there was that psychosocial spiritual and whatnot and so meditation is all part of that and certainly if you take someone a simple example as you take someone who’s extremely depressed and someone who is feeling okay in terms of their mood and they have the exact same pain you can bet that person who’s feeling extremely depressed is perceiving that pain a lot worse than the person who isn’t so again that’s why antidepressants is part of our medication management because sometimes we just give someone a medic antidepressant and they suddenly feel like they can cope better with things and they don’t need to use as much pain medication so all of those interventions are all important I think it’s important to consider having some from one realm and some from another realm so some medication and some non medication and combine them together rather than just going with one alone because probably together is what’s most beneficial anything else that I can answer for you guys