Date of Award

2024

Degree Name

Master of Science (Medicine)

Schools and Centres

Medicine

First Supervisor

Professor David Kissane

Second Supervisor

Associate Professor Natasha Michael

Abstract

Pain is a multidimensional personal experience influenced by biological, psychological, social and cultural factors. In the context of cancer pain, particularly cancer-induced bone pain (CIBP), it is essential that clinicians assess the multidimensional nature of pain to fully understand the patient’s pain experience, which often involves an evoked sense of both vulnerability and mortality.

Bone metastases are highly prevalent in advanced cancer, resulting in CIBP being one of the most common cancer pain syndromes. CIBP affects a patient’s physical and social functioning, reduces quality of life, increases psychological distress and often results in hospice or hospital admission. Yet, there is limited evidence to guide analgesic management. The complex pathophysiology and varied clinical presentation of CIBP warrant personalised management guided through standardised assessment.

In this thesis, the candidate used the Edmonton Classification System for Cancer Pain (ECS-CP) to assess the multidimensional experience of pain in patients with bone metastases. The five assessed domains were correlated with pain intensities and opioid requirements. Additionally, the candidate identified refractory CIBP and recruited these patients to examine the possible efficacy of methadone rotation (MR) compared to other opioid rotations (OOR) in a pilot randomised controlled study.

The studies reveal the challenge in managing CIBP lies in the high prevalence of breakthrough pain, which was associated with neuropathic pain, higher average and worst pain intensities and higher opioid requirements. Opioid rotation, including rotation to methadone, is safe and acceptable to patients while reducing pain intensities and pain interference in daily life. It also suggests that MR may have the additional benefits of providing earlier and more sustained pain reduction, particularly for worst pain intensity, with the utilisation of lower opioid equivalent doses.

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