BoardsBridgeBone Metastases — Cancer Pain Management for the Anesthesiologist
Multimodal analgesia and interventional options for severe cancer pain from osseous metastases — WHO stepladder, bone-modifying agents, neuraxial therapy, and perioperative opioid management.
Bone metastases from breast, lung, kidney, and prostate cancer produce severe mixed nociceptive-neuropathic pain via perineural invasion, osteoclast activation, and periosteal stretch; multimodal therapy with bone-modifying agents, opioids, NSAIDs, and interventional/neuraxial techniques is the cornerstone of management.
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BONE-MET PAIN HEADLINE: Mixed nociceptive-neuropathic; start WHO stepladder + bone-modifying agent; escalate to neuraxial or interventional when 10-20% refractory.
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Key numbers
- Neuraxial morphine 1-15 mg for refractory cancer pain (Miller's Ch 47)
- IV M6G 0.5-4 mg effective for cancer pain 2-24 h without nausea/vomiting (Osborne et al, Miller's Ch 22)
- TTS fentanyl 100 mcg/h ≈ oral morphine 200 mg/day; TTS buprenorphine 35 mcg/h ≈ oral morphine 30 mg/day
- 15-90% of solid-tumor cancer patients report pain; 60-90% of advanced/actively progressing disease
- ~20% of cancer pain is treatment-related (chemo neuropathy, radiation neuritis), NOT tumor-related
- 10-20% of cancer pain refractory to parenteral management → consider interventional/neuraxial
Uri Rozen, MD — Licensed Physician, Israel
Source guidelines: Millers Anesthesia 10 Ch48 Palliative Medicine · Millers Anesthesia 10 Ch22 Opioids · Millers Anesthesia 10 Ch47 Management OF THE Patient With Chronic Pain · Millers Anesthesia 10 Ch28 Preoperative Evaluation
Re-review cadence: 12 months from reviewed date.
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Card ID: bone-metastases · Path: aba.pain.cancer-pain.bone-metastases