Myeloma Today speaks with Daniel R. Kloster, MD
Myeloma Today: What is your specialty, Dr. Kloster?
Daniel R. Kloster, MD: I am a pain management specialist. I treat cancer and chronic pain.
MT: What is the most common complaint that you hear from myeloma patients?
DRK: Bone pain is a big problem for many myeloma patients. When the bone tissue of the vertebral body is involved, the patient can experience severe pain. Such pain is often worse with movement or weight-bearing.
MT: How do you treat such cases?
DRK: Myeloma-related pain can be tough to treat. For some such patients, an implantable morphine pump may be the answer. Morphine still has a bit of a social stigma but it is a very good medicine for combating pain.
MT: What is a morphine pump and how is it implanted?
DRK: Implanting the device involves two incisions, one in the back and one in the belly. The unit delivers approximately a raindrop of morphine per day. Morphine works in the spinal cord, regardless of whether it is taken orally, intravenously, or via a patch. When morphine is taken orally, the dosage required to achieve pain relief often causes sedation. The pump delivers the morphine directly where it needs to go, and provides excellent pain relief at a lower dosage without undesirable side effects. The rule-of-thumb calculation is that a 300 mg morphine pill provides pain relief equivalent to only 1 mg of morphine delivered via a pump.
MT: What are the risks associated with this device?
DRK: When you first put in the pump, there is a 2% to 5% risk of infection. If an infection develops, the pump must come out and the patient must wait 3 months before attempting the procedure again. That is the most common problem I've seen. I have never had a pump malfunction or seen any mishaps but, because we're dealing with morphine, I always have a very serious discussion with all my patients so that they understand all the potential consequences.
MT: How is the morphine dosage controlled?
The dosage and rate of delivery are programmed by the doctor through a computer. For some patients, it is best to receive a steady dose throughout the day. However, if a patient complains of experiencing increased pain at certain times of the day, the pump can be programmed accordingly. For example, if a patient complains of severe pain while getting up in the mornings, the pump can be set to deliver a slug of medicine 30 minutes before the alarm clock goes off.
MT: How closely do you monitor your patients?
DRK: Once they are on a steady regimen, I see them when the pump needs to be refilled, usually every 2 to 4 months. But until I've ascertained the most favorable pump settings, I see patients as often as necessary.
MT: Besides bone pain, what is another pain issue that myeloma patients encounter?
DRK: Herpes zoster (shingles) and resulting post-herpetic neuralgia (PHN). Once a person has had the chicken pox, the virus remains dormant in the spinal cord where it is held in check by the immune system. If the immune system is compromised for any reason, it may no longer be able to suppress the virus. Once a shingles outbreak occurs, the nerve is damaged by the viral infection and the patient can experience miserable pain and burning sensation. Quite frankly, PHN is the toughest thing I've had to treat.
MT: What recommendation can you make to a patient experiencing shingles or PHN?
DRK: It is essential to start taking antiviral medication at the earliest sign of shingles and to continue taking it for the entire duration of an outbreak. Taking a low-dose tricyclic antidepressant (TCA) in combination with the antiviral medication dramatically reduces the risk of developing PHN. And even if PHN does occur, it is likely to be much milder. The success rate is highest when TCA treatment is started immediately upon the onset of shingles. Nortriptyline is the TCA that I prescribe most frequently. TCAs work in the brain and spinal cord where messages of pain are received from the nerves.
MT: What other medications reduce the pain of shingles or PHN?
DRK: Anticonvulsant medications change how the body interprets pain. They help to quiet overactive nerves. Gabapentin (Neurontin) is the anticonvulsant that I prescribe most frequently, followed by topiramate (Topamax).
Opioid medications target the same locations in the body as do the body's own endorphins, so they can reduce the level of pain very quickly. Unfortunately, patients with PHN often have a suboptimal response to opioids. However, they are still worth trying.
Local anesthetics impede the pain messages sent to the brain and can be used to treat damaged nerves. For example, a lidocaine patch applied to a painful area can quiet the activity in the nerve cells damaged by shingles. Ointments and gels can be useful as well.
MT: Thank you, Dr. Kloster. Any there any closing thoughts that you would like to share with our readers?
DRK: Creating a pain-management plan is a very individualized process, which often involves trial and error. The doctor and patient must work together to find the best solution for pain relief with the least side effects possible.