You should suspect that pain is of bony origin if there are known bone metastases or a cancer which commonly spreads to bone e.g. breast, lung, renal, prostate.
Bone pain can be extremely debilitating because it affects function in so many ways. The treatment priorities are first getting pain relieved to allow sleep, then when sitting up and finally when moving about.
The two things to bear in mind are:
- Cord compression from worsening vertebral metastases. Symptoms are worsening pain or heavy legs.
- Risk of pathological fracture in a long bone. Symptoms are sudden worse pain on weight bearing.
Consider urgent scanning for rapidly changing pain.
Bone pain is usually well localised, might be worse on weight bearing (depending on site) and may be tender to touch.
An initial approach to treatment
- Apply hot or cold packs
- Paracetamol, NSAIDs and titration of a strong opioid - e.g. titrate oral morphine solution from 2.5mgs 4 hourly
- A prn dose of analgesia before planned activity may help e.g. before a walk
- Consider applying a lidocaine 5% plaster if the bone pain is very superficial e.g. a rib metastasis
- You can ask about analgesic effect 30-60 minutes post dose, as the dose may be too low
- Urgent control for severe bone pain - dexamethasone 6mg a day for 5 days and then review (a good response to steroids may be an indication to refer for radiotherapy).
- Bisphosphonates are widely used, often intravenously. There may be a role for oral bisphosphonates
- Radiotherapy is always considered for persistent metastatic bone pain
- Denosumab is a subcutaneous option that oncologists may recommend instead of bisphosphonates
- Surgical stabilisation is not often used but can be dramatically helpful