1. A Practical Approach to Cancer Pain Management

2. The Problem: One out of three people in the U.S. will develop cancer
One out to two people who develop cancer, will die of their disease
Three out of four patients who die of cancer, will have significant pain during their illness

3. Impact of Uncontrolled Pain:
Physical:
symptom complex (fatigue, depression, NC)
decreased function (work, AIDLs, ADLs)
Emotional
total mood disorder
spiritual distress
Social
family interactions
alters support structures

4. Pain Assessment:
Intensity
Etiology
Type

5. Measurement: Scales: Outcome Measure: Tools: Numeric rating scales
Visual analogue
Descriptive
Outcome Measure:
Pain intensity
Distress
Relief
Interference
Breakthrough dosing
Tools:
Brief Pain Index
Memorial Pain Assessment Card

6. Clinically Important Questions:
Current pain level
Average pain level
Worst pain level
Pain relief with medications

7. Etiology: Treatable Causes: Emergent: pathologic fracture bone met
chest wall recurrence
Emergent:
cord compression
brain met

8. Nociceptive Pain Mechanism: Pain receptor activation Subtypes: Somatic
most common type in cancer patients
bone mets most common cause
characterized by aching, throbbing, gnawing
Visceral
deep, squeezing, crampy

9. Neuropathic Pain: Mechanism: Damage to receptor or nerve
Frequently unrecognized
Types of Syndromes:
Peripheral
Drug induced (Cisplatin, Taxol)
Central
Cord compression

10. Neuropathic Pain Syndromes:
Post-amputation Limb Pain
Post-thoracotomy Pain
Post-mastectomy Pain
Brachial Plexopathy
LS Plexopathy
Celiac Infiltration

11. Assessment of the Patient:
Medical Problems
Psychological Function
Physical Function
Cognitive Function
Support Services
Financial Services
Educational Status

12. Ready to Prescribe: Rx

13. Skill Sets Required for Adequate Pain Control:
Develop a framework for writing prescriptions
Write a fixed dose regimen
Calculate an appropriate breakthrough dose
Convert from one opioid to another
Dose titrate
Understand the issues of substance abuse

14. WHO Step Ladder of Pain Management:
NSAID
Acetaminophen
Non-pharmacological techniques
Step 2
Mixed opioid + non-opioid
Low dose pure opioid (oxycodone)
Alternative pharmacological agents (i.e. Ultram)
Step 3
Pure opioids
Adjunctive medications
Invasive procedures

15. Step 3: Basic Rules for Opioid Administration
Goal: Controlled Pain (4 or fewer rescues)
Dose Escalation: Quickly until controlled pain
Maximum Dose: Does not exist
Side Effects:
Accommodation in 7-10 days
Treat aggressively
Bowel Regimen

16. Basic Rules for Opioid Administration:
Use oral or transdermal formulations if possible
Start with immediate release formulations in patients with significant pain
Use medications around-the-clock for constant pain (fixed dosing)
Fixed dose interval should be based on T1/2 of the agent
Rescue dose interval should be based on time to peak effect

17. Meperidine: By product - normeperidine
T1/2 of normeperidine is longer than meperidine
Normeperidine has a neuroexcitatory effect
Toxicity is seen when administered over a prolonged period or in patients with renal insufficiency

18. Fixed Dose Administration:
Goal: to maintain opioid levels within the therapeutic window
Fixed dosing allows a steady state to be achieved
Once steady state is achieved, dose modifications can be made in a calculated way

19. Dosing on a Fixed Interval:

20. PRN Dosing:
Patients take pain medication as needed, thus they are in pain when they take a dose.
Patients are in pain more frequently
They are more likely to have side effects

21. Dosing on A PRN Basis:

22. Fixed Dosing: Medication Half Life
Immediate Release:
Morphine: 3-4 hours
Dilaudid: 2-4 hours
Oxycodone: 3-4 hours
Hydrocodone: 3-4 hours
Sustained release:
Morphine
MS Contin: 8 to 12 hours
Avenza, Cadian: 24 hours
Oxycodone
Oxycontin: 8 to 12 hours
Fentanyl
Duragesic Patch 18 hours

23. Write a Fixed Dose Prescription for the Following:
Morphine Sulfate IR 30 mg tabs
MS Contin 30 mg tabs
Dilaudid 4 mg IR tabs
Duragesic 25 ug patch
Oxycontin 20 mg tabs

24. Write a Fixed Dose Prescription for the Following:
Morphine Sulfate IR 30 mg po q 4 hours ATC
MS Contin 30 mg po q 12 hours
Dilaudid IR 4 mg po q 3-4 hours ATC
Duragesic 25 ug patch to skin q 72 hours
Oxycontin 20 mg po q 12 hours

25. Breakthrough Dosing: Breakthrough medications should be fast acting
Dose interval based on Time to Peak Effect
Dose should be 10-15% of the 24 hour opioid fixed dose total

26. Example Breakthrough Dosing:
MS IR 60 mg po q 4 hours
24 hour fixed total = 360 mg
MS IR 30 mg po q 1-2 hours
Dilaudid 16 ug po q 4 hours
24 hour fixed total = 64 ug
Dilaudid 6 ug po q 1-2 hours
Duragesic 100 ug patch q 72
24 hour morphine equivalent
MS IR mg po q 1-2 hours

27. Acute Management: Moderate to Severe Pain
Previously on Mixed Agents:
Start with MSIR 30 mg po q 4 hours
With MS IR 15 mg po q 1-2 hours prn
Opioid Naive or Frail/Elderly
Start with MSIR 15 mg po q 4 hours
With 1/2 of a 15 mg tab po q 1-2 hours prn

28. Equi-analgesics: Need to be able to convert from one agent to another
Most tables compare to a specified dose of morphine
Equi-analgesics charts are rough estimates
Considerable inter-patient variability exists
General rule: when converting form one agent to another, find the equi-analgesic dose and decrease by 25% due to non-cross resistance

29. Key Equi-analgesics Ratios
Morphine to Dilaudid: 5 to 1
Morphine to Hydrocodone: 1 to 1
Morphine to Oxycodone: 1 to 1
Morphine to Duragesic: 2-3 to 1

30. Method: Step 1: Step 2: Step 3: Step 4:
Calculate the 24 hour fixed dose total
Step 2:
If necessary, convert to morphine equivalents
Step 3:
Using the appropriate ratio, calculate the 24 hour fixed dose equivalents of the new agent
Step 4:
Divide the 24 hour fixed dose total by the number of doses per day

31. Conversion Examples: Convert MS IR 30 mg po q 4 hours to Dilaudid
Convert MS IR 30 mg po q 4 hours to Duragesic
Convert Dilaudid 8 mg po q 3 hours to Duragesic

32. Conversion Example 1: Step 1: (calculate the 24 hour fixed dose total)
Morphine 30 mg po q 4 hours = 30 x 6 =180 mg
Step 2: (convert to morphine equivalents)
Not needed
Step 3: (apply appropriate ratio)
180 x 1/5 = 36 mg of Dilaudid
Step 4: (divide by number of doses per day)
36 / 6 = 6 mg every 4 hours

33. Conversion Example 2: Step 1: (calculate the 24 hour fixed dose total)
Morphine 30 mg po q 4 hours = 30 x 6 =180 mg
Step 2: (convert to morphine equivalents)
Not needed
Step 3: (apply appropriate ratio)
180 / 2-3 = ug of Duragesic
Step 4: (divide by number of doses per day)

34. Conversion Example 3: Step 1: (calculate the 24 hour fixed dose total)
Dilaudid 8 mg po q 4 hours = 8 x 6 = 48 mg
Step 2: (convert to morphine equivalents)
48 x 5 = 240 mg
Step 3: (apply appropriate ratio)
240 / 2-3 = mg of Duragisic
Step 4: (divide by number of doses per day)
Not needed

35. Titration Schema: Initial Fixed and Rescue Dose Controlled Pain
Moderate Pain
Severe Pain
No Change
25% Increase
50% Increase

36. Example 1: 65 yo with bone pain due to metastatic prostate cancer
Current regimen:
MSIR 30 mg po q 4h ATC
MSIR 15 mg po q 1-2h prn
Reports pain 1/10 with 10 rescue doses/24h
Calculations:
24h narcotic total = (30mg x 6)+(15mg x 10) = 330mg
New Fixed dose = 330 / 6 = approx 60 mg
New Regimen:
MSIR 60 mg po q 4h ATC
MSIR 30 mg po q 1-2h prn

37. Example 2: 65 yo with bone pain due to metastatic prostate cancer
Current regimen:
MSIR 60 mg po q 4h ATC
MSIR 30 mg po q 1-2h prn
Reports pain 5/10 with 8 rescue doses/24h
Calculations:
24h narcotic total = (60mg x 6)+(30mg x 8) = 600mg
New 24h narcotic total = = 750 mg
New Fixed dose = 750 / 6 = 120 mg
New Regimen:
MSIR 120 mg po q 4h ATC
MSIR 75 mg po q 1-2h prn

38. Example 4: 65 yo with bone pain due to metastatic prostate cancer
Current regimen:
MSIR 60 mg po q 4h ATC
MSIR 30 mg po q 1-2h prn
Reports pain 9/10 with 8 rescue doses/24h
Calculations:
24h narcotic total = (60mg x 6)+(30mg x 8) = 600mg
New 24h narcotic total = = 900 mg
New Fixed dose = 900 / 6 = 150 mg
New Regimen:
MSIR 150 mg po q 4h ATC
MSIR 90 mg po q 1-2h prn

39. Long Acting Formulations:
Should be used in controlled pain only
Determine the amount of narcotic needed to control pain with short opioids then convert to long acting formulations
If pain becomes uncontrolled, switch to short acting agents, titrate rapidly, then convert back to long acting agent

40. Sustained Release Formulations:
Morphine
Oxycodone
Fentanyl
Dilaudid

41. Example 5: 65 yo with bone pain due to metastatic prostate cancer
Current regimen:
MSIR 60 mg po q 4h ATC
MSIR 30 mg po q 1-2h prn
Reports pain 1/10 with 1-2 rescue doses/24h
Calculations for MSSR with half-life of hrs:
24h narcotic total = (60mg x 6) =360
New Fixed dose = 360 / 2 = 180 mg
New Regimen:
MSSR 180 mg po q 12h ATC

42. Transdermal Fentanyl Patch Size: 25, 50, 75 and 100 micrograms
Duration of Action: 72 hours
Advantages:
Easy, convenient use
No need to remember to take meds
Disadvantages:
Difficult when using high dose of narcotics
Thin patients with little subcutaneous tissue

43. Consider Patch in the Following Patient Populations:
Non-compliant patients
Patients unable to take oral medications
Question of drug abuse
Question of cognition

44. Conversion Factor:
100 mg Morphine
50 micrograms Fentanyl

45. Example 6: 65 yo with bone pain due to metastatic prostate cancer
Current regimen:
MSIR 60 mg po q 4h ATC
MSIR 30 mg po q 1-2h prn
Reports pain 1/10 with 1-2 rescue doses/24h
Calculations for Fentanyl (Duragesic®) Patch:
24h narcotic total = (60mg x 6) =360
New Fixed dose = 360 / 2 = 150 g
New Regimen:
Duragesic 150 g to skin q 72h ATC

46. IV/SC Narcotics Use: Relative Strength: Role of PCA Schedule: Rescue:
Pain Emergency
Unable to take po
High narcotic needs
Toxicity from po
Relative Strength:
IV 3 times more potent than po
Role of PCA
Schedule:
Continuous Infusion with bolus for rescue
Rescue:
Rapid Peak
Fast Clearance
q 10 minutes
Hourly dose equal hourly rescue

47. IV Example 1: Pt admitted for elective surgery Controlled pain on:
MSIR 60 mg po q 4h ATC
MSIR 30 mg po q 1-2h prn
24 hour narcotic total = 360 mg
IV equivalent = 360 / 3 = 120mg/24h
Hourly rate = 120 / 24 = 5 mg h
Order:
MS 5 mg/hr CIV
MS 1 mg q 10 minute IVB prn

48. Pain Emergency: Step 1: Narcotic Load
Narcotic Load using IV boluses until pain level reduced by 50-75%
Step 2: Calculate Maintenance Dose
MD = Load/2 x half-life
Step 3: New Order
MD in mg/hr
rescue - bolus q 10 minutes

49. Pain Emergency
High Dose Decadron
Anesthesiology Consult
Neurosurgery Consult

50. Barrier Reduction: Patient education: Endpoint to be assessed:
Beliefs
Communication skills
Knowledge pain control
Outcome of interventions:
Improve beliefs and adherence
Results variable for improved pain control
Physician and staff education:
Endpoints to be assessed:
Knowledge
Attitudes
Practice patterns
Pain control

51. Ongoing Education: Testing Two Intervention Strategies
Patient population:
Patients with cancer related pain requiring narcotics
Design:
Group 1: baseline education only
Group 2: “hot line” for questions or emergencies
Group 3: Provider initiated weekly follow-up
Results:
Improvement in beliefs with baseline education
No improvement in outcome with ongoing interventions

52. Narcotic Titration Order Schema: A Pilot Trial
Endpoint:
severe adverse events
Patient Selection:
pain with a level of 3 or greater
requiring narcotics
Methods:
nurse managed order schema with “physician contact” parameters
tools:
Patients: MMSE, pain dairy, BPI, CES-D, STAI
Family: F-COPES, FIRM, CSI

53. Narcotic Titration Order Schema: A Pilot Trial
Results:
No severe adverse events
Feasible in the clinic setting
Future Directions:
Phase III Trial through VICCAN
Issues for further exploration:
Non-compliance
Effect if pain on family functioning

54. Randomized Phase III Trial of Standard Care Vs Opioid Titration Order Schema
Report
Assessment
Comply
Titration
Communication
Requirements:
Beliefs
Knowledge
Resources
Requirements:
Time
Knowledge

55. Cancer Pain Management: Requirements for Success
Setting the Right Priorities
Dedicated Team
Willing to Take Time
Systematic Approach
Understanding of the Basic Principles of Symptom Control

56. Instructors can impart only a fraction of the teaching
Instructors can impart only a fraction of the teaching. It is through your own devoted practice that the mysteries are brought to life.
Morihei Ueshiba