1. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 2 Cancer Pain Management Module 2 Cancer Pain Management EPEC - Oncology Education in Palliative and End-of-life Care - Oncology

3. Overall message Pain management is an essential component of comprehensive cancer care.

4. Objectives... l Compare, contrast nociceptive, neuropathic pain l Know steps of analgesic management l Demonstrate ability to convert between opioids while maintaining analgesia l Compare, contrast nociceptive, neuropathic pain l Know steps of analgesic management l Demonstrate ability to convert between opioids while maintaining analgesia

5. ... Objectives l Know use of adjuvant analgesic agents l Know adverse effects of analgesics, their management l List barriers to pain management l Know use of adjuvant analgesic agents l Know adverse effects of analgesics, their management l List barriers to pain management

6. Video

7. General principles... l Assessment l Management PharmacologicalNon-pharmacological l Assessment l Management PharmacologicalNon-pharmacological

8. ... General principles l Education – patient, family, all caregivers l Ongoing assessment of outcomes, regular review of plan of care l Interdisciplinary care, consultative expertise l Education – patient, family, all caregivers l Ongoing assessment of outcomes, regular review of plan of care l Interdisciplinary care, consultative expertise

9. Pain pathophysiology l Acute pain Identified event, resolves days–weeks Usually nociceptive l Chronic pain Cause often not easily identified, multifactorial Indeterminate duration Nociceptive and / or neuropathic l Acute pain Identified event, resolves days–weeks Usually nociceptive l Chronic pain Cause often not easily identified, multifactorial Indeterminate duration Nociceptive and / or neuropathic Wolf CJ. Ann Intern Med. 2004.

10. Nociceptive pain... l Direct stimulation of intact nociceptors l Transmission along normal nerves Somatic Easy to describe, localize Visceral Difficult to describe, localize l Direct stimulation of intact nociceptors l Transmission along normal nerves Somatic Easy to describe, localize Visceral Difficult to describe, localize Wolf CJ. Ann Intern Med. 2004.

11. ... Nociceptive pain l Tissue injury apparent l Management Opioids Adjuvant / coanalgesics l Tissue injury apparent l Management Opioids Adjuvant / coanalgesics

12. Neuropathic pain... l Disordered peripheral or central nerves l Compression, transection, infiltration, ischemia, metabolic injury l Varied types Peripheral, deafferentation, complex regional syndromes l Disordered peripheral or central nerves l Compression, transection, infiltration, ischemia, metabolic injury l Varied types Peripheral, deafferentation, complex regional syndromes Wolf CJ. Ann Intern Med. 2004.

13. ... Neuropathic pain l Pain may exceed observable injury l Described as burning, tingling, shooting, stabbing, electrical l Management Opioids Adjuvant / coanalgesics often required l Pain may exceed observable injury l Described as burning, tingling, shooting, stabbing, electrical l Management Opioids Adjuvant / coanalgesics often required

14. Pain management l Don’t delay for investigations or disease treatment l Unmanaged pain => nervous system changes Permanent damage amplify pain l Treat underlying cause (eg, radiation for a neoplasm) l Don’t delay for investigations or disease treatment l Unmanaged pain => nervous system changes Permanent damage amplify pain l Treat underlying cause (eg, radiation for a neoplasm)

15. Placebos l No role for placebos to assess or treat pain

16. WHO 3-step Ladder 1 mild 2 moderate 3 severe Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodeine Tramadol ± Adjuvants A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodeine Tramadol ± Adjuvants ASA Acetaminophen NSAIDs ± Adjuvants ASA Acetaminophen NSAIDs ± Adjuvants WHO Geneva, 1996.

17. Acetaminophen l Step 1 analgesic, Coanalgesic l Site, mechanism of action unknown Minimally anti-inflammatory effect l Hepatic toxicity if > 4 grams / 24 hours Increased risk Hepatic disease, heavy alcohol use l Step 1 analgesic, Coanalgesic l Site, mechanism of action unknown Minimally anti-inflammatory effect l Hepatic toxicity if > 4 grams / 24 hours Increased risk Hepatic disease, heavy alcohol use Mitchell JR, Potter WZ. Med Clin North Am. 1975.

18. NSAIDs... l Step 1 analgesic, coanalgesic l Inhibit cyclooxygenase (COX) Vary in COX-2 selectivity Vary in COX-2 selectivity l All have analgesic ceiling effects Effective for bone, inflammatory pain Individual variation, serial trials l Step 1 analgesic, coanalgesic l Inhibit cyclooxygenase (COX) Vary in COX-2 selectivity Vary in COX-2 selectivity l All have analgesic ceiling effects Effective for bone, inflammatory pain Individual variation, serial trials Carson LJ, Willett LR. Drugs,1993.

19. ... NSAIDs l Highest incidence of adverse events l Gastropathy Gastric cytoprotection COX-2 selective inhibitors l Renal insufficiency Maintain adequate hydration COX-2 selective inhibitors l Inhibition of platelet aggregation Assess for coagulopathy l Highest incidence of adverse events l Gastropathy Gastric cytoprotection COX-2 selective inhibitors l Renal insufficiency Maintain adequate hydration COX-2 selective inhibitors l Inhibition of platelet aggregation Assess for coagulopathy Peura DA. Cleve Clin J Med, 2002.

20. Opioid pharmacology... l Conjugated in liver l Excreted via kidney (90–95%) l First-order kinetics l Conjugated in liver l Excreted via kidney (90–95%) l First-order kinetics Collins SL, et al. J Pain Symptom Manage. 1998.

21. Plasma Concentration 00 Half-life (t 1/2 ) TimeTime IVIV PO / pr SC / IM C max

22. ... Opioid pharmacology... l C max after PO  1 hr SC, IM  30 min IV  6 min l Half-life at steady-state PO / PR / SC / IM / IV  3-4 hrs l C max after PO  1 hr SC, IM  30 min IV  6 min l Half-life at steady-state PO / PR / SC / IM / IV  3-4 hrs

23. ... Opioid pharmacology l Steady state after 4–5 half-lives Steady state after one day (24 hours) l Duration of effect of ‘immediate- release’ formulations (except methadone) 3–5 hours PO / PR Shorter with parenteral bolus l Steady state after 4–5 half-lives Steady state after one day (24 hours) l Duration of effect of ‘immediate- release’ formulations (except methadone) 3–5 hours PO / PR Shorter with parenteral bolus

24. Routine oral dosing Immediate-release preparations l Codeine, hydrocodone, morphine, hydromorphone, oxycodone Dose q 4 h Adjust dose daily Mild / moderate pain  25–50% Severe / uncontrolled pain  50–100% Adjust more quickly for severe uncontrolled pain l Codeine, hydrocodone, morphine, hydromorphone, oxycodone Dose q 4 h Adjust dose daily Mild / moderate pain  25–50% Severe / uncontrolled pain  50–100% Adjust more quickly for severe uncontrolled pain

25. ... Routine oral dosing Extended-release preparations l Improve compliance, adherence l Dose q 8, 12 or 24 h (product specific) Don’t crush or chew tablets May flush time-release granules down feeding tubes l Adjust dose q 2–4 days (once steady state reached) l Improve compliance, adherence l Dose q 8, 12 or 24 h (product specific) Don’t crush or chew tablets May flush time-release granules down feeding tubes l Adjust dose q 2–4 days (once steady state reached)

26. Routine oral dosing Long half-life opioids l Dose interval for methadone is variable (q 6 h or q 8 h usually adequate) l Adjust methadone dose q 4–7 days l Dose interval for methadone is variable (q 6 h or q 8 h usually adequate) l Adjust methadone dose q 4–7 days

27. Breakthrough dosing l Use immediate-release opioids 5–15% of 24 hr dose offer after C max reached PO / PR  q 1 h SC, IM  q 30min IV  q 10–15min l Do NOT use extended-release opioids l Use immediate-release opioids 5–15% of 24 hr dose offer after C max reached PO / PR  q 1 h SC, IM  q 30min IV  q 10–15min l Do NOT use extended-release opioids

28. Clearance concerns l Conjugated by liver l 90–95% excreted in urine l Dehydration, renal failure, severe hepatic failure  dosing interval,  dosage size If oliguria or anuria STOP routine dosing of morphine use ONLY PRN l Conjugated by liver l 90–95% excreted in urine l Dehydration, renal failure, severe hepatic failure  dosing interval,  dosage size If oliguria or anuria STOP routine dosing of morphine use ONLY PRN Mercadante S, Arcuri E. J Pain. 2004.

29. Not recommended... l Meperidine Poor oral absorption Normeperidine is a toxic metabolite Longer half-life (6 hrs), no analgesia Psychotomimetic adverse effects, myoclonus, seizures If dosing q 3 h for analgesia, normeperidine builds up Accumulates with renal failure l Meperidine Poor oral absorption Normeperidine is a toxic metabolite Longer half-life (6 hrs), no analgesia Psychotomimetic adverse effects, myoclonus, seizures If dosing q 3 h for analgesia, normeperidine builds up Accumulates with renal failure

30. ... Not recommended... l Propoxyphene No better than placebo Low efficacy at commercially available doses Toxic metabolite at high doses l Propoxyphene No better than placebo Low efficacy at commercially available doses Toxic metabolite at high doses

31. ... Not recommended l Mixed agonist-antagonists Pentazocine, butorphanol, nalbuphine, dezocine Compete with agonists  withdrawal Analgesic ceiling effect High risk of psychotomimetic adverse effects with pentazocine, butorphanol l Mixed agonist-antagonists Pentazocine, butorphanol, nalbuphine, dezocine Compete with agonists  withdrawal Analgesic ceiling effect High risk of psychotomimetic adverse effects with pentazocine, butorphanol

32. Addiction... l Psychological dependence l Compulsive use l Loss of control over drugs l Loss of interest in pleasurable activities l Psychological dependence l Compulsive use l Loss of control over drugs l Loss of interest in pleasurable activities

33. ... Addiction l Continued use of drugs in spite of harm l A rare outcome of pain management Particularly, if no history of substance abuse l Continued use of drugs in spite of harm l A rare outcome of pain management Particularly, if no history of substance abuse

34. ... Addiction l Consider Substance use (true addiction) Pseudo-addiction (under-treatment of pain) Behavioral/family/psychological disorder Drug diversion l Consider Substance use (true addiction) Pseudo-addiction (under-treatment of pain) Behavioral/family/psychological disorder Drug diversion

35. Tolerance l Reduced effectiveness to a given dose over time l Not clinically significant with chronic dosing l If dose is increasing, suspect disease progression l Reduced effectiveness to a given dose over time l Not clinically significant with chronic dosing l If dose is increasing, suspect disease progression

36. Physical dependence l A process of neuro adaptation l Abrupt withdrawal may  abstinence syndrome l If dose reduction required, reduce by 50% q 2–3 days Avoid antagonists l A process of neuro adaptation l Abrupt withdrawal may  abstinence syndrome l If dose reduction required, reduce by 50% q 2–3 days Avoid antagonists

37. Substance users l Can have pain too l Treat with compassion l Protocols, contracting l Consultation with pain or addiction specialists l Can have pain too l Treat with compassion l Protocols, contracting l Consultation with pain or addiction specialists

38. Pain poorly-responsive to opioids l If dose escalation  adverse effects More sophisticated therapy to counteract adverse effect Alternative Route of administration Opioid (‘opioid rotation’) Coanalgesic Use a non-pharmacological approach l If dose escalation  adverse effects More sophisticated therapy to counteract adverse effect Alternative Route of administration Opioid (‘opioid rotation’) Coanalgesic Use a non-pharmacological approach

39. Ongoing assessment l Increase analgesics until pain relieved or adverse effects unacceptable l Be prepared for sudden changes in pain l Driving is safe if Pain controlled, dose stable, no adverse effects l Increase analgesics until pain relieved or adverse effects unacceptable l Be prepared for sudden changes in pain l Driving is safe if Pain controlled, dose stable, no adverse effects

40. Alternative routes of administration l Enteral feeding tubes l Transmucosal l Rectal l Transdermal l Parenteral l Intraspinal l Enteral feeding tubes l Transmucosal l Rectal l Transdermal l Parenteral l Intraspinal

41. Transdermal patch l Fentanyl Peak effect after application  24 hrs Patch lasts 48–72 hrs Ensure adherence to skin l Fentanyl Peak effect after application  24 hrs Patch lasts 48–72 hrs Ensure adherence to skin Gourlay GK, et al. Pain. 1989.

42. Parenteral l SC, IV, IM Bolus dosing q 3–4 h Continuous infusion Easier to administer More even pain control l SC, IV, IM Bolus dosing q 3–4 h Continuous infusion Easier to administer More even pain control

43. Intraspinal l Epidural l Intrathecal l Morphine, hydromorphone, fentanyl l Consultation l Epidural l Intrathecal l Morphine, hydromorphone, fentanyl l Consultation

44. Bolus effect l Swings in plasma concentration Drowsiness ½ –1 hr post ingestion Pain before next dose due l Must move to Extended-release preparation Continuous SC, IV infusion l Swings in plasma concentration Drowsiness ½ –1 hr post ingestion Pain before next dose due l Must move to Extended-release preparation Continuous SC, IV infusion

45. Changing routes of administration l Equianalgesic table Guide to initial dose selection l Significant first-pass metabolism of PO / PR doses Codeine, hydromorphone, morphine PO / PRtoSC, IV, IM 2–3  1 l Equianalgesic table Guide to initial dose selection l Significant first-pass metabolism of PO / PR doses Codeine, hydromorphone, morphine PO / PRtoSC, IV, IM 2–3  1

46. Equianalgesic doses of opioid analgesics PO / PR (mg) AnalgesicSC / IV / IM (mg) 100Codeine60 15Hydrocodone- 4Hydromorphone1.5 15Morphine5 10Oxycodone- PO / PR (mg) AnalgesicSC / IV / IM (mg) 100Codeine60 15Hydrocodone- 4Hydromorphone1.5 15Morphine5 10Oxycodone-

47. Changing opioids... l Equianalgesic table l Transdermal fentanyl 25  g patch  45–135 (likely 50–60) mg morphine / 24 hrs l Equianalgesic table l Transdermal fentanyl 25  g patch  45–135 (likely 50–60) mg morphine / 24 hrs

48. ... Changing opioids l Cross-tolerance Start with 50–75% of published equianalgesic dose More if pain, less if adverse effects l Methadone Start with 10–25% of published equianalgesic dose l Cross-tolerance Start with 50–75% of published equianalgesic dose More if pain, less if adverse effects l Methadone Start with 10–25% of published equianalgesic dose Ripamonti C, Zecca E, Bruera E. Pain. 1997.

49. Adjuvant analgesics l Medications that supplement primary analgesics May themselves be primary analgesics Use at any step of WHO ladder l Medications that supplement primary analgesics May themselves be primary analgesics Use at any step of WHO ladder

50. Gabapentin l Anticonvulsant 100 mg PO daily to tid, titrate Increase dose q 1–3 d Usual effective dose 900–1800 mg / day; max may be > 3600 mg / day Minimal adverse effects Drowsiness, tolerance develops within days l Anticonvulsant 100 mg PO daily to tid, titrate Increase dose q 1–3 d Usual effective dose 900–1800 mg / day; max may be > 3600 mg / day Minimal adverse effects Drowsiness, tolerance develops within days Backonja, et al. JAMA. 1998.

51. Other anticonvulsants l Carbamazepine 100 mg PO bid, titrate l Valproic acid 250 mg PO q hs, titrate Monitor plasma levels for risk of toxicity l Clonazepam l Lamotrigine l Carbamazepine 100 mg PO bid, titrate l Valproic acid 250 mg PO q hs, titrate Monitor plasma levels for risk of toxicity l Clonazepam l Lamotrigine McQuay, et al. BMJ. 1995. Eisenberg E, et al. Neurology. 2001.

52. Tricyclic antidepressants l Amitriptyline Most extensively studied 10–25 mg PO nightly, titrate (escalate q 4–7 d) Analgesia in days to weeks l Amitriptyline Most extensively studied 10–25 mg PO nightly, titrate (escalate q 4–7 d) Analgesia in days to weeks Max, et al.N Engl J Med. 1992.

53. ... Tricyclic antidepressants... l Amitriptyline Monitor plasma drug levels > 100 mg / 24h for risk of toxicity Anticholinergic adverse effects prominent, cardiac toxicity Sedating limited usefulness in frail, elderly l Amitriptyline Monitor plasma drug levels > 100 mg / 24h for risk of toxicity Anticholinergic adverse effects prominent, cardiac toxicity Sedating limited usefulness in frail, elderly

54. ... Tricyclic antidepressants l Desipramine Minimal anticholinergic or sedating adverse effects 10–25 mg PO q hs, titrate Tricyclic of choice in seriously ill Nortriptyline is an alternative l Desipramine Minimal anticholinergic or sedating adverse effects 10–25 mg PO q hs, titrate Tricyclic of choice in seriously ill Nortriptyline is an alternative

55. Corticosteroids... l Many uses l Dexamethasone Long half-life (>36 hrs), dose once / day Minimal mineralocorticoid effect Doses of 2–20 + mg / day l Many uses l Dexamethasone Long half-life (>36 hrs), dose once / day Minimal mineralocorticoid effect Doses of 2–20 + mg / day

56. ... Corticosteroids l Adverse effects Steroid psychosis Proximal myopathy Other long-term adverse effects l Adverse effects Steroid psychosis Proximal myopathy Other long-term adverse effects

57. Bone pain... l Constant, worse with movement l Metastases, compression or pathological fractures l Prostaglandins from inflammation, metastases l Rule out cord compression l Constant, worse with movement l Metastases, compression or pathological fractures l Prostaglandins from inflammation, metastases l Rule out cord compression Blum, et al. Oncology. 2003.

58. ... Bone pain... l Management OpioidsNSAIDsCorticosteroidsBisphosphonatesCalcitonin OpioidsNSAIDsCorticosteroidsBisphosphonatesCalcitonin

59. ... Bone pain l Management Radiopharmaceuticals External beam radiation Orthopedic intervention External bracing l Consultation l Management Radiopharmaceuticals External beam radiation Orthopedic intervention External bracing l Consultation

60. Pain from bowel obstruction... l Constipation l External compression l Bowel wall stretch, inflammation l Associated symptoms l Definitive intervention Relief of constipation Surgical removal or bypass l Constipation l External compression l Bowel wall stretch, inflammation l Associated symptoms l Definitive intervention Relief of constipation Surgical removal or bypass

61. ... Pain from bowel obstruction l Management OpioidsCorticosteroidsNSAIDs Anticholinergic medications eg, scopolamine Octreotide l Management OpioidsCorticosteroidsNSAIDs Anticholinergic medications eg, scopolamine Octreotide Muir JC, von Gunten CF. Clin Geriatr Med. 2000.

62. Opioid adverse effects CommonUncommon ConstipationBad dreams / hallucinations Dry mouthDysphoria / delirium Nausea / vomitingMyoclonus / seizures SedationPruritus / urticaria SweatsRespiratory depression Urinary retention CommonUncommon ConstipationBad dreams / hallucinations Dry mouthDysphoria / delirium Nausea / vomitingMyoclonus / seizures SedationPruritus / urticaria SweatsRespiratory depression Urinary retention

63. Opioid allergy l Nausea / vomiting, constipation, drowsiness, confusion Adverse effects, not allergic reactions l Anaphylactic reactions are the only true allergies Bronchospasm l Urticaria, bronchospasm can be allergies; need careful assessment l Nausea / vomiting, constipation, drowsiness, confusion Adverse effects, not allergic reactions l Anaphylactic reactions are the only true allergies Bronchospasm l Urticaria, bronchospasm can be allergies; need careful assessment

64. Urticaria, pruritus l Mast cell destabilization by morphine, hydromorphone l Treat with routine long-acting, non- sedating antihistamines Fexofenadine 60 mg PO bid, or higher or try diphenhydramine, loratadine or doxepin l Mast cell destabilization by morphine, hydromorphone l Treat with routine long-acting, non- sedating antihistamines Fexofenadine 60 mg PO bid, or higher or try diphenhydramine, loratadine or doxepin

65. Constipation l Common to all opioids l Opioid effects on CNS, spinal cord, myenteric plexus of gut l Easier to prevent than treat l Common to all opioids l Opioid effects on CNS, spinal cord, myenteric plexus of gut l Easier to prevent than treat

66. ... Constipation... l Diet usually insufficient l Bulk forming agents not recommended l Stimulant laxative Senna, bisacodyl, glycerine, casanthranol, etc. l Combine with a stool softener Senna + docusate sodium l Diet usually insufficient l Bulk forming agents not recommended l Stimulant laxative Senna, bisacodyl, glycerine, casanthranol, etc. l Combine with a stool softener Senna + docusate sodium

67. ... Constipation l Prokinetic agent Metoclopramide, cisapride l Osmotic laxative MOM, lactulose, sorbitol l Other measures l Prokinetic agent Metoclopramide, cisapride l Osmotic laxative MOM, lactulose, sorbitol l Other measures

68. Nausea / vomiting... l Onset with start of opioids Tolerance develops within days l Prevent or treat with dopamine- blocking antiemetics Prochlorperazine 10 mg q 6 h Haloperidol 1 mg 6 h Metoclopramide 10 mg q 6 h l Onset with start of opioids Tolerance develops within days l Prevent or treat with dopamine- blocking antiemetics Prochlorperazine 10 mg q 6 h Haloperidol 1 mg 6 h Metoclopramide 10 mg q 6 h

69. ... Nausea / vomiting l Other antiemetics may also be effective l Alternative opioid if refractory l Other antiemetics may also be effective l Alternative opioid if refractory

70. Sedation... l Onset with start of opioids Distinguish from exhaustion due to pain Tolerance develops within days l Complex in advanced disease l Onset with start of opioids Distinguish from exhaustion due to pain Tolerance develops within days l Complex in advanced disease

71. ... Sedation l If persistent, alternative opioid or route of administration l Psychostimulants may be useful Methylphenidate 5 mg q am and q noon, titrate l If persistent, alternative opioid or route of administration l Psychostimulants may be useful Methylphenidate 5 mg q am and q noon, titrate

72. Delirium... l Presentation Confusion, bad dreams, hallucinations Restlessness, agitation Myoclonic jerks, seizures Depressed level of consciousness Respiratory depression l Presentation Confusion, bad dreams, hallucinations Restlessness, agitation Myoclonic jerks, seizures Depressed level of consciousness Respiratory depression

73. ... Delirium l Rare, unless multiple factors contributing, if Opioid dosing guidelines followed Renal clearance normal l Rare, unless multiple factors contributing, if Opioid dosing guidelines followed Renal clearance normal

74. Respiratory depression... l Opioid effects differ for patients treated for pain Pain is a potent stimulus to breathe Loss of consciousness precedes respiratory depression Pharmacological tolerance rapid l Opioid effects differ for patients treated for pain Pain is a potent stimulus to breathe Loss of consciousness precedes respiratory depression Pharmacological tolerance rapid

75. ... Respiratory depression l Management Identify, treat contributing causes Reduce opioid dose Observe If unstable vital signs Naloxone 0.1-0.2 mg IV q 1-2 min l Management Identify, treat contributing causes Reduce opioid dose Observe If unstable vital signs Naloxone 0.1-0.2 mg IV q 1-2 min

76. Non-pharmacological pain management... l Neurostimulation TENS, acupuncture l Anesthesiological Nerve block l Surgical Cordotomy l Physical therapy Exercise, heat, cold l Neurostimulation TENS, acupuncture l Anesthesiological Nerve block l Surgical Cordotomy l Physical therapy Exercise, heat, cold

77. ... Non-pharmacological pain management l Psychological approaches Cognitive therapies (relaxation, imagery, hypnosis) Biofeedback Behavior therapy, psychotherapy l Complementary therapies Massage Art, music, aroma therapy l Psychological approaches Cognitive therapies (relaxation, imagery, hypnosis) Biofeedback Behavior therapy, psychotherapy l Complementary therapies Massage Art, music, aroma therapy

78. Barriers... l Not important l Poor assessment l Lack of knowledge l Fear of AddictionTolerance Adverse effects l Not important l Poor assessment l Lack of knowledge l Fear of AddictionTolerance Adverse effects

79. ... Barriers l Regulatory oversight l Patient’s unwilling to report pain l Patients unwilling to take medicine l Regulatory oversight l Patient’s unwilling to report pain l Patients unwilling to take medicine

80. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Summary Pain management is an essential component of comprehensive cancer care