A Practical Approach to Cancer Pain Management

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A Practical Approach toCancer Pain Management
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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

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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

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Pain Assessment

• Intensity
• Etiology
• Type

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Measurement

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

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Clinically Important Questions

• Current pain level
• Average pain level
• Worst pain level
• Pain relief with medications

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Etiology

• Treatable Causes
• pathologic fracture
• bone met
• chest wall recurrence
• Emergent
• cord compression
• brain met

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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

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Neuropathic Pain

• Mechanism Damage to receptor or nerve
• Frequently unrecognized
• Types of Syndromes
• Peripheral
• Drug induced (Cisplatin, Taxol)
• Central
• Cord compression

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Neuropathic Pain Syndromes

• Post-amputation Limb Pain
• Post-thoracotomy Pain
• Post-mastectomy Pain
• Brachial Plexopathy
• LS Plexopathy
• Celiac Infiltration

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Assessment of the Patient

• Medical Problems
• Psychological Function
• Physical Function
• Cognitive Function
• Support Services
• Financial Services
• Educational Status

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Ready to Prescribe
Rx
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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

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WHO Step Ladder of Pain Management

• Step 1
• 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

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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

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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

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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

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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

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Dosing on a Fixed Interval
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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

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Dosing on A PRN Basis
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Fixed DosingMedication 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

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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

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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

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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

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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 200-300
• MS IR 20-30 mg po q 1-2 hours

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Acute ManagementModerate 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

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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

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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

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Method

• Step 1
• 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

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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

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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

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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 60-90 ug of Duragesic
• Step 4 (divide by number of doses per day)
• Not needed

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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 80 - 120 mg of Duragisic
• Step 4 (divide by number of doses per day)
• Not needed

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

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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 600 150 750 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

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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 600 300 900 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

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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

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Sustained Release Formulations

• Morphine
• Oxycodone
• Fentanyl
• Dilaudid

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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 8-12
  hrs
• 24h narcotic total (60mg x 6) 360
• New Fixed dose 360 / 2 180 mg
• New Regimen
• MSSR 180 mg po q 12h ATC
• MSIR 30 mg po q 1-2h prn

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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

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Consider Patch in the Following Patient
Populations

• Non-compliant patients
• Patients unable to take oral medications
• Question of drug abuse
• Question of cognition

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Conversion Factor
100 mg Morphine
50 micrograms Fentanyl
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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
• MSIR 30 mg po q 1-2h prn

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IV/SC Narcotics

• Use
• 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

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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

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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

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Pain Emergency

• High Dose Decadron
• Anesthesiology Consult
• Neurosurgery Consult

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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

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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

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Narcotic Titration Order SchemaA 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

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Narcotic Titration Order SchemaA 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

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Randomized Phase III Trial of Standard Care Vs
Opioid Titration Order Schema
Report
Assessment
Comply
Titration
Communication

• Requirements
• Beliefs
• Knowledge
• Resources

• Requirements
• Time
• Knowledge

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Cancer Pain ManagementRequirements for Success

• Setting the Right Priorities
• Dedicated Team
• Willing to Take Time
• Systematic Approach
• Understanding of the Basic Principles of Symptom
  Control

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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