This document discusses cancer pain management. It notes that 50-90% of oncology inpatients and 35% of outpatients report breakthrough cancer pain. Common causes of cancer pain include bone metastases, visceral metastases, and neuropathic pain. Barriers to effective pain management include clinical, patient-related, and system-related factors as well as racial and ethnic barriers. A thorough pain assessment considers intensity, location, quality, timeline, alleviating factors, and prior medications. Opioids are the mainstay of cancer pain treatment, with short-acting opioids used for breakthrough pain and long-acting for persistent pain.

1. Cancer Pain Management
Suzana Makowski, MD MMM FACP FAAHPM

2. • 50 to 90 percent of oncology inpatients report
breakthrough pain
• 35 percent of community based oncology practices
patients report breakthrough pain
• 1 in 3 patients with active cancer report pain
• 3 out of 4 of patients with advanced cancer report pain
Prevalence of Cancer Pain

3. • Bone metastases
• Visceral metastases
• Immobility
• Neuropathic pain
• Soft tissue
• Constipation
• Esophagitis
• Lymphedema
• Muscle cramps
• Chronic postoperative scar
• Adapted from Twycross R, Harcourt J, Bergl S: A survey of pain in patients with advanced cancer.
J Pain Symptom Manage 1996;12:273-282.
Common Causes

4. Physical Emotional Existential
• Increased catabolic demands: Depression Suffering –
poor wound healing, weakness, muscle Anxiety “why me?”
breakdown Decreased
• Decreased limb movement: intimacy
Suicidality
increased risk of DVT/PE
• Respiratory effects:
shallow breathing, tachypnea, cough
suppression increasing risk of pneumonia and
atelectasis
• Sodium and water retention Decreased
gastrointestinal mobility
• Tachycardia and elevated blood pressure
• Decreased functional status
• Increased chronic pain
Effects of under treated pain

5. Effects of under treated pain

6. • System barriers to treating pain
• Clinical,
• Patient-related
• System-related
• Racial and ethnic barriers exist
• Language
• Perceptions
• Concern about addiction
• Differences between addiction,
• dependence,
• tolerance &
• pseudoaddiction
Barriers to Pain Control

7. Intensity • Location • Quality • Timeline •
Alleviating factors • Meds tried
Pain Assessment

8. What about for patients who cannot self-report?
Intensity

9. Category Cause Symptom Examples
Physiologic Brief exposure to a Rapid yet brief pain Touching a pin or hot
noxious stimulus perception object
Somatic or visceral tissue Moderate to severe pain, Surgical pain,
Nociceptive/infla
injury with mediators described as crushing or traumatic pain, sickle
mmatory
having an impact on stabbing cell crisis
intact nervous tissue
Damage or dysfunction Severe lancinating,
Neuropathy, CRPS.
Neuropathic of peripheral nerves or burning or electrical
Postherpetic Neuralgia
CNS shock like pain
Combinations of Low back pain, back
Combined somatic and
Mixed symptoms; soft tissue plus surgery pain
nervous tissue injury
radicular pain
Pain Quality

10. Timeline

11. • What worked?
• What doses?
• What side
effects?
Prior medications & other tx

12. Common Rare
• Constipation • Respiratory suppression
• Nausea • Neurotoxicity
• Sleepiness/somnolence • Seizures
• Pruritus
• Myoclonus
Side effects

13. Opioid Pharmacology

14. Short-acting Long-acting
• Hydrocodone/APAP
• Transdermal fentanyl
• Oxycodone +/- APAP
• methadone
• Morphine
• morphine ER
• Hydromorphone
• oxycodone ER
• Oral transmucosal fentanyl
• Cmax ~ 45 min
Cmax and T1/2 vary based on
• T1/2 ~ 4 hours
formulation and drug
• Except fentanyl
Opioid Pharmacology

15. • Conjugated by liver
• 90-95% excreted in urine
• Dehydration, renal failure, severe hepatic failure
• Decrease interval/dosing size
• If oliguria/anuria
• STOP routine dosing (basal rate) of morphine
• Use ONLY PRN
Opioid pharmacology

16. What is the half life (range) for opioids?
• 2-4 hours
How many half lives to get to steady state?
• 4-5
What do you base your scheduled dosing on: Cmax or T1/2?
• T1/2
What do you base your breakthrough dosing on: Cmax or T1/2?
• Cmax
Opioid Pharmacology

17. Equianalgesic dosing

18. What is the challenge
with Step 2 of the
ladder?
WHO Step-Ladder

19. Hector G - 65 yo man with colon cancer and bone metastases
Your colleague first started Mr. G on hydrocodone 5 mg +
acetaminophen 325 mg one tablet by mouth every 4 hours prn for
his hip and rib pain. He also ordered senna + docusate 2 tabs po
qday to prevent opioid‐induced constipation.
Today, he tells you he is taking the Vicodin 1 tablet every 4 hours
around the clock (including at night). His pain is generally
constant, aching and he rates it as 5/10, but worsens to 8/10 with
certain positions and movements.
• How will you titrate his opioid pain medication?
Case – part 1 - outpatient

20. • Convert from Vicodin to Morphine
• How to convert to a combination of long- and short-
acting morphine (the latter for breakthrough pain)?
• What co-analgesics and other treatments might you
choose?
Case – Part 1

21. • Hector comes to hospital for a procedure. He is made
NPO. His pain has been well managed. How do you
manage his pain?
• Home regimen: MSContin 30mg BID, Roxanol 10mg q2
hours prn, requiring 2 – 4 doses per day.
• What if he were on Oxycodone/Oxycontin instead?
Case – Part 2 – NPO inpatient

22. • Mr. G presents to the ER after several days of escalating hip
and rib pain, despite taking the maximum dose of morphine he
was prescribed as an outpatient. “I can’t take it anymore.” You
admit him for pain management while trying to treat his
escalating pain.
• Home medications: MSContin PO 30mg bid, Morphine liquid
10mg PO q2 hours prn (taking every dose)
In addition to imaging him, calling radiation oncology
for evaluation, how do you manage his pain?
Case – part 3

23. • This is as much of a
crisis as a code (JAMA
2008;299(12):1457-1467. doi:
10.1001/jama.299.12.1457)
• http://jama.ama-
assn.org/content/299/12/1457.full.
pdf
Pain crisis

24. Non-interventional Interventional
• Methadone (opioid + • Nerve blocks
NMDA) • Intrathecal pain pumps
• Ketamine (NMDA)
infusion
• Lidocaine infusion
Advanced pain
techniques

25. • Choosing to be CMO does not automatically increase
opioid requirement
• Caution with renal failure
Pain at End-of-Life

26. • Pain is common in cancer. Undertreated pain worsens
prognosis
• On a good day, patients should not need PRNs, and on a
bad day, should not need it more than 4 times per day.
• When converting to IV from PO – don’t forget to include
the long-acting opioid.
• Opioid conversion is not mysterious
• Pain Crises is as serious as a code
• Methadone is a great drug – but is complicated
• Avoid morphine and hydromorphone in renal failure
• Match pain pattern with opioid pharmacology
• CMO ≠ continuous morphine only
• We’re here to help
Summary: Top 10

27. • https://cissecure.nci.nih.gov/ncipubs/detail.aspx?prodid=
Q014
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