This document provides an overview of pain management and opioid use for cancer patients. It discusses how cancer pain is common and should be properly assessed and treated. The WHO pain ladder is reviewed as the standard approach for treating pain with non-opioids, weak opioids, and strong opioids. Opioid rotation and treating pain crises are covered, including calculating opioid conversions and administering parenteral opioids. Challenges in treating cancer pain in patients with addiction histories are addressed through transparency, long-acting opioids, and pain contracts. Overall guidelines aim to properly treat pain while avoiding exacerbating addiction issues.

1. Pain Management & Opioid Use for
the
Cancer Patient
Suzana Makowski, MD MMM
Co-Chief of Palliative Care
Brenda Neil, NP
Palliative Care Nurse Practitioner
UMass Memorial Healthcare

2. The obligation of physicians
to relieve suffering stretches
back to antiquity.
[However, there is] a
modern paradox: Even in the
best settings and with the
best physicians, it is not
uncommon for suffering to
occur not only during the
course of a disease, but also
as a result of its treatment.
-Eric Cassell, MD

3. Overview
• Cancer Pain – background, assessment,
treatment
• Opioid Rotation
• Pain Crisis/Pain Code
• Dealing with Drug-Seeking Behavior

4. Cancer Pain - Reported
1of 3 patients with active cancer
3 of 4 patients with advanced cancer

5. Questions to keep in mind
• Intensity
• Etiology of pain
– Tumor burden (and location)
– Drug induced
• Quality of pain
• Time-line patter of pain
• What has been tried before (helped or not)

6. Time-course of cancer pain
Generally:
– Constant pain with breakthrough periods
Rarely:
– True incident pain (movement only)
– Tougher to treat – recommend pain specialist or
palliative care specialist to evaluate.
• May need intervention (intrathecal pain pump), radiation,
etc.

7. Effects of undertreated pain

8. Challenges to treatment of cancer pain
Pain

9. WHO’s Pain Relief Ladder
Step 1
Step 2
Step 3

10. Principles of Opioid Pharmacology
Time to max effect (cmax)
For prn dosing
Half-life (t½)
For scheduled dosing
PO/PR 40-60 minutes 4 hours
SQ/IM 20 minutes 3-4 hours
IV 6-12 minutes (depending on opioid) 3-4 hours
Does not apply to methadoneDoes not apply to methadone

11. Opioid
Rotation
• Why?
• How?

12. Opioid
Rotation
• Why?
• How?

13. Case of Hector G. – part 1
• 56 yo Puerto Rican gentleman with metastatic
prostate cancer to bone. s/p radiation,
undergoing chemotherapy and hormone
therapy.
• Medications:
– Percocet 5/320 mg 1-2 tabs q4 hours prn
– Senna and colace
• Comes to visit for increased pain – ran out of
medications

14. Case of Hector G. – part 1
• Prescribe long-acting and short-acting.
– Why?
– How to calculate?
– Which medications?
Step 1: Calculate 24 hour dose of current opioid use
Hector is taking on 12 tablets of Percocet per day
= 60mg oxycodone + 3900mg acetaminophen per day
Which medication total is
more concerning?

16. Case of Hector G. – part 1
• Prescribe long-acting and short-
acting.
– Why?
– How to calculate?
– Which medications?
Step 2: Convert 24 hour current opioid to new opioid (or
stay with current opioid) and calculate long acting dose
60mg oxycodone = Oxycontin 30mg bid OR
60mg x (15 morphine/10 oxycodone)= Morphine ER 45mg
bid
Step 3: if starting new opioid, consider adjusting for
cross-tolerance:

17. Case of Hector G. – part 1
• Prescribe long-acting and short-acting.
– Why?
– How to calculate?
– Which medications?
Step 3: Calculate breakthrough dose based on 10-20% of
daily long-acting
60mg oxycodone ER  oxycodone IR 5-10mg prn
60mg morphine ER  morphine IR 7.5-15mg prn
Frequency: q2 hours prn – up to 6 doses per day
Morphine IR 15mg, ½-1 tab q2 hours prn, up to 6 doses per day #180 (perhaps #120)
If patient requires more
than 6 doses in 24 hours,
they should call

18. Case of Hector G – part 2
more calculations
1. Hector is admitted to hospital and is made
NPO.
• How do you convert his opioid to IV?
1. Hector’s cancer progresses, he is now in renal
failure with urine output less than 100ml per
day. He does not wish dialysis or IV fluids.
• What do you convert him to and why?
• What if he is NPO?
• What if he cannot have IV or SQ access?
Answers are in separate handoutAnswers are in separate handout

19. Pain Crisis
“This is as much of a crisis as a code” – Natalie Moryl
MD
http://jama.ama-assn.org/content/299/12/1457.full.pdf

20. Approach to Pain Crisis

21. Assess Pain Crisis
• Keep in mind emergencies and their associated symptoms:
– cord compression, hypercalcemia, opioid neurotoxicity, acute abdomen,
etc.
• What medications has the patient tried so far? How much?
Intensity • quality • timeline • associated symptoms • medications tried • other changes to painIntensity • quality • timeline • associated symptoms • medications tried • other changes to pain

22. Treat Pain Crisis “Pain Code”
• Parenteral opioids are best for crisis
• Convert all of last 24 hours into continuous IV
• To get pain under control
– Double highest home regimen PRN dose and convert to IV as starting
point
– Then provide doses based on time to max effect (approximately 10
minutes) until patient is comfortable. Prescriber should stay at bedside.
– If first dose has no effect, double it with next dose.
• Monitoring patient
– Pain intensity scale • sedation scale • respiratory rate/O2 Sat
• Once pain is controlled
– PCA or nurse boluses
– Anticipate conversion to non-parenteral regimen

23. Treat Pain Crisis
• Adjunct Therapies to consider:
– Steroids (dexamethasone for bone pain, tumor burden)
– Radiation therapy may be helpful
– Interventional pain/radiology for nerve blocks
– Aggressive adjust therapies that specialists may employ
include lidocaine or ketamine drips, epidural drips, etc.
– Non-pharmacologic interventions: cool or heat
therapy, touch, etc.

24. Engage and Support in Pain Crisis
• Nursing and Pharmacy colleagues
• Social work and chaplaincy
• Family
• Outside agencies – hospice may be helpful

25. At end of life…
CMO ≠ Continuous Morphine Only
Treat pain and other symptoms
Assess for side effects of therapies
Watch urine output if on continuous or long-acting opioid (other than fentanyl)
Treat pain and other symptoms
Assess for side effects of therapies
Watch urine output if on continuous or long-acting opioid (other than fentanyl)

26. Cancer and drug-seeking behavior

27. Tending to the Addict’s Pain
MH
63 yo disabled woman with
metastatic breast cancer
Severe pain due to brachial
plexopathy
History of smoking and
addiction – high opioid
tolerance
LS
53 yo disabled woman with
metastatic lung cancer.
Pain is due to bone metastases
History of addiction
Current smoker
Tx:
Methadone 60mg TID, Fentanyl
patch 100mcg/hour, Morphine 90
mg q2 hours prn up to 5 times per
day
Tx:
Fentanyl patch 25mcg/hour,
Oxycodone 10mg q4 hours prn up
to 5 times per day

28. Tending to the Addict’s Cancer
Pain
• Function is key
• Transparency is key (being explicit)
– “I am here to care for you: take care of you pain
and not feed your addiction.”
• Aim to utilize principally long-acting opioids,
minimize short-acting
• Pain contract
• Ongoing request for more short-acting
without increase of long-acting is concern
Potential diversion

29. Tending to the Addict’s Cancer
Pain
• Inpatient principles:
– PCA is a good test
• Does function increase or decrease?
– Tolerance to opioids will be high, requirement will
likely be high
– Partner with patient, nursing, social work,
pharmacy
– Set clear goals (mutually determined)

30. TJ
53 yo ex-pro football
player, heroin addict on
methadone x 20+ years
Admitted with pain crisis
Treatment:
Hydromorphone gtt 40mg/hour
Methadone 30mg IVP q8 hours (then
switch to ketamine gtt)
Lidocaine gtt 20mg/kg/hour
PRN:
Hydromorphone 10mg IVP q30 min prn

32. Prescribing opioids:
(“My general rules” for residents on rotation)

33. Thank you
Suzana Makowski, MD:
Suzana.makowski@umassmemorial.org
Office: Debbie Horgan – (508) 344-8630
Delila Katz, PharmD:
Delila.katz@umassmemorial.org
New cancer center pharmacy