opioids in cancer pain manage, a case-based approach, covering - opioid dosing and rotations - pain assessment - opioids adverse effects and managment thereof - overcoming barriers to usage

1. Demystifying
The Use of Opioids
in Cancer Pain
Chris Ralph B.Sc. Pharm. FCAPhO
Palliative Oncology Clinical Pharmacist
Tom Baker Cancer Centre
Calgary, AB

2. 2

3. 3

4. Objectives
an evidence-based
approach to personalized
cancer pain management.
principles of opioid use in
cancer pain, specifically
opioid rotations
importance of longitudinal
follow-up
4

5. Case: Justin Payne
▷ morphine SR 30 mg PO BID
▷ morphine IR 5-10 mg PO q1h prn pain
○ ~ 4 x 10 mg doses per day
▷ Insufficient pain control (hip pain)
▷ Higher doses drowsy, confused,
minor hallucinations, myoclonus
▷ Plan?
5

6. Justin Payne: MEDD 100 mg
▷ renal function declining
▷ hepatic function declining
▷ swallowing issues
▷ on enzalutamide/fluconazole
▷ issues with early part fills
▷ He’s a redhead
▷ his mother is from Saudi Arabi
▷ he only started morphine 3 days ago
▷ pain continues to increase
○ more generalized now
▷ he’s in his 70s though looks younger
6

7. Choose Your Adventure
Patient
Tailored
Follow Up
Adverse
Effects
Methadone
Cancer
Pain
Overview
Principles
of Opioid
Use
Pain
Assess-
ment
Pain Case:
Meet the
patient
Pharmaco-
genomics
Patient
Tailored
Approach
Trans-
dermal
fentanyl
Opioid
Rotations
Substance
Use
Disorder
7

8. CANCER PAIN
8

9. 9
~85% of patients
with advanced
cancer will
experience pain

10. 10
Up to 90% of cancer pain
syndromes can be
controlled using basic pain
management principles

11. 11
Cancer pain is undertreated
in ~___% of patients?
A. 15%
B. 25%
C. 35%
D. 50%

12. 12
50%

13. 13
Pain - Definition
“An unpleasant sensory & emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage.”
- IASP
(The International Association for the Study of Pain)

14. 14

15. 15
“Pain is your brain
telling you it thinks
something is
dangerous.”
Adapted from Paul Ingrahem (2011)

16. 16
Causes of Pain in Cancer Patients
70% - The disease
● Invasion of tissues, organs or nerves by cancer
20% - The treatment of disease
● Chemo induced neuropathy (CIPN), post surgical
complications, post radiotherapy complications
10% - Factors unrelated to the disease
● Pre-existing chronic pain

17. 17
Prevalence
● The prevalence of pain varies by tumor
type:
● Solid tumours: 71% of patients
● Hematologic malignancies: 41%

18. PATIENT
TAILORED
APPROACH
18

19. 19
Pain Management
Paradigm Shift
▷ Comprehensive pain assessment
▷ Characterization of pain
▷ Identify modulators of pain expression
▷ Documentation of personalized pain goals
▷ Systematic screening
▷ Implementation of a multidisciplinary Tx plan
▷ Subsequent customized longitudinal follow up

20. 20
Personalized Pain Goal (PPG)
● Tailored to the individual need
● Ask patient to identify maximal intensity of pain
from 0 to 10 still considered comfortable
● (0 = no pain; 10 = worst pain)
● Provides cutoff to define a personalized response
● Pain score ≤ PPG is defined as a response.
● Consider: activity levels, mood, sleep

21. Patient-
Tailored
Implement
Tx Plan
Follow-up
Optimize
med
doses
Minimize
Toxicity
Anticipate
adverse
effects
Monitor
aberrant
behavior
Collaborate
Conceptual Personalized Palliative Care Model
*Match treatment to patient’s goals!

22. Follow up assessment form
Sample: http://bit.ly/painassess
22

23. What is Palliative Care
“We help people with serious illness have
the best possible quality of life.”
- Dr. Diane E Meier
23

24. What is Palliative Care
‘Palliative care is simply the
pursuit of quality of life.’
- Dr. BJ Miller
PoQoL 24

25. Modulators & Predictive Factors
● Psychological distress
● CAGE, Opioid Risk Tool positivity
● Cognitive impairment - delirium
● Incident pain can be associated with significant
functional limitation
● marker of pain more difficult to control
25

26. PHARMACO-
GENOMICS
26

27. Pharmacogenetics
● Analgesia subject to interindividual
variability
● Genetic factors related to PD and PK
● Example: CYP2D6 SNPs
● PM phenotype: 7-11% Caucasion
● UM: Black Ethiopian & Saudi Arabian:
16-20%
27

28. Genetic Polymorphism of
Opioid Receptors
● The mu receptor family has numerous subtypes
● ≥25
● ≥1800 variants in OPRM1(gene encoding the
μ-opioid receptor)
● This genetic variation helps explain the large
intra-individual and interindividual variation in the
response to the different mu agonist opioids.
● Different opioids may bind or activate receptors
differently, resulting in different therapeutic effect
28

29. Redheads
Contain a mutated
melanocortin 1 receptor;
show increased analgesic
responses to opioids.
Delaney A et al (2010). PloS one, 5 (9) PMID: 20856883
29

30. OPIOIDS USE IN
CANCER PAIN
30

31. 31
Principles of Opioid
Use in Cancer Pain
active cancer
opioid therapy is first-line option
Moderate/Severe
Pain
Consensus

32. OPIOPHOBIA Like Acrophobia
If you follow the rules
and don’t engage in
dangerous behavior,
you will be fine.
If you ignore the rules
and take risks then
you may validate
your own fears.

33. Basic Principles of Pain Management
= Key Points
● By the ladder
● By the mouth
● By the clock
● With breakthrough
● Anticipate and prevent side effects
● Educate the patient & family/caregivers
● Monitor efficacy of treatment regularly
● Identify and treat underlying causes
33

34. 34

35. Pharmacological treatments in cancer pain
Pereira, Jóse L. The Pallium palliative pocketbook: a peer-reviewed, referenced resource.
2nd ed. Ottawa: The Pallium Canada, 2016.
Mild Pain
(1-3/10)
Moderate Pain
(4-6/10)
Severe Pain
(7-10/10)
Non-opioid
● Acetaminophen
● NSAIDs
● ASA
+/- Adjuvant
Weak Opioid
● Codeine
● Tramadol
● Tapentadol
● Buprenorphine
+/- Adjuvant
Avoid
● Meperidine
● Pentazocine
Strong Opioid
1st line
● Morphine
● Oxycodone
● Hydromorphone
2nd line
● Fentanyl
3rd line
● Methadone
+/- Adjuvant
Adapted from Pallium Palliative Pocketbook, 2nd Edition

36. The Opioid Initiation Process
Promoting Patient/Family Acceptance
Step 1:
● Inform the patient of your decision to start an opioid
and address potential concerns and fears
“Narcotics must mean the end is near”
“Sure I’ll be pain free, but also a zombie”
“I’ll become addicted”
“It will shorten my life”
“I can’t work or drive”
“If I take too soon, what about at the end”
36

37. “You’re not
going to send
me to orbit,
are ya!?!”
37

38. Opioid Initiation Process
Step 2:
● Select a strong opioid for regular dosing
● Rule out an opioid allergy (true opioid allergy is rare)
● Morphine, oxycodone and hydromorphone are all
reasonable first-line choices
Step 3:
● Select between short and long acting
● Immediate versus sustained release
Step 4:
● Select an appropriate route of administration (Not IM!)
38

39. Drug & Route Selection
● No evidence for drug-selective effects that would
uniformly justify selection of one drug over another
● Choice is empiric
● Opioid chosen typically based on:
● experience of clinician
● availability
● cost
● patient medication history
● patient clinical status
39

40. Opioid Initiation Process
Step 5
● Determine an appropriate starting dose
Opioid Common Starting Dose
Starting dose in frail, weak
patients or have severe
COPD
Morphine 5-10mg po q4h 2.5 – 5 mg po q4h
Hydromorphone 1-2 mg po q4h 0.5 – 1 mg po q4h
Oxycodone 2.5 - 5 mg po q4h 2.5 mg po q4h
40

41. BREAKTHROUGH
PAIN
41

42. Breakthrough Pain (BTP)
● BTP = transitory severe acute pain that occurs on a
background of chronic pain that is controlled by
an opioid regimen.
● Phenomenon is highly prevalent
● ~64% incidence per Portenoy & Hagen
● associated with adverse pain-related outcomes.
● Use of supplemental doses as needed in
combination with fixed scheduled opioid regimen.
42

43. Opioid Initiation Process
Step 6
● Add a rescue/breakthrough dose
● Usually ~5-20% of total daily dose*
● For transient increases in pain above the
stable, persistent pain controlled by opioids
● May be incident pain, spontaneous pain,
or end-of-dose failure pain
43

44. ADVERSE
EFFECTS
44

45. Opioid Initiation Process
Step 7
● Inform, Anticipate*, Prevent and Manage Side Effects
● Constipation
- will occur almost certainly
- does not go away; requires Px/Tx
- BM at least every 2-3 days
- PEG-3350*! + Senokot
*“If it ain’t workin’ you ain’t takin’ enough.”
– Dean England on PEG-3350 PO in OIC
45

46. 46

47. Anticholinergic Poetry
Can’t See
Can’t Spit
Can’t Pee
Can’t S#it (poop)
47

48. The Morph Dwarves
Dizzy, Drowsy, and Dopey
Itchy, Twitchy, and Queasy
And...the dwarf nobody
likes hanging out with, Sweaty
48

49. Constipation
■ Most common & concerning complaint
■ Does not go away with continued use
■ If not managed effectively people will
choose pain over constipation
■ Can lead to significant complications
■ It is easier to prevent than to treat
■ Discuss EVERY time you dispense an opioid
(frequency,dry, hard, straining?)
49

50. Opioid Adverse Effects: Nausea
● Induced via several mechanisms
● Up to 2/3 patients initiated on an opioid may
experience nausea; prevent/treat constipation!
● Usually subsides 3-7 days after initiation
● Tx options:
● Metoclopramide 10 mg po qid (prn)
● Haloperidol 0.5 mg BID for 3-7 days then prn only
● Many other treatment options
● Consider olanzapine for intractable nausea
50

51. Opioid Adverse Effects: Others
● Somnolence/sedation*
● Usually wearing off after 3-5 days
● If persists, consider + CNS stimulant
● Other side effects to caution of include:
● Dizziness/orthostatic hypotension
● Dry mouth
● Pruritus
● Urinary retention
● Confusion
● **Others include: myoclonus, hallucinations, delirium
(Consider OIN)
51

52. Opioids: Other Adverse Effects
● May worsen sleep apnea or cause a syndrome of
opioid-induced sleep-disordered breathing
● Opioid- induced hypogonadism
● potential for sexual dysfunction, accelerated bone loss,
mood disturbance, and fatigue.
● Opioid-induced hyperalgesia
● Phenomenon seen in animal models
● may explain anecdotal occurrence ⇧ pain in the absence
of worsening pathology
52

53. OPIOID
ROTATION
53

54. ● Change from one
opioid to another is
usually results in
improved therapeutic
outcome.
● Recent studies:
● up to 80% of patients
achieve successful
outcomes

55. Why Switch Opioids?
● Lack of therapeutic response
● Development of adverse effects
● Change in Patient Status
● Other Considerations
○ Availability
○ Cost
○ Beliefs/Prior experience
55

56. Opioid Metaphor

57. Methadone Metaphor
57

58. Opioid Equianalgesic Dosing
Drug PO Dose
Morphine 10 mg
Codeine 100 mg
Tramadol* 100 mg
Oxycodone 5-7.5 mg
Hydromorphone 2 mg
Methadone** 1 mg
● Morphine is 10 times more potent than codeine
● Oxycodone is ~1.5 – 2 times more potent than morphine
● Hydromorphone is ~5 times more potent then morphine
●**Methadone conversion is variable based on total daily dose
● *tramadol maybe more potent as also inhibits reuptake of NE & 5-HT
58

59. 59

60. Limitations of Opioid Equianalgesic Charts
● Much of the data from single-dose cross-over studies in
opioid-naïve patients with acute pain.
● Limited data on equianalgesia in chronic use
● Patient-specific variable not considered such as:
● Age, sex, ethnicity
● Polymorphism of opioid receptors
● Organ function (liver and kidney)
● Level and stability of pain control
● Duration and extent of opioid exposure
● Comorbidities
● Interacting medications
● Unidirectional Vs Bidirectional equivalences
60

61. 61

62. 62

63. Opioid Rotation
● Calculate total daily dose of current opioid
● Calc. MEDD (Morphine Equivalent Daily Dose)
● Calc. equianalgesic dose of new chosen opioid
● *Reduce new opioid dose by 20-50%
● to account for lack of cross tolerance*
● Calculate regularly scheduled dose of new opioid
plus BT doses
● Call backs - follow up!
63

64. McPherson: Demystifying Opioid Conversion Calculations, 2009 64

65. 65
The goal of an opioid switch is a
SAFE and EFFECTIVE outcome.

66. Case: Justin Payne
60 year old man with met. prostate ca
▷ morphine SR 30 mg PO BID
▷ morphine IR (Statex) 5-10 mg PO q1h prn
pain
○ Taking ~ 4 x 10 mg doses per day
▷ Insufficient pain control
▷ Higher doses drowsy, confused, minor
hallucinations, myoclonus
▷ Plan?
66

67. Patient Assessment
● MP rates the pain at 6-7/10
● He describes a constant, deep, achy pain localized in
right hip, easy to elicit pain on exam
● Walking aggravates the pain
● Rest and heat seems to provide some relief
● Bone scan reveals pelvic bone metastasis
67

68. Patient Payne Options
● Opioid-induced neurotoxicity (OIN)
● Sxs may include: delirium, myoclonus,
generalized worsening of pain
● ?Dose reduce current opioid
● (?hyperalgesia)
● Hydration
● Add adjuvant and evaluate if it allows
for lowering of the morphine dose.
● Consider rotation to another opioid.
68

69. Rotation Calculation
● Morphine 60 mg (SR per day) plus 40 mg BT/day =
100 mg/day of morphine (MEDD)
● 100 mg ÷ 5 = 20 mg hydromorphone
● 20 mg x 75% = 15 mg hydromorphone/day
● 15 mg ÷ 6 = 2.5 mg
● BT dose: 15 mg x ~10% = 1.5 mg
● Hydromorphone 3 mg po q4h (OR Hydromorph
Contin 9 mg q12h) plus 1-2 mg q1h prn
69

70. Payne Progression
● Now on HM Contin 9 mg po q12h for a while; BT
use begins to increase: ~4 doses of 2 mg per day.
● Complains of increasing drowsiness, constipation,
muscle twitching
● Wife states he seems disoriented at times.
● If she is not around he tends to forget meds.
● Rates his average pain at 4-5/10 but it increases to
6-7/10 prior to BT doses
70

71. TRANSDERMAL
FENTANYL (TDF)
71

72. Fentanyl Fast Facts
● Increased body temperature will ⇧ absorption (~30%).
● Caution with heating pads, hot tubs, saunas, fever, etc.
● Proper disposal to ensure children cannot apply
● Regular checks to ensure not peeling off (Tegaderm™)
● May require q48h/q60h application for EOD failure
● Some patients may have hypersensitivity reaction with
local skin irritation (consider corticosteroid MDI)
● Cachectic patients may not respond as well as
expected to fentanyl (altered PK)
72

73. Not appropriate for opioid naïve patients or
patients in pain crises* (*Yes in UK)
12-18 hrs to achieve therapeutic blood levels
Mind the gap!
● Overlap with previous opioid for ≥12 hours
Prescribe short-acting opioid for BT pain
Absorption (Portenoy et al):
● 47% complete at 24 hours
● 88% complete at 48 hours
● 94 % complete at 72 hours
73

74. Mind the gap! 74

75. Rotating to TD Fentanyl
● Fentanyl available as 12, 25, 37, 50, 75, and 100
mcg patches
● Gel versus matrix patches
Morphine dose (oral mg/24 hr) TD fentanyl dose (mcg/hr q72h)
45-134 25
135-224 50
225-314 75
315-404 100
405-494 125
495-584 150
585-674 175
675-764 200 75

76. Rotating to TD Fentanyl
● Fentanyl available as 12, 25, 37, 50, 75, and 100
mcg patches
● Gel versus matrix patches
Morphine dose (oral mg/24 hr) TD fentanyl dose (mcg/hr q72h)
45-134 25
135-224 50
225-314 75
315-404 100
405-494 125
495-584 150
585-674 175
675-764 200 76

77. Alternate Conversion Method*
● *The conversion charts overestimate potency of
fentanyl; may lead to under-dosing
● Fentanyl: 75-100 X more potent than morphine
● 100 mg PO morphine ~ 1 mg (1000 mcg) daily TDF
● Thus 60 mg PO morphine ~ 0.6 mg (600 mcg) daily TDF
● 0.6 mg (600 mcg) daily TDF = 25 mcg per hour TDF
● Donner et al: actual ratio ~70:1
●Therefore, use a 2:1 ratio
●Every 2 mg PO morphine per day ~ 1 mcg/hour
●Thus, MEDD/2 = mcg/hr TDF
77

78. 2:1 Method*
● Fentanyl: 70 X more potent than morphine (Donner)
● 0.6 mg (600 mcg) daily TDF = 25 mcg per hour TDF
● 600 mcg daily TDF x 70 = 42 mg PO morphine
●42 mg PO morphine ~ = 25 mcg per hour TDF
●*Therefore, use a 2:1 ratio without dose reduction
●Every 2 mg PO morphine per day ~ 1 mcg/hour
●Thus, MEDD/2 mcg/hr TDF
78

79. The Conversion Calculation
● HM Contin 9 mg q12h plus 4 BT/day x 2 mg/dose
= 26 mg hydromorphone/24 hr
● 26 mg x 5 = 130 mg morphine equivalents
(MEDD)
1. The Chart: 130 mg 25 mcg/hr
2. Alternate: 100:1 130 = 1300 mcg ÷ 24 hr =
54.2 mcg/hr
3. 2:1 Method: 130 mg ÷ 2 = 65 mcg/hr
● Can initiate with 50-62 mcg/hr and consider
adjusting in follow up.
79

80. Sample CCM Tx Plan
NEW: Fentanyl 50 mcg transdermal patch
● Along with scheduled evening dose of Hydromorph Contin, apply 1 of the 50 mcg/hr patches.
● This will be your last dose of Hydromorph Contin.
● Apply 1 patches (50 mcg total) every 3 days (every 72 hours)
● Apply patches to clean, dry skin (outer shoulder or upper chest, for example)
● Hold hand over the patch for 1-2 minutes to get warm as this can improve how well it sticks
○ TIP: If trouble sticking, try rubbing hand over the patch; heat helps activate the adhesive in the patch
○ TIP #2: Some of our patients who have had trouble with patches sticking, had success with using a
heat pack (for example, a microwaveable one) and applying it over the patch for a minute or so to help
activate the adhesive.
○ Tegaderm dressings can also be applied over the patches. We usually find that you need to do a
combination of heat (from hand or heating pad) even with these dressings.
● The patch(es) is/are changed every 3 days. Apply to a new area of skin. Rotate through 3 to 4 different
application sites. See diagram in the box that comes with patches.
● You can bathe and shower, it is OK if the patch gets wet – it should remain stuck on
● Do not put a heat source (hot water bottle, heating pad) over the patch (other than to help with it sticking). Do
not use a sauna.
● NOTE: It can take 12 to 24 hours to see good effect of the patch(es) after the first time applying (or
after a dose increase); it should continue to have better effect over days 2 and 3 after applying.
● Disposal of patches: Used patches must be folded so that the adhesive side sticks to itself, then
returned to the pharmacy for disposal. They may provide a sharps container.
● Caution: avoid grapefruit or grapefruit juice
● Note: We have faxed application to Blue Cross for special authorization for coverage
80

81. Opioid Dose Escalation
*Increase by a percentage of the present dose based
upon patient’s pain rating & current assessment.
Mild pain
1-3/10
25% increase
Moderate pain
4-6/10
25-50% increase
Severe pain
7-10/10
50-100% increase
81

82. Frequency of Dose Escalation
The frequency of dose escalation depends on the
particular opioid:
● Short-acting oral: q 2-4 hours
● Long-acting oral, except methadone:
● q 24-48 hours
● Methadone*: q 3-7 days
● transdermal fentanyl**: q 72 hours
82

83. ● Impeccable pain management requires
● longitudinal follow-up
● dose titration
● proactive management of adverse effects
Longitudinal Assessment
83

84. 84

85. METHADONE:
MAGICAL, MYSTICAL,
MISCHIEVIOUS
85

86. ● Guidelines call for the use of methadone only by
clinicians who have acquired the skills for safe use.
● This drug has been favoured by some due to:
● low cost
● potential for high efficacy
● perceived value in reducing the risk of abuse in
patients predisposed to addiction.
● Safe administration of methadone requires
knowledge of its unique characteristics.
86

87. The Methadone Advantage
● Lacks active metabolites
● Advantageous in the setting of:
● Individual genetic phenotype variation
● Renal and liver failure
● Multiple MOAs
● Most patients benefit after switch to methadone
● Emerging evidence for low dose methadone as
an adjuvant medication.
● First Line Potential?
87

88. ABERRANT
BEHAVIOUR
88

89. Risk factors for aberrant behavior
● The key risk factors for opioid misuse are:
● younger age (i.e. 45 years or younger)
● a personal history of substance abuse
● mental illness
● legal problems
● family history of substance abuse
● Environment & life circumastance
89

90. Aberrant Behaviors
● Frequent unsanctioned dose escalations
● Insistence on specific opioids
● Concurrent alcoholism & illicit drug use
● Recurrent loss of prescriptions
● Lack of follow-up
● Injection of oral formulations
● Obtaining forged prescriptions
● Selling drugs obtained with a prescription
90

91. 91

92. and/or
92

93. 93

94. Risk Management
All prescribing of opioids to ambulatory
patients should be undertaken utilizing a
universal precautions strategy…
94

95. 95

96. 96

97. Level of Control
■ Limited dispensing (daily, weekly carries)
■ Opioid agreements
■ Pill counts
■ Random urine drug screens
■ Use options with less abuse potential(buprenorphine, methadone, oxycodone/naloxone)
These steps help to create structure,
establish boundaries, creating a
framework of safety and control.
97

98. Pseudo Addiction
■ Patients with under-treated chronic pain may display what
appear to be drug seeking behaviors and incorrectly
labeled as addicts(Schnoll and Weaver, 2003)
■ Simply stated, pseudoaddiction is a misdiagnosis that results
from under treatment of chronic pain
(Kline, 2008)
■ These may, in fact, be pain relief seeking behaviors
■ Cardinal feature of this syndrome: aberrant behaviors
disappear when effective pain control achieved
(U.S. National Institute of Health, National Cancer Institute (2004)
98

99. GRAND FINALE
99

100. Secret Sauce
100

101. Secret Sauce
101

102. Talk to Your patients
Ask your patients about their pain management
Ask them if they have concerns about taking opioids
102

103. Be an Effective Educator
■ How you discuss opioids with your patients can
strongly influence their decisions (Reid, 2008)
■ You must demonstrate confidence and certainty
when discussing safety and effectiveness
■ Providing accurate information and reassurance
can increase patient acceptance
103

104. Be an Effective Educator
■ Promote open discussion of all concerns
■ Use appropriate language
opioid vs narcotic pain reliever vs painkiller
medications vs drugs person with pain vs pain patient
■ Anticipate concerns
Just because a patient doesn’t voice a particular concern does
not mean they aren’t worried about it.
104

105. Takeaways Hat-trick
1. Palliative care defined
2. EMPATHY!
3. Healthy respect for
opioids*
a. implementation
b. anticipation
c. titration
d. rotation prn
*Tremendous
opportunity for
pharmacist
impact
105

106. 106

107. Suggested Resources
● McGill National Pain Centre (Opioid Guidelines in chronic
non-cancer pain, but many principles applicable to cancer
pain)
● Link: http://nationalpaincentre.mcmaster.ca/guidelines.html
● See: (MagicApp)
● Fraser Health Palliative Care Symptom Guidelines
● https://www.fraserhealth.ca/employees/clinical-resources/hospice-palli
ative-care#.XDeQzDBKjcs
● NCI PDQ®: Supportive and Palliative Care
● http://www.cancer.gov/cancertopics/pdq/supportivecare
● Demystifying Opioid Conversion Calculations:
● A Guide For Effective Dosing textbook (ML McPherson)
@ChrisRalphRx @ChrisRa1ph 107

108. Contact Info
Twitter: @ChrisRalphRx
Web: http://bit.ly/chrisralphrx
Email: cralph@ualberta.ca
Instragram: @chrisra1ph
108

109. CAPhO Student Membership
Free for 1st
year!!!
Link: http://capho.org/membership
109

110. References
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2014
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Oncol 32:1703-1711, 2014
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evidence and translation to practice. J Clin Oncol 32:1712- 1720, 2014
12. Paice JA, Von Roenn JH: Under- or overtreatment of pain in the patient with cancer: How to achieve proper balance. J Clin
Oncol 32:1721-1726, 2014
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110

111. APPENDIX
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112. PAIN
ASSESSMENT
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113. Patient Assessment
● *Pain intensity as reported by the patient is the
gold standard for pain assessment
● numeric rating scale (0 to 10 [0, no pain; 10, worst
possible pain])
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114. LMNOPQRST
● In addition to pain intensity:
● Location
● Medical treatments
● Number of episodes
● Onset
● Position/precipitation/palliating
● Quality
● Region/radiation
● Severity
● Temporal
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115. • Existential issues
• Religious faith
• Meaning of life
& illness
• Personal value
• Grief, depression
• Anxiety, anger
• Adjustment to
condition
• Relationship with
family
• Role in family
• Work Life,
finances
• Pain due to
disease location
• Other Sxs (n,v)
• Physical decline
& fatigue
Physical Social
Spiritual
Psycho-
logical
The Concept of Total Pain

116. Patient Assessment
● MP rates the pain at 6-7/10
● He describes a constant, deep, achy pain
localized in right hip, easy to elicit pain on exam
● Walking aggravates the pain
● Rest and heat seems to provide some relief
● Bone scan reveals pelvic bone metastasis
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117. Physical Exam
■ Goal:
To identify the underlying causes of the pain
and other concurrent medical problems
■ Includes:
mental status assessment, general exam (signs
of distress/discomfort, colour, nutritional &
hydration status, neurological & MSK exam)

118. Investigations
■ May help to identify underlying cause
of pain and guide treatment
■ May include:
○ Diagnostic Imaging
■ x-ray, bone scan, CT, MRI, etc
○ Lab investigations
■ renal function, electrolytes, calcium, etc

119. Classification: Types of Pain
Nociceptive
a. somatic (well localized, sharp, dull ache)
b. visceral (collicky or capsular, referred)
Neuropathic
a. dyesthesia type (burning, changed sensation)
b. neuralgic type (lancinating, shock-like)
c. mixed
Central pain and Sympathetically maintained (CRPS)
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