Transcript A Practical Approach to Cancer Pain Management

A Practical Approach to
Cancer Pain Management
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
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
Pain Assessment:
• Intensity
• Etiology
• Type
Measurement:
• Scales:
– Numeric rating scales
– Visual analogue
– Descriptive
• Outcome Measure:
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Pain intensity
Distress
Relief
Interference
Breakthrough dosing
• Tools:
– Brief Pain Index
– Memorial Pain Assessment Card
Clinically Important Questions:
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Current pain level
Average pain level
Worst pain level
Pain relief with medications
Etiology:
• Treatable Causes:
– pathologic fracture
– bone met
– chest wall recurrence
• Emergent:
– cord compression
– brain met
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
Neuropathic Pain:
• Mechanism: Damage to receptor or nerve
• Frequently unrecognized
• Types of Syndromes:
– Peripheral
• Drug induced (Cisplatin, Taxol)
– Central
• Cord compression
Neuropathic Pain Syndromes:
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Post-amputation Limb Pain
Post-thoracotomy Pain
Post-mastectomy Pain
Brachial Plexopathy
LS Plexopathy
Celiac Infiltration
Assessment of the Patient:
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Medical Problems
Psychological Function
Physical Function
Cognitive Function
Support Services
Financial Services
Educational Status
Ready to Prescribe:
Rx
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
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
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
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
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
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
Dosing on a Fixed Interval:
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
Dosing on A PRN Basis:
Fixed Dosing:
Medication Half Life
• Immediate Release:
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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
Write a Fixed Dose Prescription
for the Following:
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Morphine Sulfate IR 30 mg tabs
MS Contin 30 mg tabs
Dilaudid 4 mg IR tabs
Duragesic 25 ug patch
Oxycontin 20 mg tabs
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
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
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
Acute Management:
Moderate 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
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
Key Equi-analgesics Ratios
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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
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
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
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
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
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
Titration Schema:
Initial Fixed and Rescue Dose
Controlled
Pain
Moderate Pain
Severe Pain
No Change
25% Increase
50% Increase
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
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
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
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
Sustained Release Formulations:
• Morphine
• Oxycodone
• Fentanyl
• Dilaudid
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
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
Consider Patch in the Following
Patient Populations:
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Non-compliant patients
Patients unable to take oral medications
Question of drug abuse
Question of cognition
Conversion Factor:
100 mg Morphine
50 micrograms Fentanyl
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
IV/SC Narcotics
• Use:
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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:
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Rapid Peak
Fast Clearance
q 10 minutes
Hourly dose equal
hourly rescue
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
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
Pain Emergency
• High Dose Decadron
• Anesthesiology Consult
• Neurosurgery Consult
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:
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Knowledge
Attitudes
Practice patterns
Pain control
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
Narcotic Titration Order Schema:
A 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
Narcotic Titration Order Schema:
A 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
Randomized Phase III Trial of Standard
Care Vs Opioid Titration Order Schema
Report
Comply
Requirements:
1. Beliefs
2. Knowledge
3. Resources
Assessment
Titration
Communication
Requirements:
1. Time
2. Knowledge
Cancer Pain Management:
Requirements for Success
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Setting the Right Priorities
Dedicated Team
Willing to Take Time
Systematic Approach
Understanding of the Basic Principles
of Symptom Control
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