Pain Management & Opioid Use for the

Cancer Patient

Suzana Makowski, MD MMMCo-Chief of Palliative Care

Brenda Neil, NPPalliative Care Nurse Practitioner

UMass Memorial Healthcare

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

Overview

• Cancer Pain – background, assessment, treatment

• Opioid Rotation• Pain Crisis/Pain Code• Dealing with Drug-Seeking Behavior

Cancer Pain - Reported

1of 3 patients with active cancer

3 of 4 patients with advanced cancer

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)

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.

Effects of undertreated pain

Challenges to treatment of cancer pain

Pain

WHO’s Pain Relief Ladder

Step 1

Step 2

Step 3

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

Opioid Rotation

• Why?• How?

Opioid Rotation

• Why?• How?

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

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?

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 OR60mg x (15 morphine/10 oxycodone)= Morphine ER 45mg bid

Step 3: if starting new opioid, consider adjusting for cross-tolerance:

~ Morphine ER 30mg bid

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 prn60mg 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

Case of Hector G – part 2more 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

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

Approach to Pain Crisis

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

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

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.

Engage and Support in Pain Crisis

• Nursing and Pharmacy colleagues• Social work and chaplaincy• Family• Outside agencies – hospice may be helpful

At end of life…

CMO ≠ Continuous Morphine Only

Treat pain and other symptomsAssess for side effects of therapiesWatch urine output if on continuous or long-acting opioid (other than fentanyl)

Treat pain and other symptomsAssess for side effects of therapiesWatch urine output if on continuous or long-acting opioid (other than fentanyl)

Cancer and drug-seeking behavior

Tending to the Addict’s Pain

MH63 yo disabled woman with metastatic breast cancerSevere pain due to brachial plexopathyHistory of smoking and addiction – high opioid tolerance

LS

53 yo disabled woman with metastatic lung cancer.Pain is due to bone metastasesHistory of addictionCurrent 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

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 concernPotential diversion

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)

TJ

53 yo ex-pro football player, heroin addict on methadone x 20+ yearsAdmitted with pain crisis

Treatment:Hydromorphone gtt 40mg/hourMethadone 30mg IVP q8 hours (then switch to ketamine gtt)Lidocaine gtt 20mg/kg/hour

PRN:Hydromorphone 10mg IVP q30 min prn

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

Thank you

Suzana Makowski, MD:Suzana.makowski@umassmemorial.orgOffice: Debbie Horgan – (508) 344-8630

Delila Katz, PharmD:Delila.katz@umassmemorial.orgNew cancer center pharmacy