In M.T.’s case, her DIRE score is 10, which would indicate she is not a
suitable candidate for long-term opioid therapy. M.T.’s DIRE score and assessment
CASE 55-7, QUESTION 5: M.T. is going to be discontinued from opioids as part of the pain management
plan. What methods are appropriate to safely discontinue opioid therapy in M.T.?
Guidelines strongly recommend that clinicians taper patients from chronic opioids
if they have repeated aberrant drug-related behaviors, experience no progress toward
meeting therapeutic goals, or experience intolerable adverse effects.
tapering patients from long-term opioid therapy, the length of time the patient has
been taking opioids needs to be considered. Approaches to opioid tapering range
from a slow 10% dose reduction per week to a more rapid 25% reduction every few
days. Evidence to guide specific recommendations on the rate of reduction is lacking,
although the slower rate may help reduce the unpleasant symptoms of opioid
There is insufficient evidence to guide recommendations for the use of short-acting
versus long-acting oral opioids, or as-needed versus around-the-clock dosing during
In this case, it is recommended that M.T.’s oxycodone dose be reduced
slowly over 2 months in conjunction with starting psychological therapy for stress
management and counseling for alcohol use. M.T. will need to be monitored for signs
of withdrawal, which include anxiety, tachycardia, sweating, and other autonomic
symptoms. Should withdrawal symptoms occur, they may be lessened by clonidine
0.1 to 0.2 mg orally twice a day.
1 Diagnosis 1 = Benign chronic condition with minimal objective findings or no definite
medical diagnosis (e.g., fibromyalgia, migraine headache, nonspecific back
1 Intractability 1 = Few therapies have been tried, and the patient takes a passive role in
his/her pain management process
7 Risk (psychological + chemical health + reliability + socialsupport)
Psychological 2 = Personality or mental health interferes moderately (e.g., depression or
Chemical Health 1 = Active or very recent use of illicit drugs, excessive alcohol, or prescription
Reliability 2 = Occasional difficulties with compliance, but generally reliable
Social Support 2 = Reduction in some relationships and life roles
1 Efficacy Score 1 = Poor function or minimal pain relief despite moderate-to-high opioid doses
Score 7–13: not a suitable candidate for long-term opioid therapy
Score 14–21: good candidate for long-term opioid therapy
DIRE, Diagnosis, Intractability, Risk, and Efficacy score.
noncancer pain. J Pain. 2009;10:113.
Cognitive Behavioral Therapies (CBT)
Psychological counseling and CBT are key components to successful management
of the patient. The psychological approach to CBT has been shown to be beneficial
be incorporated within a CBT plan (Table 55-19). The objective is to help patients
acquire a sense of hopefulness and resourcefulness, and develop positive coping
Complementary and alternative therapies such as spinal manipulation, massage,
and acupuncture are commonly used in patients with chronic pain, but data supporting
their use in FAPS are limited. Transcutaneous electrical nerve stimulation has been
tried in FAPS patients, but the results are inconclusive.
CANCER PAIN AND SYMPTOM MANAGEMENT
Pain is one of the most commonly experienced and feared symptoms of cancer.
Cancer pain is defined as pain that results from treatment of the disease or the direct
impact of tumor growth. During cancer treatment, 35% to 56% of patients will have
pain with up to one-third of those patients having severe pain.
cancer pain can be classified as somatic, neuropathic, or visceral. Approximately
one-half of all cancer pain is somatic, arising from bone, muscle, ligament,
his/her physiologic responses by manipulating the auditory or visualsignals.
Guided imagery—useful method to help patients with pain to relax and achieve a sense of control and
Somatic pain is frequent with breast cancer, genitourinary tumors, bone metastasis,
and lymphatic malignancies. Neuropathic pain may be caused by surgery, cancer
chemotherapy, radiation, herpes zoster (shingles), and tumor progression such as
advanced head and neck cancer. Visceral pain often presents with gastrointestinal
Sixty-four percent of patients with advanced cancer report an increased frequency
and intensity of pain compared with patients with early-stage cancer.
influencing the degree of pain
include the primary cancer, stage of disease, location of metastasis, and comorbid
164,165 Each pain complaint must be assessed for time of onset,
body location, pattern of progression, impairment of physical function, psychosocial
impact, and other associated symptoms such as nausea, fatigue, shortness of breath,
constipation, and mental status changes.
The initial treatment of cancer pain is based on the severity as reported by the
patient. Factors to consider when starting an analgesic regimen include the pain
etiology, patient tolerance (e.g., opioid doses), setting where the medication will be
administered, and previous experience with analgesics that were efficacious or
produced adverse effects. In general, mild pain (e.g., pain rated ≤4 out of 10 in
severity) can be managed with nonopioid or a combination of nonopioid and a low
dose of an opioid analgesic. Moderate-to-severe pain (e.g., pain rated >4 out of 10 in
severity) usually requires a higher dose of an opioid analgesic. The treatment of
neuropathic pain may require the use of anticonvulsant or antidepressant medication.
Nerve blocks and invasive surgical procedures are options for pain control that is
refractory to conventional medication management.
Presentation and Treatment of Cancer Pain
QUESTION 1: L.V. is a 58-year-old man who was diagnosed with stage IV squamous cell carcinoma of the
had a modified neck resection to remove the primary tumor and lymph nodes while sparing the larynx.
Chemoradiation therapy began 3 weeks after surgery with cisplatin 100 mg/m
2 every 3 weeks (days 1, 22, and
The radiation oncologist orders laboratory tests and the results are as follows:
White blood cell count, 7.1 × 10
Red blood cell count, 3.25 × 10
Mean cell hemoglobin, 30 pg/cell
Mean cell hemoglobin concentration, 33 g/dL
Absolute lymphocytes, 1.2 × 10
are the possible etiologies of L.V.’s pain?
L.V. is presenting with a new complaint of a severe sore throat and persistent neck
and shoulder pain. Laboratory data ruled out infection and myelosuppression. His
kidney function may be impaired by dehydration and cisplatin therapy. The most
likely causes of L.V.’s pain are the recent surgical neck resection and mucositis from
L.V. also has postoperative peripheral neuropathy characterized by shock-like
sensation in the neck and shoulders after the resection of the tumor. The physical
examination of L.V.’s neck and shoulders is remarkable for allodynia, which can be
present with neuropathy. The cervical lymph node resection may have caused
neuropathy due to nerve damage via crushing, pressure, incision, or inflammation.
This results in ectopic firing and changes in the receptive field causing nerve
excitability and spontaneous activity (e.g., windup). Neuronal hyperexcitability may
be related to overexpression of sodium channels and activation of the NMDA
166 Cervical plexopathy may also be contributing to the discomfort.
Mucositis occurs in up to 45% of individuals treated for head and neck cancer
with the chemoradiation regimen L.V. is receiving.
167,168 Chemotherapy and radiation
directly affect the proliferation of epithelial cells and connective tissue, causing
damage to and loss of the mucosal barrier. On physical examination, the oropharynx
is red and ulcerated, which is indicative of mucositis. Chapter 94, Adverse Effects of
Chemotherapy and Targeted Agents provides information on the signs and symptoms
of mucositis. Pain associated with mucositis is dependent on the degree of tissue
damage, sensitization of nociceptors, and activation of inflammatory and pain
mediators. L.V.’s complaint of sore throat pain limiting his ability to swallow is a
common presentation of mucositis. In head and neck cancer patients treated with
radiation, pain intensity scores directly correspond to mucositis and increase at week
3, often peak at week 5, and persist for weeks after the end of treatment.
In addition, L.V. may have cisplatin-related neurotoxicity. Approximately 30% to
40% of patients may experience sensory loss as a result of direct neuronal DNA
damage and apoptotic cell death caused by cisplatin. Neurotoxicity is a dose-limiting
side effect for all the platinum agents. Cisplatin peripheral toxicity can occur in
patients who receive a cumulative dose of more than 400 to 500 mg/m2
sensory modalities are involved, but loss of large fiber function is often prominent.
Persistent dysesthetic pain (i.e., an unpleasant abnormal sensation, whether
spontaneous or evoked) is a late phenomenon that may continue to progress for
several months after cessation of cisplatin.
CASE 55-8, QUESTION 2: L.V. was started on intravenous hydromorphone using patient-controlled
patch dose should L.V. be started on, and what are the instructions for use?
TRANSDERMAL FENTANYL DOSE CALCULATION
Historically, the World Health Organization (WHO) analgesic ladder has been used
to guide cancer pain management.
170 The downside to using this algorithm is that
cancer pain rarely progresses in the stepwise fashion that the WHO ladder implies.
Therefore, several organizations including the American Pain Society and National
Comprehensive Cancer Network have proposed different strategies for managing
cancer pain based on the assessment of the patient, development of an individualized
care plan for pain, and symptom management.
Before starting intravenous hydromorphone, L.V. has severe throat pain rated 10
out of 10 and moderate-to-severe neck and shoulder pain rated 6 out of 10. Because
of the severity of pain and inability to swallow, intravenous opioid therapy using
PCA is appropriate. Hydromorphone is a good choice for intravenous opioid therapy
because it does not have active metabolites that could accumulate with renal
insufficiency. The transdermal fentanyl patch is an excellent choice for L.V.’s
eventual outpatient pain management because it will provide continuous release of
opioid and is convenient to use.
172 Kadian, an extended-release morphine capsule,
can be administered via a 16 French gastrostomy tube because the capsule can be
opened and contents flushed through the feeding tube with water.
use of this formulation in L.V. include the need for patient manipulation of the gastric
feeding tube with self-administration and the potential for morphine side effects
secondary to metabolite accumulation if renal insufficiency persists.
Transdermal fentanyl patches are intended for opioid-tolerant patients with stable
chronic pain. Opioid-tolerant patients are those who have been taking daily, for a
week or longer, at least 60 mg of oral morphine, 30 mg of oral oxycodone, or at least
8 mg of oral hydromorphone or an equianalgesic dose of another opioid.
pain that is managed with PRN opioid administration.
hospital admission, L.V. was taking 120 mg of ER morphine per day with additional
oral immediate-release morphine for breakthrough pain; therefore, L.V. is a good
candidate for a transdermal fentanyl patch.
L.V.’s transdermal fentanyl regimen will need to be determined by converting
intravenous hydromorphone using an equianalgesic dose approximation. Doses of
two different opioids (or two different routes of administration of the same opioid)
are considered to be equianalgesic if they provide the same degree of pain relief.
Table 55-20 provides equianalgesic opioid doses.
42,174 The calculations to convert
L.V. from IV hydromorphone to transdermal fentanyl (Duragesic) are shown in Figure
55-7. There are several published tables for converting morphine to transdermal
fentanyl that have been developed by researchers and manufacturers of transdermal
fentanyl products. They provide slightly different dose conversion recommendations.
Duragesic has wide morphine dose ranges, which may result in underdosing the
transdermal fentanyl patch in cancer patients.
174,176 Breitbart et al. recommend a 2:1
ratio of oral morphine to transdermal fentanyl (i.e., 2 mg oral morphine/day is
equivalent to 1 mcg/hour transdermal fentanyl), resulting in higher transdermal
fentanyl doses, which may be excessive for elderly patients.
al. suggested a dose ratio of 60 mg/day oral morphine is equal to 25 mcg/hour
transdermal fentanyl, which falls between the manufacturer’s table and the study
recommendations by Breitbart et al.
176–178 The Donner conversion ratio is used in
most references because it is less likely to cause underdosing or overdosing.
Standard for comparison of opioid analgesics.
Morphine not recommended in patients with
Exalgo (extended release) dosed every 24 hours.
Can be used in patients with renal or liver
Refer to Figure 55-7 for transdermal fentanyl
Equianalgesic conversion ratios have not been
established for transmucosal and transbuccal
Can be used in patients with renal or liver
OxyContin (controlled release) is dosed every 8
3–6 hours Can be used in patients with renal impairment.
0.3 (SL) 0.4 Available as sublingual tablets, sublingual film,
transdermal patch, and injection.
Suboxone (buprenorphine and naloxone)
restricted to treatment of opioid dependence.
Partial agonists not recommended for cancer
300 100 Not recommended for routine clinical use by the
toxic metabolite that produces anxiety, tremors,
myoclonus, and generalized seizures.
SL, sublingual; SC, subcutaneous; PO, oral; IV, intravenous.
L.V.’s transdermal fentanyl patch dose is 116 mcg/hour ( Fig. 55-7) using the dose
ratio 60 mg/day oral morphine to 25 mcg/hour transdermal fentanyl. Because L.V.’s
pain is well controlled based on the intensity rating of 4 out of 10, the dose of
transdermal fentanyl should be rounded down to the nearest available patch size,
If L.V.’s pain was not controlled, the transdermal patch
dose should be rounded up to the nearest available patch size.
Patients who have been on opioid therapy for a prolonged time are likely to exhibit
tolerance to the therapeutic effect. However, when switched to a different opioid, the
level of tolerance may change (i.e., diminished tolerance to the new opioid) owing to
the pharmacokinetic properties of the new opioid. This change in sensitivity to the
new opioid is called incomplete cross-tolerance.
174 Most opioid doses need to be
reduced by 25% to 50% after the conversion calculation to account for the
42 The exception to this is methadone and fentanyl.
Conversion ratios for methadone and fentanyl have already accounted for incomplete
cross tolerance, so no further reductions are generally needed.
transdermal fentanyl patch dose should not be reduced for incomplete crosstolerance.
After the initial transdermal patch is applied, it will take 12 hours to reach the
minimal effective blood concentration and up to 36 hours to achieve the maximal
concentration. The transdermal fentanyl patch must be changed every 72 hours to
maintain the steady-state blood concentration. Elderly, cachectic, or debilitated
patients may have altered pharmacokinetics (i.e., more rapid rate of release) as a
result of poor subcutaneous fat stores, thus requiring the transdermal fentanyl patch
Figure 55-7 Conversion of L.V. from intravenous hydromorphone to transdermal fentanyl.
L.V. should be instructed that the transdermal fentanyl patch should be applied to
an intact, nonirritated and nonirradiated flat skin surface such as the chest, back,
174 He should be warned about the risk of elevated body
temperature (e.g., 40°C or 104°F) resulting in a faster release of fentanyl from the
patch. The increased fentanyl level could cause serious respiratory depression. L.V.
should be cautioned about avoiding external heating sources such as electric
blankets, heating pads, tanning beds, sunbathing, hot baths, hot tubs, saunas, and
174 Fentanyl transdermal skin patches should not be used if
damaged or cut because this may increase the absorption of the medication. L.V.
should be told to wash his hands immediately if contact is made with the fentanyl gel
that was inside the transdermal patch.
CASE 55-8, QUESTION 3: How should L.V. be transitioned from IV hydromorphone to the transdermal
TRANSITION TO TRANSDERMAL FENTANYL
Reducing the intravenous hydromorphone continuous infusion by 50% should occur 6
hours after the initial transdermal fentanyl patch is placed. Discontinuation of the IV
hydromorphone continuous infusion and PCA dose should occur 12 hours after the
initial transdermal fentanyl patch placement.
174 L.V. may need to use a short-acting
(i.e., immediate-release) opioid until the maximal fentanyl blood concentration is
achieved. Additional short-acting opioid may be needed for pain that occurs near the
end of the 72-hour dose interval.
CASE 55-8, QUESTION 4: What are L.V.’s options for breakthrough pain management?
OPIOID THERAPY FOR BREAKTHROUGH PAIN MANAGEMENT
Breakthrough pain can be classified as spontaneous pain (i.e., frequently idiopathic,
occurring with no known stimulus), incident pain (i.e., secondary to a stimulus that
the patient may or may not be able to control), or end-of-dose failure (i.e., pain at the
end of the dosing interval of the ER/LA opioid).
Incident pain can be reduced by
instructing the patient to take a dose of short-acting opioid 30 minutes before activity.
Spontaneous breakthrough pain should be treated by administering a short-acting
opioid as soon as the pain is experienced. For patients on ER/LA opioid
formulations experiencing end-of-dose failure, APS guidelines recommend
supplementary doses of a short-acting opioid equivalent to 5% to 15% of the total
daily dose to be taken every 2 hours as needed.
42 Short-acting opioid/acetaminophen
products have a maximal dose to prevent liver toxicity with acetaminophen, thus
creating a ceiling limit on the analgesic efficacy. Plain short-acting opioids (e.g.,
morphine, oxycodone, hydromorphone) should be used for patients requiring large
In L.V.’s case, a short-acting opioid solution should be available for breakthrough
pain before discontinuation of intravenous hydromorphone. The short-acting opioid
can be administered in solution form through the gastric feeding tube or as oral
tablets if L.V. can tolerate swallowing. L.V.’s oncologist would like to use oral
morphine solution for breakthrough pain management. Because the transdermal
fentanyl total daily dose is approximately equal to a total daily dose of 280 mg of
oral morphine (Fig. 55-7), 10% of the total daily morphine dose would be 28 mg.
The dose should be rounded to the nearest tablet size for a short-acting formulation,
which is 30 mg, if L.V. would eventually take morphine tablets.
If more than two supplemental doses of short-acting morphine 30 mg are required
daily to keep L.V.’s pain under control, an increase in the transdermal fentanyl patch
dose should be considered. Moderate-to-severe pain may require an increase in the
opioid total daily dose by 50% to 100%.
Equianalgesic Doses for Actiq (Transmucosal Fentanyl) and Fentora (Buccal
Current Actiq Dose (mcg) Initial Fentora Dose (mcg)
Fentanyl administration by oral and intranasal transmucosal routes is approved for
breakthrough pain management in cancer patients. The dose of both formulations is
determined by titration (i.e., starting with the lowest dose and increasing based on
pain relief) rather than a percentage of the total daily dose.
of the transmucosal immediate-release fentanyl products are summarized in Table
55-21. The oral transmucosal route would not be preferred in L.V.’s case due to his
dry oral mucous membranes secondary to radiation, which will impact absorption.
Xerostomia is a common problem associated with radiation therapy of the head and
neck and occurs in 80% of patients by week 7 of treatment. Problems related to
xerostomia include difficulty speaking, chewing, swallowing, infections, mouth pain,
Effects of Chemotherapy and Targeted Agents, provides information on topical
treatment of mucositis and xerostomia.
CASE 55-8, QUESTION 5: L.V. has now completed chemoradiation therapy, and the mucositis pain has
methadone dose should L.V. be started on?
Methadone is an opioid agonist with analgesic activity at mu and delta receptors.
Additional mechanisms of action that make it unique from other opioids and a good
option for neuropathic pain include 5-HT and NE reuptake inhibition and antagonist
effects at the NMDA receptor. Rotation to methadone is recommended when a patient
has an inadequate response to other opioids or experiences intolerable side effects
such as delirium, myoclonus, or nausea. A trial with methadone is warranted for L.V.
because his neuropathic pain is not well controlled with transdermal fentanyl and
other coanalgesics, including gabapentin and lidocaine. Refer to Case 55-4 for
treatment of neuropathic pain.
Unlike short-acting opioids, methadone has a long half-life that ranges from 15 to
60 hours with a duration of action of 6 to 12 hours.
42 The conversion to methadone is
not proportional like other opioid equianalgesic dose calculations. Older opioid
dosing tables list a single conversion factor of 20 mg of oral methadone (or 10 mg IV
methadone) equianalgesic to 30 mg of oral morphine. The single methadone
conversion factor was intended for acute pain and does not account for chronic use.
The conversion ratios vary with the morphine dose. Contemporary tables contain
three or more morphine-to-methadone ratios to adjust for the magnitude of the
methadone dose potency with higher morphine daily dose requirements for chronic
noncancer and cancer pain. The most commonly used morphine-to-methadone
conversions are provided in Table 55-22.
Morphine-to-Methadone Equianalgesic Dose Ratio
Oral morphine dose (mg/day) <100
Oral morphine-to-oral methadone ratio 3:1 5:1 10:1 12:1 15:1 20:1
L.V.’s total daily dose of morphine is 390 mg after converting transdermal fentanyl
and adding the immediate-release morphine. Figure 55-8 provides the calculation to
convert transdermal fentanyl to oral methadone in L.V. The dose of oral morphine
falls within the dose range of 301 to 600 mg, which corresponds to a 10:1 oral
morphine to oral methadone ratio (Table 55-22). L.V.’s total daily dose of
methadone is approximately 39 mg (Figure 55-8). Guidelines recommend when
switching to methadone from higher doses of another opioid, start methadone therapy
no higher than 30 to 40 mg/day, with initial dose increases of no more than 10 mg/day
183 For most patients, the recommended methadone dose interval is
every 8 hours. Older adults or frail patients may need methadone dosed every 12
hours to reduce the occurrence of side effects such as sedation.
L.V.’s total daily dose of methadone should be divided into three doses and
administered on an 8-hour interval. However, methadone is available in tablets (5
and 10 mg) or oral solution. The problem with L.V.’s total daily methadone dose is
that it does not divide evenly using tablets. Splitting methadone tablets is not
recommended because of the inconsistency in the dose with unequal tablet portions.
Methadone solution is not convenient to use, and the dose needs to be drawn
accurately with an oral syringe to prevent overdosing. L.V. would need
approximately 11 to 13 mg of oral methadone solution per dose, which may be
difficult to calibrate with the oral syringe. Therefore, L.V.’s methadone dose should
be rounded down to the nearest available tablet size (e.g., 10 mg). Using a rapid
switch transition from transdermal fentanyl to methadone, L.V. should be instructed to
remove the transdermal fentanyl patch and begin methadone 10 mg orally every 8
hours approximately 12 hours after the patch has been removed. L.V. can continue to
use morphine sulfate immediate-release 30 mg every 2 hours as needed for
breakthrough pain. The immediate-release morphine dose may need to be reduced if
L.V. has a good response to methadone.
Figure 55-8 Conversion of L.V. from transdermal fentanyl to oral methadone.
Because methadone has a long terminal half-life, it will take 4 or more days to
achieve steady state. Unless L.V. is experiencing severe pain, the methadone dose
should not be increased before 5 days. L.V. should be encouraged to use the
immediate-release morphine during the transition period. The methadone dose can be
adjusted based on the total daily dose of morphine used for pain control during the
CASE 55-8, QUESTION 6: What are the signs and symptoms of methadone toxicity that should be
METHADONE TOXICITY SIGNS AND SYMPTOMS
L.V. should be instructed to take methadone exactly as prescribed to prevent serious
problems with breathing. He should be told about the signs and symptoms of
methadone toxicity including shallow breathing, slowed respirations followed by
periods of not breathing, slurred speech or difficulty talking, loud snoring, and
174 L.V. should be told to seek medical attention
immediately if he experiences any of these signs and symptoms of methadone toxicity.
He should also let family members living with him know about the risks of
methadone so they can be aware of the signs and symptoms of methadone toxicity.
Naloxone nasal spray and injection kits are now available for purchase at
pharmacies to prevent fatal respiratory depression caused by opioids. L.V’s family
members should be counseled that this antidote would be beneficial to keep at home
due to the risks associated with methadone.
CASE 55-8, QUESTION 7: What are the recommendations for monitoring cardiac toxicity associated with
Methadone can cause prolongation of the QTc interval and increase the risk for
development of torsades de pointes (potentially fatal arrhythmia). Factors associated
with QTc prolongation are methadone doses greater than 100 mg/day, hypokalemia,
low prothrombin level (suggestive of reduced liver function), and drug interactions
involving the cytochrome P-450 3A4 enzyme.
Consensus guidelines have been published on cardiac monitoring for patients
taking methadone. The guidelines recommend pretreatment screening,
electrocardiogram (ECG) evaluation, and risk stratification for QTc intervals
exceeding 500 ms. For a QTc interval exceeding 500 ms, the consensus guidelines
recommend reducing or discontinuing methadone (Table 55-23).
have an ECG ordered prior to initiation of methadone to check his baseline cardiac
function. Periodic ECG monitoring should be done if the dose is increased or L.V.
experiences new symptoms such as dizziness or fainting which may signal a change
CASE 55-8, QUESTION 8: How should opioid-related side effects be managed in L.V.?
Appropriate use of opioids requires minimizing the occurrence of side effects
including sedation, nausea, vomiting, pruritus, myoclonus, and cognitive
185 Table 55-24 provides information on the treatment of common opioidrelated side effects.
In cancer patients, multiple factors may contribute to the
emergence of opioid side effects such as renal insufficiency, nausea, and vomiting
caused by changes in gut motility or chemotherapy, sedation owing to metabolic
disturbances, and concomitant use of other sedatives or antiemetics. Tolerance to
most of the opioid side effects develops in 3 to 7 days. If the side effects do not
diminish with time, treatment may include switching to a different opioid or adding
another medication to counteract the undesired effect.
Respiratory depression is a serious adverse event and often is preceded by
sedation. With methadone, the peak respiratory depressant effects typically occur
later and persist longer than with other opioids. Naloxone is an opioid receptor
antagonist that can be used to reverse respiratory depression caused by opioid
medications. Opioid-tolerant patients are exquisitely sensitive to opioid antagonists.
If naloxone is necessary, it should be titrated to effect to prevent profound
withdrawal, seizures, arrhythmias, and severe pain (e.g., the analgesic effect of
opioids is reversed with naloxone).
42 Patients who are overdosed on methadone will
require a continuous IV infusion of naloxone for 24 to 36 hours because of the long
elimination half-life of methadone.
Consensus Recommendations for Methadone QTc Prolongation
Inform patients of arrhythmia risk before prescribing methadone
Obtain patient history of structural heart disease, arrhythmia, and syncope
Reduce or discontinue methadone if the QTc interval exceeds 500 milliseconds
antifungal agents, protease inhibitors, phenytoin, rifampin, phenobarbital, droperidol)
ECG, electrocardiogram; SSRIs, selective serotonin reuptake inhibitors.
Pharmacologic Treatments for Opioid-Related Side Effects
Constipation Stoolsoftener, laxative, methylnaltrexone, oral naloxone, naloxegol
Sedation Methylphenidate, modafinil
Pruritus Diphenhydramine, hydroxyzine
Nausea Prochlorperazine, haloperidol, metoclopramide, ondansetron, antihistamine
Dysphoria Haloperidol, opioid rotation
Cognitive impairment Methylphenidate, modafinil, opioid rotation
Myoclonus Clonazepam, dose reduction, opioid rotation
REFRACTORY CANCER PAIN MANAGEMENT
Neuraxial opioid administration (epidural or intrathecal) can be used to treat cancer
pain that is refractory to conventional therapy with opioids and coanalgesic
medications. Long-term neuraxial therapy must be administered through an
implantable intrathecal pump to avoid infection complications. Indications
for use of neuraxial therapy include neuropathic pain and mixed neuropathic–
nociceptive pain. Medication selection is based on the patient’s allergy history and
response to a screening trial. Opioids (e.g., morphine, hydromorphone, fentanyl),
local anesthetics (e.g., bupivacaine, ropivacaine), clonidine, ziconotide, and
baclofen are commonly used in neuraxial regimens.
Complementary and alternative medicine therapies are widely used by patients in
the management of cancer pain, dyspnea, and nausea and vomiting. Auricular
acupuncture, therapeutic touch, and hypnosis may help with the management of cancer
pain. Music therapy, massage, meditation, and hypnosis may help to reduce anxiety
caused by dyspnea. Acupuncture and guided imagery may be beneficial in treating
chemotherapy-induced nausea and vomiting.
Oral cannabinoid formulations (dronabinol and nabilone) are approved by the
FDA for chemotherapy-induced nausea and vomiting refractory to conventional
186 Several studies of the endogenous cannabinoid receptors (CB1
) have demonstrated efficacy in the management of pain.
receptor is expressed in the areas involved in nociceptive processing, including
the periaqueductal gray matter and dorsal horn of the spinal cord. The CB2
is expressed on cells of the immune system and is involved in modulation of
receptor activation has been shown to be analgesic in
188,189 Medical use of cannabinoids has been debated in
many states. In October 2009, the Department of Justice issued a memorandum to US
Attorneys stating that federal resources should not be used to prosecute persons
whose actions comply with their state’s laws permitting medical use of cannabis.
Currently, 23 states and Washington D.C. allow the use of medical cannabis for
various diseases and including cancer pain.
A full list of references for this chapter can be found at
http://thepoint.lww.com/AT11e. Below are the key reference and websites for this
chapter, with the corresponding reference number in this chapter found in parentheses
Med. 2008;148:247]. Ann Intern Med. 2007;147:505. (70)
Journal of Pain. 2014; 15(4):321–337 (184)
Chou R et al. Guidelines on the management of postoperative pain. J Pain. 2016;17(2):131–157. (30)
Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004;63:959. (105)
primary care. Eur Spine J. 2010;19:2075. (65)
prescribing in chronic non-cancer pain: part 2 guidance. Pain Physician. 2012;15:S67–S116. (151)
American Society of Health-System Pharmacists; 2010. (174)
centralsensitization pain. Pain Physician. 2015;18(3):E333–E346. (62)
Principles of Analgesic Use. 7th Edition Chicago, IL: American Pain Society, 2016. (42)
Centers for Disease Control and Prevention.
http://www.cdc.gov/primarycare/materials/opoidabuse/index.html.
National Hospice and Palliative Care Organization. www.nhpco.org.
American Pain Society. http://americanpainsociety.org/.
International Association for the Study of Pain. https://www.iasp-pain.org/.
COMPLETE REFERENCES CHAPTER 55 PAIN AND ITS
International Association for the Study of Pain. http://www.iasp-pain.org/Taxonomy?
navItemNumber=576#Pain. Accessed April 27, 2016.
continues to be undermanaged. Anesth Analg. 2003;97:534–540.
survey. Curr Med Res Opin. 2014;30:149–160.
http://www.cdc.gov/nchs/data/hus/hus06.pdf. Accessed April 27, 2016.
Comments
Post a Comment
اكتب تعليق حول الموضوع