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cancer pain

Complications: - increasing back pain in a patient with known spinal metastases should cause concern for spinal cord compression (see Management:) [15] Management: 1) use acetaminophen, aspirin or NSAIDs for mild to moderate pain - may be continued after addition of opioid [13] 2) if pain persists of increases, add a low-dose or low-potency opioid - reasonable to go straight to strong opiate (morphine, oxycodone) if non-opioid analgesics insufficient [4] - no specific opioids recommended over others 3) increase opioid potency or use higher doses for persistent pain or moderate to severe pain at onset - initiate opioid at lowest possible dose [13] - no specific dosage escalation, but increases of 25-50% common 4) add adjuvant agents at any step a) neuropathic pain 1] tricylcic antidepressants 2] anticonvulsants 3] local anesthetics 4) topical analgesics b) corticosteroids a) anti-inflammatory b) mood elevation c) appetite stimulation c) osteolytic bone lesions - IV bisphosphonate (pamidronate zoledronate) - pregabalin ineffective for painful bone metastases [5] 5) prescribe analgesics around the clock for persistent, chronic pain, rather than as needed 6) do not exceed maximum doses of NSAIDs & acetaminophen a) be judicious in accounting for analgesic combinations b) acetaminophen: 4000 mg/day c) ibuprofen 2400 mg/day, naproxen 1250 mg/day d) aspirin 4000 mg/day 7) treatment of acute cancer pain with bolus doses of intravenous opioids a) do not use partial opioid agonists (buprenorphine) b) do not use meperidine (even with biliary disease) - naloxone does not reverse CNS toxicity caused by normeperidine & may actually increase neuroexcitability 8) IV patient-controlled analgesia (morphine pump) in hospitalized patients - hydromorphone is a better option in patients with impaired renal function [10] - basal rate equivalent to 50-100% of 24 hour outpatient dose - demand dose of 10-20% of 24 hour outpatient dose [14] 9) manage chronic pain with around-the-clock long-acting opiates plus short-acting opioids for breakthrough pain - start long-acting opiate with 30-50% of 24-hour opioid dosage [18] - dose breakthrough opioids at 10-15% of the morphine equivalent daily dose every 3-4 hours [13,16] 10) titrate total analgesic dose by adding the total opiate dose (long-acting + short-acting) & using this dose for the new around-the-clock long-acting opiate dose - titration easiest if both long-acting & long-acting opiate are the same drug [18] 11) recognized & manage adverse effects of opiates a) constipation: 1] prophylaxis with initiation of opiates 2] stool softener 3] stimulant laxative b) sedation c) delirium (rotate to different opiate) [17] d) nausea e) pruritus: antihistamines f) except for constipation, tolerance develops 12) tolerance & physical-dependence is not addiction 13) interventional strategies for refractory pain [3] - intrathecal opiates - small doses can have profound analgesic effects & cause fewer adverse effects than would systemic opioids [3] - start with temporary intrathecal drug delivery system - palliative sedation to relieve intractable pain in terminally ill patients [3] - rotate opioid to another opioid if pain persists despite high-dose of one opioid (i.e. morphine to methadone) [16] 14) interventions for specific cancer pain presentations - unremitting neck pain or back pain - spinal imaging (MRI of spine to rule out spinal cord compression) - intravenous glucocorticoids (dexamethasone) [1] - admit & initiate intravenous morphine (bolus dosing) [15] - celiac plexus block vs celiac plexus neurolysis for intractable pancreatic cancer or other upper abdominal cancer pain [10] - cachectic patients do not absorb fentanyl well 15) massage therapy is helpful - 20 minutes 3-4 time/week provided by a caregiver can alleviate cancer pain & improve mood [6,7,8,9] 16) acupuncture may be of benefit [12] 17) both acupuncture & massage associated with pain reduction & improved fatigue, insomnia, & quality of life [19] - no significant different between acupuncture & massage therapy [19] 18) screening for risk of substance abuse suggested [10] - use CAGE questions modified for opioid use * opiate dose is only limited by signs of overdose

Interactions

disease interactions

General

cancer complication pain [odyn-]

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 14, 17, 18 American College of Physicians, Philadelphia 2006, 2015, 2018.
  2. Colson J, Koyyalagunta D, Falco FJ, Manchikanti L. A systematic review of observational studies on the effectiveness of opioid therapy for cancer pain. Pain Physician. 2011 Mar-Apr;14(2):E85-102 PMID: 21412384
  3. Kamdar MM, Doyle KP, Sequist LV et al Case 17-2015 - A 44-Year-Old Woman with Intractable Pain Due to Metastatic Lung Cancer. N Engl J Med 2015; 372:2137-2147. May 28, 2015 PMID: 26017825 http://www.nejm.org/doi/full/10.1056/NEJMcpc1404141
  4. Bandieri E et al. Randomized trial of low-dose morphine versus weak opioids in moderate cancer pain. J Clin Oncol 2016 Feb 10; 34:436. PMID: 26644526
  5. Fallon M et al. Randomized double-blind trial of pregabalin versus placebo in conjunction with palliative radiotherapy for cancer- induced bone pain. J Clin Oncol 2016 Feb 20; 34:550. PMID: 26644535 - Raman S et al. Does pregabalin still have a role in treating cancer- induced bone pain? J Clin Oncol 2016 Feb 20; 34:524. PMID: 26644542
  6. Kozak L, Vig E, Simons C, Eugenio E, Collinge W, Chapko M. A feasibility study of caregiver-provided massage as supportive care for Veterans with cancer. J Support Oncol. 2013 Sep;11(3):133-43. PMID: 24400393
  7. Collinge W, Kahn J, Walton T et al Touch, Caring, and Cancer: randomized controlled trial of a multimedia caregiver education program. Support Care Cancer. 2013 May;21(5):1405-14. PMID: 23262808 Free PMC Article
  8. Kutner JS, Smith MC, Corbin L et al Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer: a randomized trial. Ann Intern Med. 2008 Sep 16;149(6):369-79. PMID: 18794556 Free PMC Article
  9. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  10. Nelson R Managing Cancer Pain in the Era of an Opioid Crisis. Medscape. Jun 13, 2018. https://www.medscape.com/viewarticle/898009 - Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni PA. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database Syst Rev. 2011 Mar 16;2011(3):CD007519. PMID: 21412903 PMCID: PMC6464722 Free PMC article
  11. NEJM Knowldege+ Question of the Week. March 20, 2018 https://knowledgeplus.nejm.org/question-of-week/1018/
  12. He Y, Guo X, May BH et al Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer PainA Systematic Review and Meta-Analysis. JAMA Oncol. Published online December 19, 2019. PMID: 31855257 https://jamanetwork.com/journals/jamaoncology/fullarticle/2757396 - He Y, May BH, Zhang AL et al Acupuncture for cancer pain: protocol for a pilot pragmatic randomised controlled trial. BMJ Open. 2019 Jul 9;9(7):e025564. PMID: 31289059 Free PMC Article
  13. Paice JA et al. Use of opioids for adults with pain from cancer or cancer treatment: ASCO guideline. J Clin Oncol 2023 Feb 1; 41:914. PMID: 36469839 https://ascopubs.org/doi/10.1200/JCO.22.02198
  14. Blinderman CD, Billings JA. Comfort Care for Patients Dying in the Hospital. N Engl J Med. 2015 Dec 24;373(26):2549-61. PMID: 26699170 Free article. Review.
  15. Dalal S, Bruera E. Assessing cancer pain. Curr Pain Headache Rep. 2012 Aug;16(4):314-24. PMID: 22585314 Review.
  16. Fallon M, Giusti R, Aielli F et al Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2018 Oct 1;29(Suppl 4):iv166-iv191 PMID: 30052758 Free article. No abstract available.
  17. Centeno C, Sanz A, Bruera E. Delirium in advanced cancer patients. Palliat Med. 2004 Apr;18(3):184-94. PMID: 15198131 Review.
  18. Alexander K, Goldberg J, Korc-Grodzicki B. Palliative care and symptom management in older patients with cancer. Clin Geriatr Med. 2016;32:45-62. PMID: 26614860
  19. Epstein AS, Liou KT, Romero SAD et al. Acupuncture vs Massage for Pain in Patients Living With Advanced Cancer: The IMPACT Randomized Clinical Trial. JAMA Netw Open. 2023 Nov 1;6(11):e2342482. PMID: 37962891 PMCID: PMC10646731 Free PMC article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10646731/