[186] Pain Management

Mild

NCCN classification rating of 1 - 3 corresponds to --- pain

Moderate

NCCN classification rating of 4 - 7 corresponds to --- pain

Severe

NCCN classification rating of 8 - 10 corresponds to --- pain

Numerical Rating Scale

Rating scale where Px are asked to rate the pain from 0 to 10

Numerical Rating Scale

Type of rating scale where exact numerical range of each level of pain is unclear

Verbal Rating scale

Type of rating scale that provides a clear ranking of pain

Visual Analog Scale

Type of rating scale where Px are asked to make along the line the level of pain they are experiencing

Face Scale

Type of rating scale where different number assignments are used; severe pain is 5 instead of 10

NCCN Classification

Standard way of classifying pain intensity

Analgesia, Activities, Adverse Events, Aberrant Drug Taking, Affect

Optimize pain treatment outcomes in these give dimensions (5As)

Analgesia

Determine dimension (5As): Optimizing pain relief

Activities

Determine dimension (5As): Optimizing psychosocial functioning

Adverse events

Determine dimension (5As): minimize possible AEs

Aberrant Drug Taking

Determine dimension (5As): should be managed to avoid possible addiction-related outcomes

Aberrant Drug Taking

Indicator of drug misuse and/or abuse

Affect

Determine dimension (5As): refers to the emotional component of the pain; pertains to the relationship between pain and mood

Non-opioids, adjuvant therapies

These should be given to manage mild pain unless Px is contraindicated due to AE or potential drug interactions

short-acting opioids

This may be added to non-opioids and adjuvant therapies as needed to manage moderate pain

30 - 50%

short-acting opioids are titrated with the goal of increasing the daily dose by --- every day

long-acting opiods

These may be considered if the Px consistently requires 3-4 doses of short-acting opioids for managing moderate pain

regular schedule, rescue dose

For persistent moderate pain, you may initiate --- of opioid with *---* as needed

Opioids

These are used to manage severe pain

Hospital, inpatient admission

For severe pain, -- or -- may be done to achieve patient-specific goals for comfort and function

Mild

Determine intensity of pain based on treatment given:

non-opioid +/- adjuvant analgesics

Moderate

Determine intensity of pain based on treatment given:

non-opioids +/- adjuvant therapies +/- weak opioids

Severe

Determine intensity of pain based on treatment given:

non-opioids may still be given +/- adjuvant therapies +/- strong opioids

Non-opioid

\[Non-opioid/ Opioid/ Adjuvant\]

Acetaminophen

Non-opioid

\[Non-opioid/ Opioid/ Adjuvant\]

NSAIDS

Opioid

\[Non-opioid/ Opioid/ Adjuvant\]

Morphine

Opioid

\[Non-opioid/ Opioid/ Adjuvant\]

Fentanyl

Opioid

\[Non-opioid/ Opioid/ Adjuvant\]

Hydrocodone

Opioid

\[Non-opioid/ Opioid/ Adjuvant\]

Codeine

Opioid

\[Non-opioid/ Opioid/ Adjuvant\]

Hydromorphone

Opioid

\[Non-opioid/ Opioid/ Adjuvant\]

Oxycodone

Opioid

\[Non-opioid/ Opioid/ Adjuvant\]

Oxymorphone

Opioid

\[Non-opioid/ Opioid/ Adjuvant\]

Methadone

Opioid

\[Non-opioid/ Opioid/ Adjuvant\]

Levorphanol

Opioid

\[Non-opioid/ Opioid/ Adjuvant\]

Tramadol

Opioid

\[Non-opioid/ Opioid/ Adjuvant\]

Tapentadol

Adjuvant

\[Non-opioid/ Opioid/ Adjuvant\]

SSRIs, SNRIs, TCAs

Adjuvant

\[Non-opioid/ Opioid/ Adjuvant\]

Gabapentin

Adjuvant

\[Non-opioid/ Opioid/ Adjuvant\]

Pregabalin

Adjuvant

\[Non-opioid/ Opioid/ Adjuvant\]

Corticosteroids

Adjuvant

\[Non-opioid/ Opioid/ Adjuvant\]

Local anesthetics

Adjuvant

\[Non-opioid/ Opioid/ Adjuvant\]

Lidocaine patches

Mu

Which opioid receptor causes physical dependence, EUphoria, respiratory and cardiac depression, reduced gastrointestinal motility, sedation, and analgesia (CNS, most opioids)?

Kappa

Which opioid receptor causes Miosis, DYsphoria, sedatino, and analgesia (PNS, some opioids)?

Delta

Which opioid receptor causes antidepressant effects and analgesia (PNS, some opioids)?

Morphine

Pure; Mu receptor agonist, weak kappa receptor agonist

\
short half-life, standard staring DOC

PO preferred

Hydromorphone

Pure; Mu receptor agonist, weak delta receptor agonist

\
similar to morphine

short half-life

has a metabolite that may lead to opioid neurotoxicity

Myoclonus, hyperalgesia, seizures

symptoms of opioid neurotoxicity

Fentanyl

Pure; Mu receptor agonist

\
highly lipid-soluble

short half-life

may be administered parenteral, spinal, transdermal, transmucosal, buccal, and intranasal

Fentanyl

ToC if px is unable to swallow

Methadone

Pure; Mu receptor agonist, N-methyl-D-aspartate (NMDA) receptor antagonist

\
long half-life (8 - 120 hours)

high potency

harder to manage but similar potency and efficacy to morphine

should be monitored due to possible drug accumulation

Has varied equivalence dosing with morphine

\
Possible AE: Torsades de pointes, QTc prolongation

Oxycodone

Pure; Mu, kappa, and delta receptor agonist

\
similar analgesic and AE to morphine

short half-life

Hydrocodone

Pure; Mu and delta receptor agonist

\
Equipotent with oral morphine but data are not substantiated

Oxymorphone

Primarily a mu-receptor agonist

Codeine

Pure; weak Mu and delta receptor agonist with little direct analgesic effect

\
weak opioid

depends on CYP240, especially CYP2D6

exhibits CYP2D6 polymorphism

Levorphanol

Pure; Mu, kappa, and delta receptor agonist and NMDA antagonist

\
short half-life

predictable metabolism

varied equivalent dosing with morphine

similar benefit to methadone, less prescribing complexities and AEs

Buprenorphine

Partial; Mu receptor agonist

\
treating cancer pain in px with Renal Impairment

has ceiling analgesic activity

if administered with high dose opioids, may cause withdrawal symptoms

Tramadol

Mixed mechanism; weak mu receptor agonist with some NorE and 5-HT3 reuptake inhibition

\
used in caution in Px taking TCAs, SSRIs, SNRIs, and MAOIs

Tapentadol

Mixed mechanism; mu receptor analgesic with NorE reuptake inhibition

\
used in caution in Px taking TCAs, SSRIs, SNRIs, and MAOIs

Acetaminophen

aka Paracetamol

Acetaminophen

has analgesic and antipyretic activity WITHOUT anti-inflammatory

\
has risk for hepatotoxicity and renal impairment

\
Used with caution or not used at all with combination of opioid-acetaminophen products to prevent excess acetaminophen dosing

3g

Acetaminophen limit according to NCCN recommendations

NSAIDs

has antipyretic, analgesic, anti-platelet, and anti-inflammatory effects

\
addition of this drug class to opioids is said to be beneficial due to possibility of opioid dose reduction esp when sedation, cognitive function, or other CNS effects of opioids are burdensome

Misoprostol, PPIs

Drugs used as prophylaxis for NSAID-induced peptic ulcers

CHF, HTN

For patients that are of high risk for cardiac toxicities, NSAIDs should be discontinued if -- or -- worsens/develops.

Warfarin, Heparin

If px is taking anticoagulants such as -- and -- with NSAIDs, there a significant increase in risk for bleeding complications → avoid Oral NSAIDs in prophylactic or therapeutic anticoagulation

Diclofenac

If Px is taking anticoagulants instead of oral NSAIDS, use of -- gel or patch is more recommended.

Adjuvant analgesics

refer to medication coadministered to enhance opioid analgesia and reduce AEs

helpful if Px experiences pain that is only partially responsive to opioids

helps to manage bone pain, neuropathic pain, and visceral pain; also helps reduce opioid requirement

Gabapentin, Cryotherapy, Local anesthetic formulations, oral care protocols

Therapies to manage mucositis, pharyngitis, and esophagitis

NSAIDs, Acetaminophen, steroids

Therapies to manage bone pain without oncologic emergency

bisphosphonates, denosumab

bone-modifying agents that may be considered if Px has bone pain without oncologic emergency

Hormonal therapy, chemotherapy, corticosteroids, radioisotopes

Treatments that may be considered if Px has diffuse bone pain without oncologic emergency

Local RT, nerve block, vertebral augmentation, radiofrequency ablation

Treatments that may be considered if Px has local bone pain without oncologic emergency

Surgical intervention

If bowel obstruction is due to cancer, this treatment should be considered.

Corticosteroids, metoclopramide

If px has partial bowel obstruction, these medical management may be considered

Bowel rest, nasogastric suction, percutaneous gastrostomy drainage, corticosteroids, H2 blockers, anticholinergics, ocreotide

Agents that could be considered for palliative management of bowel obstruction

Scopolamine, hyoscyamine, glycopryrrolate

examples of anticholinergics used for palliative management of bowel obstruction (3)

Corticosteroids

Nerve pain compression or inflammation, trial of -- may be considered

Antidepressants, anticonvulsants, topical agents

Nerve pain compression or inflammation, trial of --, --, or may be considered

referral

most appropriate action if px has refractory neuropathic pain which may be paired with the use of interventional strategies

radiation, hormones, chemotherapy

For painful lesions that are unlikely to respond to antineoplastic therapies, may consider (3)

Topical Lidocaine

examples of topical agent that may be used for neuropathic pain

Neuropathic pain

type of pain that results from nerve damage or malfunctioning of the nervous system → may be due to the cancer itself or to the acute or chronic effects of cancer

\
pain comes and goes but is chronic

\
Sx: shooting, burning pain; tingling and numbness

dronabinol, nabilone, cannabidiol

3 approved FDA cannabinoids

Dronabinol, nabilone

tetrahydrocannabinol (THC or THC mimics)

\
used to treat refractory nausea and vomiting associated with cancer treatment.

Cannabidiol

cannabinoid approved for treatment of seizures with rare forms of severe epilepsy

Dronabinol

cannabinoid approved to treat anorexia and weight loss related to AIDS

Marijuana

cannabinoid classified as a Schedule 1 substance → high potential for abuse, no current accepted medical use and lack of accepted safety

Inhaled cannabis

Cannabinoid hyperemesis syndrome is most common for --

Edible cannabis

Acute psychiatric symptoms, intoxication, and cardiovascular symptoms are most common for --

Opioids

principle analgesic for moderate to severe pain → high risk for dependence

10 - 20%

Dose reduction for Px with the following condition:

* never or rarely required breakthrough analgesic
* completion of acute pain event
* improvement of pain control through use of non-opioid pain management therapies
* well controlled pain in the setting of stable disease

10 - 25%

dose reduction for px experiencing unmanageable AEs and mild pain (1-3)

50 - 75%

dose reduction for Px with significant safety issues (i.e. sedation due to sepsis)

Opioid-induced hyperalgesia

considered when increasing opioid dose leads to worsening of pain → dose reduction or rotation with attention to other pain therapies

Opioid-induced hyperalgesia

state of nociceptive sensitization caused by exposure to opioids; paradoxical response where px receiving tx for pain becomes more sensitive to certain painful stimuli C

Codeine, morphine, hydromorphone, hydrocodone, oxymorphone

used in caution for Px with fluctuating renal function

\
metabolites of these drugs may accumulate