Donna 3

MANAGEMENT OF CANCER PAIN

Donna Vazirnia, PharmD

Midwestern University College of Pharmacy

DISCLOSURES

  • No conflicts of interest

  • No affiliations or bias to disclose

LEARNING OBJECTIVES

  • Calculate: Be able to switch between different opioids.

  • Create: Create a plan to monitor and manage opioid side effects.

  • Recommend: Recommend specific strategies to mitigate the risk of opioid use disorder and overdose.

  • Utilize: Utilize pharmacokinetics and patient specific factors to identify appropriate therapy selection and dose titration.

  • Recall: Recall appropriate adjuvant pain medications specific to this population based upon the cause of pain.

  • Recognize: Recognize the "5 A’s" of pain management outcomes.

HISTORICAL CONTEXT

OPIOIDS FOR ACUTE PAIN

TIMELINE OF EVENTS

  • Noted that the timeline includes events referenced in the clinical literature surrounding opioid use for acute pain management.

  • Relevant literature:   - Morone NE, et al. Clin Ther, 2013. 35(11):1728-1732.   - Baker DW. Joint Commission Statement, April 2016.   - Policy D-450.956. AMA, 2016.

OPIOIDS FOR CHRONIC PAIN

TIMELINE OF EVENTS

  • Major shifts in guidelines and policies affecting chronic pain management with opioids highlighted in various studies:   - Page R, et al. JOP, 2019. 15(5):229-231.   - ASCO in Action: New Medicare Part D Opioid Prescribing Guidelines for 2019, Nov 2018.   - Dowell D, et al. MMWR, 2016. 65(1):1-49.   - ASCO Policy Statement on Opioid Therapy, May 2016.   - ASCO-led Resolution on Opioid Therapy, November 2016.

MEDICARE OPIOID-PRESCRIBING POLICY

  • Key Points:   - 7-day supply limits for opioid-naïve patients.   - Pharmacy alert mechanism if Morphine Milligram Equivalents (MMEs) exceed 90 → contact prescriber.

  • Effective Date: January 2019   - Target groups include:     - Long-term care facility patients     - Hospice patients     - Palliative patients     - Patients with cancer-related pain (ICD10 Code G89.3)

ARIZONA OPIOID PRESCRIBING GUIDELINES (2018)

SUMMARY GUIDELINES FOR THE TREATMENT OF ACUTE AND CHRONIC PAIN

  • More than two Arizonans are dying daily from opioid overdose; majority due to prescription opioids.

  • Highlights imperativeness of crafting safe prescribing practices while managing patient pain effectively.

  • Seventeen guidelines tailored for non-cancer, non-terminal pain are enumerated to enhance provider decision-making without superseding medical judgment and risk-benefit analyses.

NATIONAL DRUG-INVOLVED OVERDOSE DEATHS (1999-2021)

FIGURE: Overdose Statistics

  • Statistics from the CDC on the rise of various drug involvement in overdose deaths.

  • Significant figures presented include:   - Synthetic opioids other than methadone (primarily fentanyl)   - Prescriptions for natural & semi-synthetic opioids and methadone.     - Detailed breakdown of drug overdose deaths.

CANCER-RELATED PAIN AND ITS PREVALENCE

  • Statistics:   - 25% of newly diagnosed cancer patients experience pain.   - 55% of patients with cancer have chronic pain.   - 40% of cancer survivors experience pain related to their previous cancer treatments.

CAUSES OF CANCER-RELATED PAIN

  • Major Contributors:   - Tumor growth and tissue injury.   - Metastasis affecting nerve pain and organ function.   - Chemotherapy and radiation-induced pain (e.g., mucositis, skin irritation).   - Surgical complications and pain associated with treatment-related constipation.

TIME-BASED DEFINITIONS OF PAIN

  • Pain Classification:   - Acute Pain: Lasting less than 90 days.   - Chronic Pain: Lasting longer than 3-6 months.   - Breakthrough Pain: Transient increase in pain over baseline level.

CLASSIFICATION OF PAIN

  • Acute Pain:   - Easily identifiable source; subjective and objective signs; autonomic nervous system hyperactivity.

  • Chronic Pain:   - Lasts longer than 3 months; affects quality of life significantly; may cause personality and lifestyle changes.

COMPREHENSIVE PAIN ASSESSMENT

  • Components:   - Pain: Level of intensity for each pain site; history and side effects assessment.   - Function: Ability to carry out daily activities and mobility.   - Psychological Assessment: Family support and psychological issues should be evaluated.   - Personalized Goals: Determine patient comfort and achievement in various domains.

THREE-STEP ANALGESIC LADDER

  1. Step 1: Mild to moderate pain    - Recommended Medications: Non-opioids (e.g., acetaminophen, NSAIDs).

  2. Step 2: Moderate pain not relieved by non-opioids    - Recommended Medications: Combination of non-opioid and low-dose opioids (e.g., codeine, morphine).

  3. Step 3: Severe pain or inadequate relief    - Recommended Medications: High-dose opioids (e.g., morphine, hydromorphone).

OPIOID PRESCRIBING CHRONIC CANCER-RELATED PAIN

EXISTING GUIDELINES

  • Referencing the National Comprehensive Cancer Network (NCCN) guidelines for adult cancer pain management, and the American Society of Clinical Oncology (ASCO), which emphasizes an integrative approach.

NCCN GUIDELINES FOR OPIOID-NAÏVE PATIENTS

SUMMARY OF RECOMMENDATIONS (PHARMACOLOGIC)

  • Mild Pain (1-3/10):   - Non-opioid analgesics unless contraindicated.

  • Moderate Pain (4-7/10):   - Non-opioid analgesics plus short-acting opioid (various options listed).

  • Severe pain (>8/10):   - Inpatient or hospice admission should be considered for comfort.

NCCN GUIDELINES FOR OPIOID-TOLERANT PATIENTS

SUMMARY OF RECOMMENDATIONS (PHARMACOLOGIC)

  • Defined as patients requiring opioids for more than a week.

  • Pain management strategies adjusted by assessing individual medication efficacy and titration.

PAIN CRISIS MANAGEMENT

  • Opioid Naïve Patients:   - Recommended dosages provided for managing acute crises.

  • Opioid Tolerant Patients:   - A guideline for managing pain with individualized dosages based on MMEs.

THE “5 A’S” OF OUTCOMES IN PAIN MANAGEMENT

  • Analgesia: Measure of pain relief.

  • Activities: Patient engagement in daily living or activities.

  • Adverse Effects: Monitoring side effects of pain management interventions.

  • Aberrant Drug Use: Assessment of potential misuse or addiction behaviors.

CASE STUDY EXAMPLE

Patient Management Scenario

  • Analyzing a patient with cancer pain needing adjustments in his pain management plan, considering medication doses, side effects, and patient quality of life.

ADJUVANT ONCOLOGY THERAPIES

INTEGRATIVE INTERVENTIONS

  • Exploration of cognitive modalities, spiritual care, physical modalities, and specific treatments such as acupuncture proven effective in managing cancer-related pain.

OPIOID PRESCRIBING GUIDELINES FOR NERVE PAIN

MEDICATION STRATEGIES

  • Recommendations for using Antidepressants, Anticonvulsants, and Topical agents.

OPIOID TARGETING AGENT CONSIDERATIONS

  • Discussion surrounding different opioids and their appropriate usages in varying patient contexts, considering drug interactions.

OPIOID TAPERS AND MANAGEMENT OF ADVERSE EFFECTS

OPIOID INDUCED CONSTIPATION (OIC)

  • Recommendations for managing OIC through lifestyle modifications, medication adjustments, and preventive measures.

NALOXONE AND RESPIRATORY DEPRESSION

  • Overview of naloxone's role as an opioid antagonist in respiratory depression incidences, detailing administration methods and emergency guidelines.

CONCLUSION

  • Emphasizes the importance of timely treatment of cancer pain, utilizing multiple pharmacologic strategies while ensuring patient safety through monitoring of drug interactions and adherence to current guidelines for optimal care.