Going Beyond Efficacy: Strategies for Cancer Pain Management
Abstract
:1. Introduction
2. Review of the Basics in Cancer Pain Management
2.1. Types of Cancer-Related Pain
- Nociceptive pain occurs when tissues surrounding nociceptive fibres are injured or stressed. Nociceptive pain can be further divided into somatic pain (which originates in the skin, bones, joints, or muscles) and visceral pain (which originates in internal organs) [1]. Patients with somatic pain are usually able to localize the pain well. They will often report an ache that worsens with movement of, or pressure on, the affected area. Visceral pain, usually described as a cramping or pressure-like pain, is often not well localized [1].
- Neuropathic pain is pain related to damage or dysfunction of the nervous system, and this pain type is described in more detail in its own subsection, later in this article.Patients may simultaneously experience more than one type of pain at more than one location, with each pain being likely to respond in varying degrees to various therapies.
2.2. The Analgesic Ladder
2.3. General Dosing Considerations for Analgesics.
3. Agents for Special Types of Cancer Pain
3.1. Bony Pain
3.2. Neuropathic Pain
3.2.1. Anticonvulsants
3.2.2. Antidepressants
3.2.3. Corticosteroids
3.2.4. Methadone
3.2.5. Interventional Cancer Pain Management
3.2.6. Cannabinoids
3.2.7. Ketamine
3.2.8. Tramadol
3.2.9. Buprenorphine
3.3. Treatment-Related Pain Syndromes
4. Education of Patients, Caregivers, and Clinicians
5. Summary
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Initial dosage of “strong opioid” in opioid-naive patient: |
Fit patient: Morphine 5 mg orally every 4 hours or equivalent |
Frail patient: Morphine 2.5 mg orally every 4 hours or equivalent |
Thereafter, titrate to pain relief or unacceptable side effects. |
Fentanyl patches should not be prescribed for the opioid-naive patient. (If patients are on “weak opioids”—for example, Tylenol 3, combined acetaminophen–oxycodone—they are not opioid-naïve!) |
Dosage of “strong opioid” in patients already on opioids (including “weak opioids”): Determine starting dose of “strong opioid” by using equianalgesic table. |
When rotating opioids, reduce the calculated dose of the new opioid by approximately 30% (incomplete cross tolerance). |
Drug | Dose | |
Oral | Subcutaneous | |
Codeine | 100 mg | — |
Morphine | 10 mg | 5 mg |
Oxycodone | 5 mg | — |
Hydromorphone | 2 mg | 1 mg |
Side Effect | Management Strategy |
Nausea | Haloperidol 0.5 mg as needed |
Prochlorperazine 10 mg as needed | |
Sedation | Educate and reassure as to transient nature of effect |
For persistent sedation, decrease dose, rotate opioid, or consider stimulant (methylphenidate) | |
Constipation | Stool softener (docusate), plus stimulant laxative (senna) given routinely |
Urinary retention | Decrease dose or rotate opioid |
Puritius | Antihistamine |
Consider rotation to synthetic opioid | |
Opioid toxicity (respiratory depression, a delirium, myoclonus, hyperalgesia, seizure, pinpoint pupils) | Decrease opioid dose |
Consider opioid rotation | |
Maximize adjuvant analgesics | |
Reserve use of naloxone for diagnostic purposes and in setting of severe toxicity only | |
Rule out sepsis, hypercalcemia, or other metabolic disturbances that may have predisposed |
Day 1 | Initiate 300 mg at half strength for 3 days |
Day 4 | Increase to 300 mg twice daily for 3 days |
Day 7 | Increase to 300 mg three times daily |
Subsequent days | Continue to titrate based on response to a maximum of 3600 mg daily a |
Clinically significant CYP3A4 inducers (that is, they lower methadone concentration) |
Amprenavir, efavirenz, neifinavir, nevirapine, phenobarbital, phenytoin, rifampin, ritonavir |
Possibly clinically significant CYP3A4 inducers | Carbamazepine, chronic ethanol |
Clinically significant CYP3A4 inhibitors (that is, they increase methadone concentration) | Benzodiazepines, ciprofloxacin, ethanol, fluconazole |
Possibly clinically significant CYP3A4 inhibitors | Cimetidine, fluoxetine, omeprazole, quinidine, paroxetine |
Sympathetic ganglia | Pain syndrome |
Cervicothoracic (stellate) ganglion | Neuropathic pain from head and neck cancers, post-mastectomy pain, superior sulcus syndrome |
Celiac plexus | Upper abdominal or back pain associated with cancer of the esophagus, pancreas, liver, or stomach |
Lumbar ganglia | Flank pain or lower abdominal pain from urologic cancers |
Superior hypogastric plexus | Lower pelvic pain from colon, rectal, or gynecologic cancers |
Ganglion impar | Perineal and rectal pain from anal or rectal cancer |
© 2008 by the author. Multimed Inc.
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Myers, J.; Shetty, N. Going Beyond Efficacy: Strategies for Cancer Pain Management. Curr. Oncol. 2008, 15, 41-49. https://doi.org/10.3747/co.v15i0.201
Myers J, Shetty N. Going Beyond Efficacy: Strategies for Cancer Pain Management. Current Oncology. 2008; 15(s1):41-49. https://doi.org/10.3747/co.v15i0.201
Chicago/Turabian StyleMyers, J., and N. Shetty. 2008. "Going Beyond Efficacy: Strategies for Cancer Pain Management" Current Oncology 15, no. s1: 41-49. https://doi.org/10.3747/co.v15i0.201
APA StyleMyers, J., & Shetty, N. (2008). Going Beyond Efficacy: Strategies for Cancer Pain Management. Current Oncology, 15(s1), 41-49. https://doi.org/10.3747/co.v15i0.201