Hematology and Oncology Book

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Cancer Pain Medications

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  1. See Also
    1. Cancer Pain Narcotics
    2. Cancer Pain Management
    3. Narcotic Analgesic
  2. General pointers
    1. Assess patient's pain with a self rating pain scale
    2. Scale
      1. No pain: 0
      2. Mild pain: 1-4
      3. Moderate pain: 5-6
      4. Severe pain: 7-10
  3. WHO Analgesic Ladder
    1. Step 1: Mild Pain (pain score of 1 to 4)
      1. Adequate analgesia for 20-25% of cancer patients
      2. Acetaminophen
      3. Aspirin
      4. NSAIDs or COX2 Inhibitors
    2. Step 2: Moderate Pain (pain score of 5 to 6)
      1. Acetaminophen with codeine (Tylenol #3)
      2. Acetaminophen with Hydrocodone (Vicodin, Lorcet)
      3. Tramadol (Ultram)
    3. Step 3: Severe Pain (pain score of 7 to 10)
      1. Morphine Sulfate
      2. Hydromorphone
      3. Transdermal Fentanyl
      4. Levorphanol
      5. Methadone
      6. Avoid Meperidine (Demerol)
        1. Too short acting, lower efficacy
  4. Routes of Administration
    1. Oral Route (90% of cancer cases, preferred route)
    2. Subcutaneous (5% of cancer cases)
      1. Programmed Subcutaneous pump is first choice option
    3. Rectal (5% of cancer cases)
    4. Avoid regular Intramuscular dosing (no indication)
  5. Management: Somatic pain including bone metastases
    1. Pain Characteristics
      1. Aching or throbbing sensation
      2. Stabbing sensation
      3. Pressure sensation
    2. Medications: General
      1. See Cancer Pain Narcotics
      2. COX2 Inhibitors (e.g. Vioxx or Celebrex)
      3. Nonsteroidal Antiinflammatory drugs (NSAIDs)
        1. Diclofenac (Voltaren)
        2. Naprosyn
      4. Radioactive Strontium
    3. Medications: Bone Metastases
      1. Pamidronate (Aredia) 90 mg IV over 2-4 hours qMonth
      2. Calcitonin
      3. Corticosteroids
        1. Prednisone 30 to 60 mg/day PO
        2. Dexamethasone 16 mg/day PO
        3. Methylprednisolone 120 mg/day PO
  6. Management: Neuropathic pain
    1. Type I: Chronic Lancinating Pain (Paroxysmal pain)
      1. Characteristics
        1. Sudden sharp, stabbing or "Zinger" pain
        2. Sudden knifelike pain
      2. Medications
        1. Gabapentin (Neurontin) 100 mg PO tid
        2. Carbamazepine (Tegretol) 200 mg PO bid
        3. Valproic Acid (Depakote) 10 mg/kg/day PO
        4. Clonazepam (Klonopin) 0.5 mg PO tid
        5. Lamotrigine (Lamictal) 50 mg PO qd
        6. Baclofen (Lioresal) 5 mg PO tid
    2. Type II: Continuous Dysesthesias
      1. Characteristics
        1. Continuous burning
        2. Continuous electrical sensations
      2. Medications
        1. Tricyclic Antidepressants
          1. Amitriptyline (Elavil) 30 to 100 mg PO qhs
          2. Doxepin (Sinequan) 50 to 75 mg PO qhs
          3. Imipramine (Tofranil) 50 to 75 mg PO qhs
        2. Systemic Anesthetics
          1. Mexiletine (Mexitil) 200 mg PO q8 hours
          2. Tocainide (Tonocard) 400 mg PO q8 hours
        3. Other medications for refractory pain
          1. Gabapentin (Neurontin) 300 mg PO tid
          2. Clonidine (Catapres) 0.1 mg PO bid
          3. Capsaicin (Zostrix) 0.025% AAA tid
  7. Management: Visceral Pain
    1. Capsule swelling (e.g. hepatic)
      1. Corticosteroids
    2. Bowel Obstruction
      1. See Cancer Related Bowel Obstruction
  8. References
    1. Abrahm (1999) Ann Intern Med 131:37
    2. Cherny (2000) CA Cancer J Clin 50(2):70
    3. Levy (1996) N Engl J Med 335:1124
    4. Miller (2001) Am Fam Physician 64(7):1227

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