Hematology and Oncology Book

http://www.fpnotebook.com/

Cancer Pain Narcotics

Advertisement

  1. See Also
    1. Cancer Pain Medications
    2. Cancer Pain
    3. Narcotic Analgesic
  2. Protocol: Give Chronic Pain medication around-the-clock scheduled
    1. Use 'patient may refuse' approach
    2. Contrast with as needed dosing
  3. Protocol: Starting Narcotic Analgesic (WHO Step 3)
    1. Choice drug: Morphine Sulfate
    2. Begin short acting Morphine Sulfate 5-10 mg q4h
      1. Daily Starting dose: 30-60 mg/day
  4. Protocol: Establishing maintenance dosing After 1 week
    1. Maintenance Pain Management
      1. Convert short acting morphine to long acting morphine
    2. Assess for excruciating pain (pain score >9)
      1. Increase dose by 50 to 100%
      2. Continue to dose until pain is relieved
      3. Pain relief should be goal, not fixed amount
      4. Morphine doses may need to exceed 600 mg/day
        1. High dose morphine is safe as end of life analgesia
        2. Bercovitch (1999) Cancer 86:871
    3. Assess rescue dosing for breakthrough pain
      1. Use immediate release form of Step 3 Opioid
        1. Short acting Morphine Sulfate
      2. Calculate rescue dose and interval
        1. Rescue doses represent 10% of total daily dosing
        2. Dose: One third of long acting agent dose
        3. Frequency
          1. One third of long acting interval
          2. Dose up to every 1-2 hours until pain relieved
    4. End-Of-Dose Pain (medications wear off early)
      1. First, try increasing long acting Opioid dose
      2. Next, consider short-acting agent timed to cover break-through pain
      3. Next, consider shortening the long-acting Opioid dose interval (for fast metabolizer)
        1. MS Contin may be dosed as often as three times daily
        2. Fentanyl Patches may be changed as often as every 48 hours
  5. Protocol: Treat Opioid adverse effects
    1. Begin Bowel regime concurrently with Narcotics
      1. See Bowel Regimen in Chronic Narcotic Use
      2. See Constipation in Cancer
      3. Lactulose OR Stool Softener (Colace) AND
      4. Peristaltic stimulant (senna alkaloid)
    2. Consider Antiemetic for first few weeks of Narcotic
      1. Prochlorperazine
      2. Dimenhydrinate
      3. Metoclopramide
    3. Reverse Narcotic Analgesic related confusion
      1. Methylphenidate
  6. 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

Navigation Tree