FT. LAUDERDALE, FlaTreatment pathways describing when and how
to titrate short-acting opioids rapidly are now part of the National
Comprehensive Cancer Network (NCCN) Practice Guidelines for Cancer
Other additions to the newly revised guidelines include treatment
pathways for surgical and anesthetic interventions, three scales for
rating pain intensity, and an expanded discussion of the components
of psychosocial support. The guidelines were presented at the Fifth
Annual NCCN conference.
Cancer pain remains inadequately treated, despite the fact that most
cancer patients experience significant pain, said Stuart A. Grossman,
MD, professor of oncology, medicine, and neurosurgery, and director
of neuro-oncology, Johns Hopkins Oncology Center.
The NCCN guidelines have been written to help physicians manage most
forms of cancer pain without consulting with pain specialists. This
is designed to make you a pain expert, Dr. Grossman emphasized.
In other words, you should be able to take care of most of the
pain problems by yourself.
The treatment pathways for the titration of short-acting opioids are
designed to help physicians treat the immediate emergency and then to
individualize the amount of medication a patient with cancer pain
will need on an ongoing basis. The algorithm includes specific
dosages and escalation dosages.
Using a 0 to 10 numerical scale, it divides patients into those with
pain measuring 7 and above and those with pain measuring 4 to 6.
Patients are also divided into those who are taking opioids and those
who are opioid naïve.
Short-Acting Agents Preferred
Dr. Grossman observed that many hospitals treat pain emergencies with
long-acting opioids, but that his panel of experts felt strongly that
short-acting agents were preferable.
The primary advantage of a short-acting agent is that you can
actually figure out what a patients dose requirements are by
escalating them quickly, he said. Once the proper dosage is
determined, long-acting agents can be prescribed for patient
For example, the guidelines recommend that an opioid-naïve
patient with pain measuring 7 to 10 receive either an oral dose of 5
to 10 mg of immediate-release morphine sulfate or a dose of 2 to 5 mg
of IV morphine sulfate.
Pain is reassessed at the medication peak. (The oral medication peaks
in 60 minutes; the IV medication peaks in 15 minutes.) If the pain is
unchanged, a double dose of the original amount is given.
This cycle of opioid administration is repeated until the pain is
decreased by 50% or more. At that point, the physician can calculate
the total amount of medication given over 4 hours and consider this
to be the effective dose for every 4 hours. This calculation is then
used to determine what the patient will need on an ongoing basis.
In addition to providing the baseline amount of medication, the
physician should also prescribe rescue doses of
medication for breakthrough pain.
The detailed management of opioid side effects is also described in
the guidelines. We want you to be able to manage major side
effects yourself, Dr. Grossman said. Were trying to
make the pain subspecialist extinct.
In the updated guidelines, the discussion of surgical and anesthetic
approaches to the management of cancer pain has been expanded. Dr.
Grossman noted that physicians are urged to consider specialty
consultations if pain levels remain high despite opioid medication or
if excessive opioid toxicity cannot be controlled.
The guidelines now offer a treatment pathway to help pain specialists
evaluate the appropriateness of surgical and anesthetic procedures.
The pathway starts by observing that certain procedures, such as
celiac plexus blocks, have a high benefit-to-risk ratio if done early
The pathway then asks physicians to consider whether the intervention
under consideration will relieve 50% of the pain. If yes, the next
step would be to perform a neurolytic block, if possible. If not
possible, or if the neurolytic block fails, spinal analgesia should
The new guidelines include an expanded description of what the
medical team should provide in the way of psychosocial support is
Opioid phobia is often present in both patients and
medical staff members, and confusion over addiction, dependence, and
tolerance must be addressed, said Matthew Loscalzo, MSW, director of
Patient and Family Services, Johns Hopkins Oncology Center, and
research associate, Johns Hopkins School of Medicine.
A written care plan is a powerful tool, Mr. Loscalzo said. A
written plan gives the patient a physical connection with you. You
play a very special role in the patients life that no one else
can play, he said. You are, in their mind, linked with
survival and life.
The psychological value of a written plan cannot be underestimated,
he said. If patients have a plan of action, they can cope with
almost anything. Its when they feel abandoned and separated and
detached from their medical care that they panic and get very
agitated. And pain can be a manifestation of that, Mr. Loscalzo
The medical team should be the patients advocate and help
access resources for pain management, he said. This may include
negotiating with pharmacies, managed care providers, and even the
primary health care team. The patient should also be taught coping
skills to help deal with pain and enhance a sense of personal control.
Finally, physicians should inform the patient and family that there
are always additional measures that can be taken to control pain, Mr.
Loscalzo said. The NCCN guidelines are a map and a recipe you
can use today for effective pain management, he said.