Management Principles

                                                                   MANAGEMENT PRINCIPLES

1. Use a multi-drug approach. Combine Opioids with non-opioid adjuvants.
2. Opioids should be limited to the agonist drugs. See Equianalgesic Chart below. Avoid Meperidine
      (Demerol) and the mixed agonist-antagonist opioids (e.g. Stadol, Nubain, Talwin).
3. Cancer pain is chronic in nature and requires, with rare exception, both scheduled and rescue dosing.
     Scheduled dosing will maintain even serum drug levels and provide consistent relief. Rescue dosing
     should be available on an as-needed basis and can be increased or decreased depending on its effects.
     Frequent rescue dosing requires a change in the scheduled long acting drug dose.
4. Base the administration schedule on the analgesic's duration of effect. If possible, use sustained
     release opioids for scheduled dosing and always use immediate release opioids for rescue dosing.
5. A non-invasive route is preferred. For pain that is severe and escalating, it may be necessary to provide
     intravenous analgesics until the pain is managed. If oral, rectal, or transdermal dosing is no longer
     practical or appropriate, continuous subcutaneous or intravenous infusions are indicated.
6. Take into account the equianalgesic differences of the various routes of administration. The first pass
     effect of hepatic metabolism requires higher oral opioid dosing than parenteral dosing. When changing
     from oral to parenteral or when changing opiates, allow for individual differences, and then titrate dose.
7. Manage opioid side effects aggressively. Be mindful that patients never become tolerant to the constipating
     effects of opioids.

DRUG	DOSAGE FORM/STRENGTHS	DURATION	MORPHINE EQUIVALENCE IM/SC/IV ORAL
Morphine	Immediate Release Tablets MSIR - 15, 30 mg Sustained Release Tablets Avinza- 30, 60, 90, 120 mg (2) MS Contin - 15, 30, 60, 100, 200 mg (1) Kadian - 20, 30, 50, 60, 100 mg (1,2) Oramorph SR - 15, 30, 60, 100 mg (1) Oral Liquid MSIR Oral Solution - 2 mg/ml, 4 mg/ml MSIR Oral concentrate - 20 mg/ml Roxanol Concentrate - 20 mg/ml Suppository Rectal Morphine Sulfate (RMS) 5, 10, 20, 30 mg	q 3-6 hrs q 24 hrs q 12 hrs q 24 hrs q 12 hrs q 3-6 hrs q 3-6 hrs q 3-6 hrs q 4 hrs	10 mg	30 mg
Hydromorphone	Tablets Dilaudid - 2, 4, 8 mg Liquid Dilaudid - 2 mg/ml Dilaudid HP - 10 mg/ml Suppository Dilaudid - 3 mg	q 3-6 hrs q 3-6 hrs q 3-6 hrs q 6-8 hrs	1.5 mg	7.5 mg
Oxycodone	Immediate Release Tablets Oxy IR - 5 mg Roxicodone - 5, 15, 30 mg Oxycodone/Acetaminophen (3) Percocet - 5/325, 7.5/325, 10/325 mg (3) Roxicet - 5/325, 5/500 mg (3) Sustained Release Tablets Oxycontin - 10, 20, 40, 80 mg Liquid Roxicodone - 1 mg/ml, 20 mg/ml OxyFAST - 20 mg/ml	q 3-4 hrs q 3-4 hrs q 4-6 hrs q 3-4 hrs q 8-12 hrs q 3-4 hrs q 3-4 hrs		20 - 30 mg
Fentanyl Transdermal	Skin Patch (4) Duragesic - 25, 50, 75, 100 mcg/hr	q 48-72 hrs	100 mcg patch q 2-3 days = 66 mg IV Morphine q 24 hrs OR 2.7 mg IV Morphine q 1 hr	100 mcg patch q 2-3 days = 200 mg Oral Morphine q 24 hrs OR 33 mg Oral Morphine q 4 hrs
Fentanyl Transmucosal	Oral Lonzenge (5) Actiq - 200, 400, 600, 800, 1200, 1600 mcg	- - -	- - -	- - -
Methadone (6, 7)	Tablet Dolophine - 5, 10 mg Liquid Generic Methadone - 1, 2 mg/ml	q 4-12 hrs	10 mg acute 2-4 mg chronic 1 - 2 mg	20 mg acute 2-4 mg chronic 2.5 - 5 mg
Hydrocodone	Hydrocodone/Acetaminophen Tablets (3) Vicodin - 5/500 mg Vicodin ES - 7.5/750 mg Lorcet or Vicodin HP - 10 mg/650 mg Lortab - 2.5/500 mg, 5/500 mg 7.5/500 mg, 10/500 mg Norco - 5/325 mg, 7.5/325 mg, 10/325 mg Hydrocodone/Ibuprofen Vicoprofen - 7.5/200 mg	q 4-6 hrs q 4-6 hrs q 4-6 hrs q 4-6 hrs q 4-6 hrs q 4-6 hrs q 4-6 hrs		Vicodin 5 mg/500 mg = 9 mg Oral Morphine

   1. Do not crush or chew tablets.
   2. Capsules may be opened and granules sprinkled on food or placed in NG tube.
   3. Dose in 24 hrs. limited to maximum acetaminophen 4000 mg.
   4. Do not cut patch. Must be in contact with skin.
   5. Onset 5 minutes; not recommended for opioid naive patients.
   6. Accumulates with repeated dosing, requiring decreases in dose size and frequency, especially on days 2-5.
   7. May wish to titrate on a q 8 hr schedule.

NOTES:

Butorphanol (Standol), Meperidine (Demerol), Nalbuphine HLC (Nubain), Pentazocine (Talwin) and
Propoxyphene (Darvon, Darvocet) are not recommended for the management of cancer pain.

TRIPLICATE PRESCRIPTIONS ARE NOT REQUIRED FOR TERMINALLY ILL PATIENTS IN
CALIFORNIA. Clinicians must indicate "11159.2 exemption" on regular prescription form.

SOURCES OF PAIN

PAIN SOURCE	PAIN CHARACTER	DRUG CLASS/EXAMPLES
Myofacial Somatic Pain	Constant and well localized.	Muscle relaxants
Visceral Pain	Injury to sympathetically innervated organs. Pain is vague in quality. Deep, dull, aching. Referred Pain.	Opioids
Bone Pain	Axial skeleton with thoracic and lumbar spine most common.	Radiation therapy NSAIDs: Celebrex,Vioxx, Motrin, Naproxen, Dolobid, Orudis, Trilisate, Toradol Corticosteroids Bisphosphonates
Neuropathic Pain Nerve Damage Dysesthesia	Injury to some element of the nervous system (plexus or spinal root). Dysesthesia, burning, tingling, numbing, shooting electrical pain. May not respond well to opioid analgesics.	Tricyclic Antidepressants: Amitriptyline (Elavil), Desipramine (Norpramin, Pertofrane) for burning pain Anticonvulsants: Neurontin, Tegretol or Klonopin Corticosteroids Anti-arrhythmic (Mexiletine) Topical Anesthetic: Lidocaine Patch5% (Lidoderm) Opioids

Nonsteroidal anti-inflammatory drugs for bone pain and antidepressants or anticonvulsants are but two of many potential co-analgesics. Corticosteriods, neuroleptic agents, bisphosphonates and calcitonin, and some anxiolytic agents may be useful in selected patient populations. Avoid benzodiazepines unless primary anxiety disorder persists after pain relieved.

STEP 3 Severe Pain (rating 8-10)

Morphine, hydromophone, oxycodone, fentanyl, or methadone
Pain may require oral, transdermal, parenteral, or intraspinal routes for adequate analgesia
Invasive techniques should be considered for patients who do not respond to Step 3. ******************

STEP 2 Moderate Pain (rating 4-7)

Acetaminophen/oxycodone combination (Percocet)
Acetaminophen/hydrocodone combination (Vicodin)
When the maximum tolerated or recommended dosage is reached, or pain is unresponsive, proceed to Step 3 interventions..
******************

STEP 1 Mild Pain (rating 1-3)

Acetaminophen or an NSAID (e.g. ibuprofen)
When the maximum tolerated or recommended dosage is reached, or pain is unresponsive, proceed to Step 2 interventions.
******************

At each level adjust or add: 1) nonpharmacologic interventions and/or 2) psychosocial support

	OPIOID SIDE EFFECT MANAGEMENT
Constipation	Senokot-S or Pericolace 2 tabs bid. May increase to 4 tabs bid. If no BM in 2 days must add a laxative (Dulcolax, Milk of Magnesia or Lactulose). Lactulose effectiveness is dose related. Start at 4 tbsp. q 4 hrs until BM, especially when constipation is opioid related.
Nausea/ Vomiting	Compazine 10 mg po q 6 hr. PRN or 25 mg suppository PR q 6 hr. PRN. May add Ativan 0.5mg q 6 hr. po/sl, PRN or Reglan 10 mg po qid. If oral route cannot be tolerated or is ineffective, check with MD for alternative routes. Scopolamine TD patch is effective for opioid related nausea q 72 hrs.

CANCER PAIN MANAGEMENT
REFERENCE CARD

The Southern California Cancer Pain Initiative
c/o City of Hope National Medical Center
1500 E. Duarte Road, Duarte, California 91010
Phone: 626-359-8111 Ext. 63202 Fax: 626-301-8941
Email: sccpi@coh.org

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NO PAIN WORST PAIN

The SCCPI Cancer Pain Management Reference Card can be duplicated for your organization or ordered from SCCPI.
The dimensions of the card are 10 ½" by 5 ½".

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