Sonja Chandler

Intravenous methadone for cancer pain unrelieved by morphine and hydromorphone: clinical observations

Abstract Methadone is a very effective second‐line opioid for treatment of cancer pain. However, the starting doses of methadone indicated on opioid conversion charts may over‐estimate the dose of intravenous (i.v.) methadone needed. In this report, we describe four patients with cancer‐related pain treated with continuous i.v. morphine and hydromorphone. Because of persistent pain and opioid side effects limiting increases in opioid dose, each patient was switched to i.v. methadone. All four patients had excellent pain relief without significant side effects at a dose that, according to the available conversion charts, was approximately 3% of the calculated equi‐analgesic dose of hydromorphone. When converting from continuous i.v. hydromorphone to continuous i.v. methadone, much lower doses than those suggested by the opioid conversion charts should be used as starting doses.

Guidelines for the clinical use of transdermal fentanyl.

Transdermal (TTS) fentanyl therapy has emerged as an effective alternative to the use of oral opioids for the control of pain in certain cancer patients. These patients are those with moderate to severe chronic pain, with a stable baseline pain pattern. Patients receiving this treatment should first be titrated to stable pain relief with oral opioids and should have recourse during therapy to fast-acting, short-duration analgesics for the control of incident pain. TTS fentanyl dosing schedules should be based upon the patients requirement for rescue dosing and duration of effective pain control. The average requirement to change fentanyl patches is every 72 h, although 48-h dosing is necessary in a few patients. This novel route of fentanyl administration allows convenient outpatient treatment, the possibility of a lower incidence of side effects, and may thus aid compliance.

Inappropriate use of naloxone in cancer patients with pain

Opioid overdose is rarely the primary cause of altered mental status in cancer patients receiving opioid therapy. The inappropriate administration of naloxone to reverse an abnormal mental status can cause severe withdrawal symptoms and pain. To illustrate this problem, we report the case of a patient inappropriately treated with naloxone and the results of a retrospective review of the medical records of 15 consecutive patients with cancer treated with naloxone in the emergency department over a 5-month period. We offer guidelines for a more thoughtful approach to the management of patients with cancer who present with encephalopathy.

Nebulized opioids to treat dyspnea

Breathlessness secondary to cancer and nonmalignant disease is very distressing and exhausting to patients and families. Patient quality of life and functionality can be greatly improved with effective management. The pathophysiology and treatment of dyspnea are where the science of pain management was 20 years ago. While the optimal therapy for dyspnea would be to treat the underlying cause, this is frequently not possible. Research results evaluating dosages and effectiveness of nebulized morphine are conflicting. Some researchers have reported dramatic benefit to patients in relieving the symptoms of dyspnea, increasing exercise endurance, and improving function. Other studies have reported no significant differences between nebulized morphine and saline with or without oxygen. Studies that administer single predetermined doses that are not titrated to relief in patients that do not have end-stage lung or cardiac disease may report false-negative results. Other factors such as the placebo effect of saline and oxygen, if not controlled, may cause false-positive results. The dramatic positive benefits documented warrant further investigation on the appropriate patient selection criteria and therapeutic potential. Clearly, large scale randomized trials on opioid nebulized treatments for patients with severe dyspnea need to be published to reach a clear consensus outlining efficacy and administration parameters. Until that time, we must rely on anecdotal reports for treatment options. Such reports of the effectiveness of nebulized morphine as an alternative to hospital or hospice admission are encouraging for patients and family members managing severe dyspnea in the home.

Outcome of cancer pain consultations

All major cancer centers in the United States are equipped with pain management consultation services. We report on the outcome of such consultations within 24 hours from the intervention.

High-dose epidural infusion of opioids for cancer pain: Cost issues

The safety and efficacy of intraspinal opioids as therapy for selected patients with cancer pain are well-established. The choice of the appropriate drug is influenced by many variables that are to date incompletely elucidated. The cost of therapy is an increasingly important component of decision-making. This report describes the management of a patient who achieved excellent pain control with the administration of epidural sufentanil and bupivacaine. Daily Average Wholesale Price for sufentanil was, however,

Economics of unrelieved cancer pain.

698. Until the data comparing the efficacy of different epidurally administered opioids in the treatment of cancer pain are available, we suggest that treatment with more costly opioids be reserved for patients for whom analgesia cannot be achieved after maximizing epidural morphine analgesia with aggressive side-effect management.

Combined administration of opioids with selected drugs to manage pain and other cancer symptoms initial safety screening for compatibility

Diagnosis Related Groups, managed care contracts and capitation, hospitals had little incentive to control costs. Now hospitals have shifted to a more cost-effective environment by striving for improved patient clinical outcomes, satisfaction, and functionality while also acknowledging the need for fiscal restraint. For society at large and especially oncology patients in pain, the risk in this shift is an underutilization of resources to relieve pain driven by the the mistaken belief that good pain management takes too much time and is therefore an expensive “luxury.” However, the reality is that unrelieved cancer pain results in patient suffering, decreased quality of life and ultimately higher medical and non-medical costs—due to increased likelihood of patient and family lost wages and higher utilization of medical services, such as emergency department visits and unnecessary hospitalizations. Between 30 and 50 percent of cancer patients in active treatment and 70 to 90 percent of those with advanced disease experience moderate to severe pain.1 Cancer pain may be acute or chronic and can be caused by the tumor growing in tissues and organs, such as the liver or bone, or can be caused by treatments for the cancer, such as chemotherapy, radiotherapy, or surgery. Table 1 outlines the many ways that unrelieved cancer pain affects the lives of patients and their families. Decreased quality of life, functionality, activity, appetite and productivity can result in the patient’s unwillingness to continue antineoplastic treatment. The most disturbing result of unrelieved pain is the movement to legalize euthanasia for terminally ill patients. A reported 69 percent of the general public surveyed indicated that they would consider suicide if pain became intolerable.2 The clinical problem of unrelieved pain has received much attention in the last decade with an emphasis on medical community education, national clinical practice guidelines, and new pharmacotherapeutic options for treatment. In fact, for the vast majority of cancer patients with pain, the use of analgesic medications is the mainstay of treatment. When pain is relieved at home, patients and their families incur only the costs associated with treatment, usually pharmacotherapy. When pain is unrelieved at home, patients frequently require emergency department visits, which may result in expensive inpatient admissions. In these pain crisis situations, direct medical costs, direct and indirect non-medical costs to patients, and intangible pain and suffering costs are high (Table 2). Evaluations of the costs of unrelieved cancer pain have shown that the most expensive therapies are the ones that don’t work. Economic reports from two cancer centers confirmed the significance of hospital costs for unscheduled hospital admissions for unrelieved pain (Table 3).3,4 During the evaluation period, each hospital spent about

Neuropathic pain in patients with cancer.

5 million annually for patients admitted for pain management with longer than average hospital lengths of stay. City of Hope National Medical Center in Duarte, California, instituted a quality assurance program in pain management to educate the medical community on appropriate opioid administration, side effect management, and identification of high-risk patients for referral to the hospital’s Pain & Symptom Management Consultation Service. These efforts resulted in a

An alternative algorithm for dosing transdermal fentanyl for cancer-related pain.

1 million savings to the hospital.5 There is a tendency in health care to overlook out-of-pocket costs for direct and indirect costs borne by the patient and family in managing cancer pain. Stommel6 quantified these costs for a three-month period and annualized the family cost to