Cancer Pain Medications

Aka: Cancer Pain Medications, Pharmacologic Management of Pain at the End of Life, Analgesics for Pain Management in the Terminally Ill

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II. Symptoms

  1. See Pain Scale
  2. See Pain Assessment in Advanced Dementia Scale
  3. Assess patient's pain with a self rating Pain Scale
  4. Scale
    1. No pain: 0
    2. Mild pain: 1-4
    3. Moderate pain: 5-6
    4. Severe pain: 7-10

III. Management: 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 (Dilaudid)
    3. Transdermal Fentanyl
    4. Levorphanol
    5. Methadone
      1. Cheap and effective (esp. neuropathic pain)
      2. Half-Life varies considerably (from 7 to 72 hours)
      3. Prescriptions typically limited to Palliative Care and pain management specialists
    6. Avoid Meperidine (Demerol)
      1. Too short acting, lower efficacy
  4. Intractable Pain (Emergency Department)
    1. Opioids as above (e.g. Morphine, Hydromorphone)
    2. Lidocaine (8 mg/ml)
      1. Bolus: 1.5 mg/kg IV (up to 100 mg) delivered over 20-30 minutes
      2. Infusion: 0.5 to 2 mg/kg/hour (up to 100 mg/hour)
    3. Ketamine (Analgesic, low dose)
      1. Dose: 0.1 to 0.2 mg/kg IV
      2. Effective in refractory non-Cancer Pain
      3. However, evidence for benefit in cancer-related pain is lacking
    4. Cannabinoids
      1. Limited evidence to date of benefit in Cancer Pain
    5. Epidural or intrathecal medications
      1. Opioids (Morphine, Hydromorphone)
      2. Ziconotide (Calcium Channel Blocker)
      3. Baclofen
      4. Bupivicaine
      5. Clonidine
    6. Other neuropathic pain agents
      1. Tricyclic Antidepressants
      2. Gabapentin or Pregabalin
      3. Duloxetine (Cymbalta)
      4. Carbamazepine
  5. Refractory Pain at the End of Life
    1. Severe, refractory cancer Pain at the End of Life may require very high doses of Opioid Analgesics
      1. These very high doses may result in apnea, and could shorten a patient's life
      2. When the goals of care are pain relief (not euthanasia), high doses are ethically supported
    2. Palliative Sedation
      1. Consider in severe patient suffering despite maximal medical therapy
      2. Palliative Sedation (StatPearls)
        1. https://www.ncbi.nlm.nih.gov/books/NBK470545/

IV. Dosing: Routes of Administration

  1. Oral Route (90% of cancer cases, preferred route)
    1. Peak effect in 1 hour after dosing
  2. Sublingual Route
    1. Some medications may be given sublingually (e.g. Morphine, Lorazepam)
  3. Subcutaneous (5% of cancer cases)
    1. Programmed Subcutaneous pump is first choice option
    2. Peak effect 20-30 minutes after dosing
  4. Intravenous
    1. Not typically used for Cancer Pain Management outside of hospital care
    2. Peak effect 10 minutes after dose
  5. Transdermal
  6. Rectal (5% of cancer cases)
    1. Many oral preparations may be given rectally (e.g. MS Contin tablets)
  7. Avoid regular Intramuscular dosing (no indication)

V. 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. Bisphosphonates
      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

VI. 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. Pregabalin (Lyrica)
      3. Carbamazepine (Tegretol) 200 mg PO bid
      4. Valproic Acid (Depakote) 10 mg/kg/day PO
      5. Clonazepam (Klonopin) 0.5 mg PO tid
      6. Lamotrigine (Lamictal) 50 mg PO qd
      7. 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
  3. Localized pain
    1. Lidocaine cream, gel or patch
    2. Capsaicin (poorly tolerated)

VII. Management: Visceral Pain

  1. Characteristics
    1. Squeezing
    2. Cramping
    3. Pressure-like pain
  2. Causes
    1. Hepatic metastases
    2. Biliary obstruction
    3. Bowel Obstruction
    4. Pancreatitis
  3. Medications
    1. General analgesia
      1. Opioids
    2. Capsule swelling (e.g. hepatic)
      1. Corticosteroids
    3. Bowel Obstruction
      1. See Cancer Related Bowel Obstruction
      2. Octreotide (Sandostatin)
    4. Biliary Colic
      1. NSAIDs

VIII. References

  1. Glauser and Money (2019) Crit Dec Emerg Med 23(8): 3-10
  2. Abrahm (1999) Ann Intern Med 131:37-46 [PubMed]
  3. Cherny (2000) CA Cancer J Clin 50(2):70-116 [PubMed]
  4. Groninger (2014) Am Fam Physician 90(1): 26-32 [PubMed]
  5. Levy (1996) N Engl J Med 335:1124-32 [PubMed]
  6. Miller (2001) Am Fam Physician 64(7):1227-34 [PubMed]

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