The Cancer Pain Journey: Optimizing Identification and...

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The Cancer Pain Journey: Optimizing Identification and Management CME / ABIM MOC

Supported by an independent educational grant from Insys Therapeutics


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Target AudienceThis activity is intended for Hem/Onc specialists, anesthesiologists, neurologists, pharmacists, and nurses.

GoalThe goal of this activity is to educate oncology and pain clinicians about strategies to assess pain in patients with cancer and match treatment to cause and severity of that pain.

Learning ObjectivesUpon completion of this activity, participants will:

have increased knowledge regarding the:

• Strategies for the assessment of cancer-related pain

have increased knowledge regarding the:

• Selection of appropriate therapies for the management of cancer-related pain

Credits AvailablePhysicians - maximum of 0.50 AMA PRA Category 1 Credit(s)™

ABIM Diplomates - maximum of 0.50 ABIM MOC points

Nurses - 0.50 ANCC Contact Hour(s) (0.25 contact hours are in the area of pharmacology)

Pharmacists - 0.50 Knowledge-based ACPE (0.050 CEUs)

Accreditation Statements

In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

For Physicians Medscape, LLC designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM MOC: Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.50 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

This article is a CME / ABIM MOC certified activity.To earn credit for this activity visit:


CME / ABIM MOC Released: 6/16/2017; Valid for credit through: 6/16/2018


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For Nurses:Awarded 0.5 contact hour(s) of continuing nursing education for RNs and APNs; 0.25 contact hours are in the area of pharmacology.

For PharmacistsMedscape designates this continuing education activity for 0.50 contact hour(s) (0.050 CEUs) (Universal Activity Number 0461-0000-17-094-H01-P)

Medscape, LLC staff have disclosed that they have no relevant financial relationships.

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This activity is designed to be completed within the time designated on page 2; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on page 2. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

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Disclosures

Moderator

Natalie Moryl, MD Associate Professor, Cornell Medical College, Associate Attending, Division of Survivorship and Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York, New York

Disclosure: Natalie Moryl, MDMD, has disclosed the following relevant financial relationships:

Served as an advisor or consultant for: Collegium Pharmaceuticals

Dr Moryl does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

Dr Moryl does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Panelist

Kathy Madden, FNP-BC, AOCNP Nurse Practitioner, Melanoma Program, NYU Langone Perlmutter, Cancer Center, New York, New York

Disclosure: Kathy Madden, FNP-BC, AOCNPFNP-BC, AOCNP, has disclosed the following relevant financial relationships:

Served as an advisor or consultant for: Bristol-Myers Squibb Company; Merck & Co., Inc.; Novartis Pharmaceuticals Corporation

Served as a speaker or a member of a speakers bureau for: Bristol-Myers Squibb Company; Genentech, Inc.; Merck & Co., Inc.; Novartis Pharmaceuticals Corporation

Ms Madden does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

Ms Madden does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Editors

Stacey J.P. Ullman, MHS Senior Scientific Director, Medscape, LLC

Christina T. Loguidice

Disclosure: Christina T. Loguidice has disclosed no relevant financial relationships.

Christin Melton

Disclosure: Christin Melton has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

Amy Bernard, MS, BSN, RN-BC

Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial


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The Cancer Pain Journey: Optimizing Identification and Management

Natalie Moryl, MD: Hello I am Doctor Natalie Moryl, an Associate Attending with the Division of Survivorship and Supportive Care Service, in the Department of Medicine at Memorial Sloan Kettering Cancer Center, and an Associate Professor of Medicine at Cornell Medical College, New York. Welcome to this program titled, “The Cancer Pain Journey, Optimizing Identification and Management.”

Joining me today is Kathy Madden, a Nurse Practitioner with the Melanoma Program at NYU Langone Perlmutter Cancer Center, in New York City. Welcome, Kathy.

Kathy Madden, NP: Thank you. A pleasure to be here.

Program Goals

Dr Moryl: Cancer-related pain severely affects patients’ quality of life, yet pain is often undertreated. Optimally managing pain improves quality of life and may even prolong survival. The goals of this activity are to educate healthcare providers about strategies to assess pain in patients with cancer and to discuss the appropriate selection of therapies to manage cancer-related pain.

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Introduction[1,2]

Today more attention and resources are being devoted to managing pain in patients with cancer. Data show that between 2007 and 2013, undertreatment of cancer pain declined 25%. However, one-third of patients with cancer do not receive pharmacologic treatment commensurate with the severity of their pain. In addition, approximately 40% of cancer survivors experience long-term pain as a result of cancer treatment.

Barriers to Effective Pain Management[2,3]

Several barriers exist to effective management of cancer-related pain. They are disease-related factors, assessment or treatment issues, and patients’ perspectives and practices. Kathy and I are going to use a patient case to illustrate effective strategies for recognizing and managing cancer pain. But before we get to the case, Kathy, can you explain more about the types and causes of cancer-related pain?


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Categorizing Cancer-Related Pain[4,5]

Ms Madden: Sure. Broadly, cancer-related pain may be caused by diagnostic procedures, treatment, or the malignancy itself. Pain is generally divided into 3 categories, and someone with cancer may experience any or all of them.

Somatic Pain[5,6]

Somatic pain is the most common pain experienced by patients with cancer. It occurs when pain receptors in skin or deep tissues are activated. Somatic pain can be constant or intermittent. Common causes can be related to bone metastases, which may be a deeply experienced pain or postsurgical pain, more superficial, and cutaneous. Deep somatic pain is localized; aching, gnawing, throbbing, or cramping sensations. Cutaneous somatic pain is often described as sharp, burning or a tickling sensation.

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Visceral Pain[5,6]

Visceral pain involves activation of pain receptors in the cardiovascular, respiratory, gastrointestinal, or genitourinary systems.

These can result from tumor compression, infiltration, extension, or stretching of the viscera. The pain is not well localized and is typically described as deep or squeezing or colicky. Visceral pain is common in patients with abdominal metastasis or pancreatic cancer.

Neuropathic Pain[5-7]

Differently, neuropathic pain, as its name suggests, results from injury to the central nervous system or to peripheral nerves. It may be caused by the tumor or treatment. Tumor compression or infiltration of nerves or even the spinal cord can be the source. Damage to nervous system peripheral nerves can be from chemotherapy, radiation, or surgery such as mastectomy or thoracotomy. The pain is described generally as burning, tingling, electrical, or painful numbness.


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Further Classification of Pain[5,8]

Dr Moryl: We also know that cancer pain like any other pain can be further classified as acute or chronic. Acute, which could be episodically intermittent, is characterized by sudden onset, clear cause, and short duration. Usually that happens due to diagnostic procedures or antineoplastic therapy. But, most often it is due to cancer itself.

Chronic pain is defined as pain with duration of about 3 months and usually it’s disease-related pain but may result from antineoplastic therapy as well. It can be persistent or breakthrough.

Breakthrough is flare-up of severe pain despite pain medication controlling baseline pain. Different cancers may be associated with distinct pain syndromes.

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Case: Man With Multiple Myeloma

So let’s start with our case. Our patient is a 50-year-old man with newly diagnosed multiple myeloma. He visited his primary care provider for ongoing pain in the lower back and ribs, which worsened with activity and often woke him up at night.

After suspicious laboratory tests, he was referred to a hematologist, and a full workup revealed the diagnosis of multiple myeloma. A skeletal survey after diagnosis showed lytic lesions in the lumbar spine and ribs but no fractures and no spinal cord compression. Based on what we know so far, how would you categorize his pain at this time?

Ms Madden: This patient has chronic somatic pain; more specific, bone pain due to myeloma involvement. Approximately 70% of patients with multiple myeloma have pain at diagnosis. The pain is usually related to bone involvement and may start months before diagnosis. But to get the full picture of his pain we would need to do an assessment.


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Pain Assessments[10,11]

Dr Moryl: Exactly. We have seen a growing emphasis on the need to assess cancer pain. NCCN [National Comprehensive Cancer Network] Guidelines for adult cancer pain recommend screening for pain at every visit. Pain assessment must be done before prescribing analgesics, because the assessment may reveal information that affects the choice of treatment. Kathy, what are some essential elements of a comprehensive pain assessment?

Obtaining the Pain History[10,11]

Ms Madden: Patient’s report of pain is the gold standard. Pain history should include the location, the intensity, precipitating and alleviating factors. We should ask questions like: where is the pain? Is there referred pain? When did the pain start? Is it persistent or intermittent? What treatments were tried? Did they work? For noncommunicative patients, clinicians should talk to people close to the patient about any signs of pain.

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Main Goals of the Pain Assessment[10,11]

Two main goals of the assessment are to quantify pain intensity and quality, and identify pain syndrome to help us make better diagnoses. When quantifying pain intensity, you want to learn the severity of the pain now and over the last 24 hours. Severity of pain at rest, during activity, and how it affects the patient’s activity and mood.

Tools to Evaluate Pain Intensity

Many tools exist to evaluate pain intensity. These include the Numeric Rating Scale, Categorical Scale, or Visual Analogue Scale, and the FACES Pain Rating Scale. All of them are valid, and none are any better than another. However, one may work better than another for a particular individual or situation. We can also use percentages, for example; we might ask patients: “what is the percentage in the change of your pain from before? What’s the percentage of your relief?” There are also multidimensional scales such as the Brief Pain Inventory or the PROMIS PI. Other tools are available for special populations, such as children, or adults with dementia.


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Characterizing Pain Quality[10,11]

Characterizing pain quality is also essential. Have the patient describe the pain: is it aching, cramping, burning, squeezing? The character of the pain tells us whether the pain is likely somatic, visceral, neuropathic, or even a combination of these. It can also tell us about the pathophysiology, or cause of the pain and help identify the cancer pain syndrome, such as neuropathy, plexopathy, osseous metastatic pain, or postmastectomy pain.

Importance of a Multidisciplinary Team[4]

Nurses really are an integral part of the process and often the front line in assessing quantity and quality of pain.

Dr Moryl: I agree. Nursing professionals are instrumental in pain assessment, patient education, and monitoring of treatment outcomes. It is often helpful to have a multidisciplinary team when assessing pain. As part of the assessment, the clinician performs a physical examination to determine if the pain is localized or diffuse? Is the pain reproducible? Is it associated with sensory changes? Is there muscle weakness? Is there a limitation in the range of motion?

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Neurological examination is an important part of the pain assessment. Additional tests, including x-rays, CT [computed tomography] scan, MRI [magnetic resonance imaging], may be needed to confirm or rule out a diagnosis such as bone metastases, a fracture, nerve root involvement, entrapment, or spinal cord compression.

Beyond the Physical[4,11]

Ms Madden: Also people forget pain is not just physical. Pain can affect the patient’s psychological state, and the patient’s psychological state can conversely affect pain. All patients should be assessed for psychiatric or psychosocial conditions that might affect pain perception or worsen distress, such as depression, anxiety, low self-esteem, and catastrophic thinking. Cultural factors can also be very important in measuring patient’s psychological state and social support systems. Assessing care goals is important. It’s also important to identify whether there is a history of, or active substance abuse in the patient or the family before we get into prescribing these medications. Finally, if the patient’s demeanor suggests the patient is underreporting pain, it may be helpful to talk with someone who spends more time with the patient.


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Case: Results of Pain Assessment

Dr Moryl: Results of these assessments for our case show the following: this patient with multiple myeloma had lower back pain 4 months ago. At the time he rated his pain as mild, but the patient now rates it as moderate. Pain is continuous, quality is dull and aching, and over-the-counter, non-steroidal anti-inflammatory medications have not been effective lately. Physical examination is positive for reproducible midline lumbar spine pain without any sensory or motor deficits. The assessment suggests the patient has chronic, moderate somatic bone pain.

Kathy, what are the possible options for managing his pain?

WHO Analgesic Ladder[12]

Ms Madden: It’s a great question. To answer it, we need to go back a little bit in history, with the WHO [World Health Organization] analgesic ladder. In 1996, the World Health Organization published an analgesic ladder, which is essentially the gold standard of pain management. It’s a 3-step approach that starts with nonopioids, it steps up to weak opioids, and then concludes with strong opioids. At every step, other treatments, like adjuvant analgesics, nonpharmacologic options, or integrative therapies can be added to augment pharmacotherapy.

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Nonopioid Analgesics[24]

The patient has not had success with nonopioids, and now reports moderate pain.

Dr Moryl: The consensus for moderate to severe pain related to cancer is to start with opioid therapy, and we’ll do that with this case as well. Let’s review the different pharmacologic options for cancer pain and their pros and cons, starting with nonopioid analgesics. By nonopioid analgesics, we generally mean acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs).

Both acetaminophen and NSAIDs have significant advantages. They offer rapid onset of action. They have no cognitive adverse events, no risk of addiction or physical dependence. They are not constipating, which is great.

Unfortunately, there are limitations associated with these agents as well. There is a ceiling affect for analgesia and there is potential to mask infections. Acetaminophen can be hepatotoxic at high doses, and NSAIDs pose a problem in terms of GI [gastrointestinal] and renal toxicity, as well as prothrombotic cardiovascular effects and hematologic effects.

Ms Madden: It is important that as part of the assessment we learn as much as possible about the patient’s medical history and current medications. We want to minimize the risk of adverse events with any pain medications, such as peptic ulcer disease and renal insufficiency, when ordering NSAIDs. As you mentioned, hepatotoxicity is a concern with acetaminophen, so we want to ensure that the patient is not using any other medication that contains acetaminophen. Also, certain chemotherapy drugs, or therapeutic anticoagulants, increase the risk of toxicity with NSAID use.


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Opioids[13,14,24]

Dr Moryl: For our patient’s pain plan, we agree on starting with opioids. Even if he has not already tried NSAIDs, multiple myeloma increases the risk of renal toxicity and chronic NSAIDs may be undesirable in this case.

The pros of starting opioids include: routes of delivery, rapid onset of action, and no ceiling effect. Of course, there are cons: adverse events, constipation, nausea, vomiting, early satiety, sedation, confusion, even delirium, as well as tolerance and addiction. There are many opioids to choose from, which have different doses and delivery options.

Factors That Affect Opioid Choice[13]

Several factors affect the choice of opioid, such as the route of administration and the dose. Is the patient opioid naive or opioid tolerant? What is the clinician’s experience with opioids? What is drug availability in your facility or in the community, and what are costs of medication for the patient?

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There is no clear evidence of effectiveness of choosing 1 opioid over another; however, their adverse events may also differ depending on comorbidities and that may be taken into consideration while choosing an opioid. Usually, we start with short-acting opioids and then we transition to long-acting opioids if pain persists or if the patient requires multiple doses of short-acting opioid a day.

Risk of Opioid Misuse[15]

Ms Madden: We hear a lot these days about the risk of opioid addiction and overdose. There are also concerns for cancer patients because patients with cancer are living longer with their diseases and with chronic pain, which can persist even into cancer remission phases.

Dr Moryl: We always need to apply due diligence when prescribing opioids. Patients should be screened for risk of opioid misuse or abuse. These include anxiety, depression, personal or family history of substance abuse. Patients need to be monitored for inappropriate opioid use. However, risk of addiction really needs to be balanced with the need for effective pain management, and should not be a barrier to pain control for patients with cancer.

Ms Madden: I’ve found many of my patients are worried about getting addicted to opioid medications and are reluctant to take them even though they really need them. I also have patients who are eager to stop taking opioids once their therapies start working, and they start feeling relief, because their treatments are effective. So they start trying their own experiments with pain relief. I really find that ongoing education and support are key factors with prescribing opioids.


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Educating Patients on Opioids[16]

Addiction is an important conversation to have, and not just about the patient’s risk. Diversion of opioid drugs into the community may pose a serious problem and we know that it’s an ongoing conversation frequently in current events.

Dr Moryl: It is. A 2010 national survey on drug use and health found that 76% of people who misuse opioids took drugs prescribed to someone else. When educating patients on opioids, we need to discuss the importance of storing them securely. Patients need to store their medications securely in safe, locked spaces, not available to other people in the family or in the community. We also need to educate patients about not sharing their medications, not borrowing, no lending, not selling, and safe disposal. There are DEA [Drug Enforcement Administration]-authorized collectors such as pharmacy or law enforcement programs.

Case (cont)[17]

Let’s continue with our case. Our patient is opioid naive, and does not have renal compromise, so he’s prescribed oral morphine 15 mg every 4 hours as needed, as well as a laxative, as we know that opioids are usually quite constipating.

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Ms Madden: The nurse follows up with the patient within 2 to 3 days over the phone, as clinically indicated in clinic, to evaluate the 4 As: analgesia, adverse events, activity, and aberrant behavior (or addiction). These are ongoing assessments at every time point. This is the first time point, within the first 24 to 72 hours, after the patient starts treatment.

Dr Moryl: So patient indicates to you that the pain is well controlled.

Case (cont)[9]

Are any further changes needed then, at this time? Probably not, unless the patient needs multiple doses a day, in which case a long-acting opioid may be started. However, after 4 cycles of chemotherapy, the patient reports a burning tingling feeling in his hands and feet. It sounds like the patient now has peripheral neuropathy, which is a fairly common adverse event of bortezomib and some other chemotherapies. What would be some options for managing peripheral neuropathy in these or other patients?

Ms Madden: This case illustrates why follow-up and rescreening for pain at each and every visit, or time point, is so important. At this time, the patient might benefit from an adjunctive analgesic known to help with chemotherapy-induced peripheral neuropathy.


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Adjuvant Analgesics for Peripheral Neuropathy[24]

Dr Moryl: There are a few different classes of adjuvant analgesics used for cancer-related pain that can be used in this case. One group of medications is gabapentinoids and the other are antidepressants. They’re both effective for neuropathy.

Here are their pros: adjuvant analgesics are non-habit forming and tend to have mild adverse events. They also have cons: they’re not fast-acting, they need days to weeks for the titration process to achieve analgesia. There is also the potential for drug-drug interaction with antidepressants, specifically for SSRIs [selective serotonin reuptake inhibitors].

In addition to the nurse and physician, or an advanced practice provider, a multidisciplinary team may offer the best approaches in some cases and probably in most cases. A pain management specialist can help in the assessment and treatment of pain, and the oncologist/hematologist should be supported by a pain management/palliative care team, when management of pain becomes complicated, time consuming, or outside the comfort zone of the treating oncologist.

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Integrative Therapies[18,19]

Ms Madden: Absolutely, and in addition, integrative therapies might also be helpful. Some early studies in patients with multiple myeloma suggest acupuncture might improve neuropathic pain due to bortezomib. Other integrative therapies, such as aromatherapy, imagery, music therapy, reiki, or other energy or touch therapies, and massage all work to elicit internal responses of relaxation and healing, thereby promoting pain and other symptom management. While data may be limited regarding use of integrative therapies, patients with cancer are utilizing modalities at increasing rates, and the National Center for Integrative Health and other institutions and organizations continue to support clinical research.

Psychological or Behavioral Approaches[19,20]

There are also some psychological or behavioral approaches: cognitive behavioral therapy, hypnotherapy, psychological counseling, especially if the patient has depression. These approaches are based on data that associate distress and pain with cancer and cancer treatments. Relieving distress may also provide pain relief.


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Dr Moryl: In patients with anxiety, depression and substance abuse disorder, involvement of a mental health professional, such as a psychiatrist, a social worker, or an addiction counselor may be very beneficial.

Other Interventions for Pain[24]

As we discussed, in addition to opioid analgesics, nonopioid pharmacologic agents and integrative medicine, as well as psychosocial interventions, there are other interventions that we can use to treat cancer pain. There are different procedures and interventions such as injections -- trigger point injections -- epidural injections, facet joint injections. There is a spinal cord stimulation technique, peripheral nerve stimulation, there are intrathecal pumps that could be used to deliver opioids and adjuvant analgesics centrally. There is also kyphoplasty vertebroplasty, which is the injection of rapidly hardening cement into the vertebra. Several studies have shown that vertebral augmentation with kyphoplasty vertebroplasty or vertebroplasty are relatively safe and very effective in decreasing pain intensity in patients with cancer who suffer a compression fracture.

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Case Conclusion

Let’s go back to our case. The patient with grade 3 peripheral neuropathy may benefit from gabapentin, starting at a low dose. Sometimes we start at 100 mg once or 3 times a day, and we need to titrate to the effective dose, which for the majority of patients is about 2700 to 3600 mg a day.

If neuropathy is really incapacitating, hematologists may reduce the dose of the chemotherapy agent or even interrupt treatment. The neuropathy improves and resolves a couple of months after the patient finishes chemotherapy, in most cases. Our patient’s neuropathy has improved. His bone pain has also improved, allowing him to decrease his opioid. Now, it’s 6 months later, he again has severe back pain, and an x-ray shows a vertebral compression fracture.


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What Is BTcP?[14,17,22,23]

Ms Madden: This case illustrates the complexity of breakthrough pain very clearly. And this is a very common problem with patients who are dealing with cancer issues. Like in this case, chronic pain may be well controlled with opioids and adjunctive therapies, but then he’ll have these flare-ups of intense pain that require fast-acting treatment. The pain can last a few minutes to an hour or more, and can be caused by the cancer, a particular situation, like the fracture in this case, or other cancer-related factors, such as treatment.

Dr Moryl, what is your approach to management of breakthrough pain?

Treatment of BTcP?[14,17]

Dr Moryl: As breakthrough pain is characterized by sudden onset of short-lived pain that breaks through otherwise controlled baseline pain, short-acting opioids are used to control it. If the patient has numerous episodes of breakthrough pain during the day, then it’s not feasible to treat or address every incident of breakthrough pain with a short-acting opioid, then a long-acting opioid should be considered instead.

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Oral Transmucosal Fentanyl for BTcP[14,17]

Recently, a transmucosal fentanyl with ultrafast onset of action has become available to treat breakthrough pain. To prescribe these, the provider needs to complete an online REMS [Risk Evaluation and Mitigation Strategy] course. Then the prescriber, patient, and the pharmacist all sign a contract agreeing on safe use and safe storage.

Ms Madden: I have a question for you regarding the transmucosal fentanyl. It’s very effective treatment, but sometimes it can be a little challenging to obtain for patients. Do you ever have any difficulties with insurance or obtaining those therapies for the patients?

Dr Moryl: Yes. For one, as I said, the provider needs to be certified, and recertified every couple of years. You need to have a pharmacy that has these medications available and stored properly. With regard to the insurance companies, it’s not uncommon for the insurance company to consider it too expensive, so often pre-authorization phone calls may be necessary. So that’s a big commitment on the part of the prescriber. But for severe breakthrough pain these are very effective, so we do choose to invest a significant amount of resources into providing patients with access to these medications.

Ms Madden: So, it’s knowing that you have the effective treatment, and having a little bit of know-how on the provider’s part and identifying who your resources are. It sounds like just a big commitment up front, but getting our patients what they need and getting the access to that is important, and what we do.

Dr Moryl: Absolutely.

Ms Madden: Thank you, we’ve encountered the same issues at our hospital.


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Other Considerations for Managing BTcP[14]

So, some other things that we would want to consider for our case is medicating before the pain becomes intolerable. I oftentimes hear patients say that they’re toughing it out, and waiting until the pain gets so bad, and sometimes they even remark that the pain medication doesn’t work -- the breakthrough pain medication specifically -- because the pain has superseded beyond where the analgesic effect is going to be optimized.

And importantly, I find I’m doing a lot of education not only with patients and care providers, but also with other healthcare professionals so that they understand that the mechanism of action and the onset of the medications is really important. I often explain to them that the long-acting and the short-acting pain medications can be given very safely, concurrently. It’s important sometimes to explain how that to manage the pain effectively, that medications should never be stopped suddenly, unless medically advised, and that they should be tapered slowly with guidance.

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Key Messages

Dr Moryl: Thank you Kathy. To sum it up, despite increased attention to the importance of managing cancer-related pain, many patients with cancer and cancer survivors continue to experience pain. Pain is different with different cancers and changes over the course of the disease. It is important to assess patients for pain at every visit, and to develop an individualized pain management plan that is consistent with the patient’s priorities and goals of treatment. Opioids are the mainstay of treatment for cancer-related pain, and care must be taken to reduce the risk of misuse, or abuse by the patient or people around the patient. I’d like to thank you Kathy, for joining me in this interesting discussion.

Ms Madden: Thank you Dr Moryl, it’s been a pleasure.

Thank You

Dr Moryl: And thank you for participating in this activity. Click on the “Earn CME/CE Credit” link, and the post-test and evaluation will follow. Thank you.


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AbbreviationsAE = adverse eventsBTcP = breakthrough cancer painCNS = central nervous systemCT = computed tomography DEA = Drug Enforcement AdministrationGI = gastrointestinalMRI = magnetic resonance imagingNCCN = National Comprehensive Cancer NetworkNCI = National Cancer InstituteNSAID = nonsteroidal anti-inflammatory drugPNS = peripheral nerve stimulationREMS = Risk Evaluation and Mitigation StrategySCS = spinal cord stimulationSSRI = selective serotonin reuptake inhibitorWHO = World Health Organization

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The Cancer Pain Journey: Optimizing Identification and...

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