Overcoming obstacles to pain management.
Neil Ellison, MD is interviewed by pain.com
 Neil M. Ellison, MD, is Board certified in Medical Oncology and Hospice and Palliative Care. He also is a Fellow of the American College of Physicians, and a member of the American Society of Clinical Oncology, the American Pain Society, the Academy of Hospice Physicians and the American Academy of Hospice and Palliative Medicine. He also served on the steering committee and professional education subcommittee of the Pennsylvania Cancer Pain Initiative. He graduated from the University of Rochester, Rochester, NY, prior to completing medical school at Upstate medical Center in Syracuse NY. Dr. Ellison is fellowship trained in Medical Oncology at the National Cancer Institute in Bethesda, MD. He is a noted and prolific author of numerous textbook chapters and peer review articles. Dr. Ellison is currently the Director, Palliative Medicine Program, Geisinger Medical Center, Danville, PA.
Pain.com:What is meant by breakthrough pain?
Dr. Ellison: Chronic pain is usually defined as pain intensity existing for more than 12 hours per day. Exacerbation in the amount of pain experienced is referred to as breakthrough pain. For example, an individual using the visual analog or numeric pain scale as outlined below may have pain of 5/10 most of the day but may also desribe more severe pain of 9/10 with activities (breakthrough pain). Breakthrough pain is a common occurrence, especially in patients with chronic cancer-related pain. It is estimated that it occurs in more than 70% of cancer patients. More than four breakthrough episodes per day is an independent poor prognostic feature in the quest for adequate pain control.
Pain.com: What are the most common types of breakthrough pain?
Dr. Ellison: The most common types of breakthrough pain are incidental, idiopathic, and end of dose pain. Incidental pain occurs in an expected fashion with an activity or other predictive factor such as time of day. Taking an extra dose of an analgesic prior to the predictive event can be beneficial. Idiopathic breakthrough pain is more problematic to treat since it is unpredictable. As with all pain, an accurate history and evaluation may elucidate the cause and allow easier management. The use of anticonvulsants, analeptics, antidepressants, and other drugs in addition to or instead of primary analgesics may be of benefit. End of dose pain occurs when analgesics are given in an around-the-clock fashion and pain control is good until relatively proximal to the next dose. This pain can be alleviated by increasing the frequency of the medications but is usually more optimally handled by increasing the baseline dose. There are frequent instances where breakthrough pain may be consistently more prominent at one time of day. Asymetric dosing of long-acting oral opioids could be of benefit here. Another dose is given for the interval period of time when the pain is anticipated to be worse.
Pain.com: What is the best way to determine what medications should be used for the management of breakthrough pain?
Dr. Ellison: Whenever possible, the same medication given for continuous pain control should be used for breakthrough pain. This narrows the possibilities of different opioids causing different side effects. A common way to calculate the amount of medication to give for breakthrough pain is to add the total amount of oral opioid given in 24 hours to control the pain adequately and give 10-15% of that dose every 2-3 hours.
Example:
If someone is taking 20 mg of oral Oxycodone every 4 hours, then 6 doses/day
=
120 mg/day. The baseline medication can be given as 60 mg of controlled
release
Oxycodone every 12 hours. Ten-fifteen% of 120 mg Oxycodone equal 10-15mg
of
immediate release Oxycodone given orally every 2-3 hours for breakthrough
pain.
If someone consistently takes more than 3 breakthrough doses a day, he will
usually
benefit from increasing the amount of ATC dose.
Example:
60 mg controlled release Oxycodone q12h 120 mg
8 breakthrough doses of 10 mg 80 mg
Total p.o. Oxycodone/day 200 mg
In this example, the ATC dose could be 100 (80 + 20) mg long-acting
Oxycodone
q 12 h and 20 mg immediate release Oxycodone every 2 hours
for breakthrough
pain. Someone being treated with a continuous infusion of an
opioid at X mg/hour
could have a PCA of X/4 mg given every 15 minutes. If an analgesic
dose of Z mg is
given IV or orally q4h, then Z/4 mg could be given IV or orally q1h for breakthrough
pain.
Pain.com: Would you briefly discuss some of the myths concerning pain management with opioids?
Dr. Ellison: Opioid analgesic medications can be extremely effective and well tolerated treatments of moderate to severe acute and chronic pain. When used correctly, they can improve the patient's quality of life and functionality. Frequently held misconceptions regarding opioid use can interfere with the delivery of optimal patient care.
Pain.com: What about the myth that patients using opioids frequently become addicted to them?
Dr. Ellison: The fact is when used to control acute or chronic cancer-related pain, the incidence of addiction is about 1/3,000 (0.3%). The incidence of addiction is also low when opioids are used to treat chronic nonmalignant pain. The therapeutic goal should be to improve functionality. As a rule of thumb, the person taking opioids for pain relief becomes more functional while the addicted personality (seeking drugs for their recreational or euphoric effect) is less functional.
Pain.com: How do you respond to the myth that opioids should be "saved" for the last weeks or months of life?
Dr. Ellison: The fact is that about one-half of patients with chronic pain syndromes not controlled by other means can have a beneficial response to opioids and improve their functionality and their life. Similarly, for patients with terminal diseases, opioids should be used as early as necessary to control moderate to severe pain. Patients can continue to use opioids for pain management for years or decades. When tolerance (the need to use more opioids to control the same painful stimulus) develops, analgesia can usually be maintained by gradually increasing the opioid dose.
Pain.com: And then there is the myth that a patient cannot work or do normal activities when taking opioids.
Dr. Ellison: Well, again, the fact is that patients with severe pain have difficulty or find it impossible to perform normal activities. This includes maintaining normal relationships. By achieving adequate pain management, they can often resume normal activities within the confines of their underlying disease process as opposed to being limited by their pain. Cognitive and motor skills (including the operation of motor vehicles) have been shown to be similar for patients on steady doses of opioids for more than two weeks when compared to control groups with similar underlying disease processes but who are not taking opioids. In many states laws prohibit driving if the driver is impaired by any drug. Patients should be told not to drive whenever an opioid is started or the dose increased and to refrain from driving for at least a week or longer, until normal cognitive and motor skills are fully recovered. Individual state regulations should be reviewed regarding the operation of motor vehicles and the ingestion of many drugs including opioids.
Pain.com: One last question please: What is the reason that JCAHO suggests Meperidine (Demerol) be deleted as an analgesic from hospital formularies?
Dr. Ellison: Meperidine (Demerol) should not be used as a primary opioid analgesic because it is more toxic than many of the other opioids. Meperidine is an opioid analgesic with 75 mg as an equivalent analgesic potency to 10 mg of parenteral morphine. Oral equivalent doses would be 300 mg and 30 mg respectively. Meperidine is metabolized to an active metabolite normeperidine. This drug is twice as potent as a convulsant and half as potent as an analgesic as its parent compound. Because normeperidine has a half-life of 15-30 hours, repetitive use of meperidine can cause high levels of plasma normeperidine. This can result in confusion, tremors, multifocal myoclonus, and seizures. It is even more problematic in patients with renal failure. Naloxone is not effective in treating these seizures and in fact, may precipitate them in patients with high levels of normeperidine.
Although meperidine causes a lesser rise in common bile duct pressure than morphine, this has never been shown to be clinically significant. Furthermore, a drug interaction between meperidine and MAO inhibitors has been documented to result in severe respiratory depression or a syndrome of excitation, delirium, hyperpyrexia and seizures. Either of these can be fatal.
When used as a single parenteral dose, meperidine has a faster onset and shorter analgesic duration (2-3 hours) than morphine (3-4 hours). This enhances its attractiveness as a narcotic with a high abuse potential. Other safer opioids such as hydromorphone (dilaudid) also have a faster onset of efficacy than morphine.
In summary, there are many opioid analgesics which are as effective or more effective and less toxic than meperidine. Equivalent analgesic doses of these are as follows:
|
Parenteral (IV or
Subcutaneous) |
P.O. |
| Morphine |
10 |
30 |
| Hydromorphone |
1.5 |
6-8 |
| Levorphanol |
2 |
4 |
| Oxycodone |
N/A |
12-20 |
Meperidine (Not
recommended) |
75 |
300 |
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