Rapid Titration of Short-Acting Opioids: NCCN Guidelines

FT. LAUDERDALE, Fla—Treatment pathways describing when and how to titrate short-acting opioids rapidly are now part of the National Comprehensive Cancer Network (NCCN) Practice Guidelines for Cancer Pain.

Other additions to the newly revised guidelines include treatment pathways for surgical and anesthetic interventions, three scales for rating pain intensity, and an expanded discussion of the components of psychosocial support. The guidelines were presented at the Fifth Annual NCCN conference.

Cancer pain remains inadequately treated, despite the fact that most cancer patients experience significant pain, said Stuart A. Grossman, MD, professor of oncology, medicine, and neurosurgery, and director of neuro-oncology, Johns Hopkins Oncology Center.

The NCCN guidelines have been written to help physicians manage most forms of cancer pain without consulting with pain specialists. This is designed to make you a pain expert,” Dr. Grossman emphasized. “In other words, you should be able to take care of most of the pain problems by yourself.”

The treatment pathways for the titration of short-acting opioids are designed to help physicians treat the immediate emergency and then to individualize the amount of medication a patient with cancer pain will need on an ongoing basis. The algorithm includes specific dosages and escalation dosages.

Using a 0 to 10 numerical scale, it divides patients into those with pain measuring 7 and above and those with pain measuring 4 to 6. Patients are also divided into those who are taking opioids and those who are opioid naïve.

Short-Acting Agents Preferred

Dr. Grossman observed that many hospitals treat pain emergencies with long-acting opioids, but that his panel of experts felt strongly that short-acting agents were preferable.

“The primary advantage of a short-acting agent is that you can actually figure out what a patient’s dose requirements are by escalating them quickly,” he said. Once the proper dosage is determined, long-acting agents can be prescribed for patient convenience.

For example, the guidelines recommend that an opioid-naïve patient with pain measuring 7 to 10 receive either an oral dose of 5 to 10 mg of immediate-release morphine sulfate or a dose of 2 to 5 mg of IV morphine sulfate.

Pain is reassessed at the medication peak. (The oral medication peaks in 60 minutes; the IV medication peaks in 15 minutes.) If the pain is unchanged, a double dose of the original amount is given.

This cycle of opioid administration is repeated until the pain is decreased by 50% or more. At that point, the physician can calculate the total amount of medication given over 4 hours and consider this to be the effective dose for every 4 hours. This calculation is then used to determine what the patient will need on an ongoing basis.

In addition to providing the baseline amount of medication, the physician should also prescribe “rescue doses” of medication for breakthrough pain.

The detailed management of opioid side effects is also described in the guidelines. “We want you to be able to manage major side effects yourself,” Dr. Grossman said. “We’re trying to make the pain subspecialist extinct.”

In the updated guidelines, the discussion of surgical and anesthetic approaches to the management of cancer pain has been expanded. Dr. Grossman noted that physicians are urged to consider specialty consultations if pain levels remain high despite opioid medication or if excessive opioid toxicity cannot be controlled.

The guidelines now offer a treatment pathway to help pain specialists evaluate the appropriateness of surgical and anesthetic procedures. The pathway starts by observing that certain procedures, such as celiac plexus blocks, have a high benefit-to-risk ratio if done early in therapy.

The pathway then asks physicians to consider whether the intervention under consideration will relieve 50% of the pain. If yes, the next step would be to perform a neurolytic block, if possible. If not possible, or if the neurolytic block fails, spinal analgesia should be considered.

Psychosocial Support

The new guidelines include an expanded description of what the medical team should provide in the way of psychosocial support is included.

“Opioid phobia” is often present in both patients and medical staff members, and confusion over addiction, dependence, and tolerance must be addressed, said Matthew Loscalzo, MSW, director of Patient and Family Services, Johns Hopkins Oncology Center, and research associate, Johns Hopkins School of Medicine.

A written care plan is a powerful tool, Mr. Loscalzo said. “A written plan gives the patient a physical connection with you. You play a very special role in the patient’s life that no one else can play,” he said. “You are, in their mind, linked with survival and life.”

The psychological value of a written plan cannot be underestimated, he said. “If patients have a plan of action, they can cope with almost anything. It’s when they feel abandoned and separated and detached from their medical care that they panic and get very agitated. And pain can be a manifestation of that,” Mr. Loscalzo commented.

The medical team should be the patient’s advocate and help access resources for pain management, he said. This may include negotiating with pharmacies, managed care providers, and even the primary health care team. The patient should also be taught coping skills to help deal with pain and enhance a sense of personal control.

Finally, physicians should inform the patient and family that there are always additional measures that can be taken to control pain, Mr. Loscalzo said. The NCCN guidelines are “a map and a recipe you can use today for effective pain management,” he said.