Challenges in Managing Cancer Pain

1. Challenges in Managing Cancer Pain
Anay Moscu, Pharm.D.,BCPS,BCOP
Pharmacy Manager, PGY-2 Oncology Residency
Director

2. Objectives
1. Discuss the new ASCO Policy Statement on Opioid
therapy and Access to Treatment
2. Identify barriers to pain management in the cancer
patient
3. Understand the role of the oncology pharmacist or
supportive care pharmacist in managing cancer pain
in the hospital setting
4. Understand the Joint commission (JC) standards on
pain management and apply strategies on safe use
of opioids in the hospital setting

3. • Organization:
– Educates all prescribers on assessing and
managing pain
– Respect patient’s right to pain management
– Assess and manages patient’s pain
• Conducts comprehensive pain assessment
• Methods to assess pain that are consistent
• Reassess and responds to patient’s pain
• Either treats pain or refers for treatment
JC Pain Management Standards

4. Pain Management
Painpersisting:Moveuponestep
Painsubsidingortoxicity:
Movedownonestep
Step 2: Moderate pain
Weak opioids
+ non-opioids
+/- adjuvant
Step 3: Severe pain
Strong opioids
+ non-opioids
+/- adjuvant
Step 1: Mild pain
Non-opioids
+/- adjuvant
Pain score 1-3
Pain score 4-6
Pain score 7-10
Adapted from The World Health Organization Analgesic Stepladder Approach

5. • Pharmacological
– Opioids
– Non-opioid analgesics
– Adjuvant analgesics
• Non-Pharmacological
– Integrative Interventions
• Physical
• Cognitive
• Spiritual
Multi-modal

6. Persistent pain
ADR
Management
Adding/Adjusting
adjuvant
analgesics
Psychosocial
Support
Cancer Pain Management

8. • Safe when used appropriately
– ADR: dizziness, N/V, sedation, constipation
respiratory depression
• Prospective Analysis, n= 3,695 inpatient ADRs
– 16% opioid related
• JC Sentinel Event Database report system
– 47% Wrong dose
– 29% Improper monitoring
– 11% Excessive dosing, interactions, ADRs
Safe use of opioids

9. • Effective Processes and Tools
• Safe Technology
• Appropriate Education and Training
JC Recommended Actions

10. • Policies and Procedures
– Pain Assessment
• All patients should be assessed for pain
– Quality Oncology Practice Initiative (QOPI)
• Define who, how, and frequency
– Pain Reassessment (Post-intervention)
• Based on medication onset and peak effect
– Orals: 1 hour
– Intravenous: 20-30 minutes
Effective Processes

11. • Opioid Induced Respiratory Depression
– Screening tools Pasero Opioid-Induced Sedation
Scale (POSS)
– Pulse Oximetry
– Capnography
Effective Processes & Tools
Risk Factors
Sleep Apnea Opioid naive
Morbid Obesity Post-surgical
Elderly Concurrent sedating drugs
Cardiac/Pulmonary history History of Smoking

12. • Track and Analyze opioid-related incidents for
quality improvement
– Adverse drug reporting system
– Classify based on severity
– Report quarterly to P/T Committee
• Opioid related events forwarded to Collaborative Pain
Committee for action plan
Effective Processes

13. ADR Classification
Severity Scale Definition
Level 1 No change in treatment with the suspected drug
Level 2 Required that treatment with the suspected drug be
held, discontinued, or otherwise changed. No antidote
or other treatment required. No increase in length of
stay (LOS).
Level 3 Required that treatment with the suspected drug be
held, discontinued, or otherwise changed, and/or an
antidote or other treatment was required. No increase
in LOS.
Level 4A Any level 3 ADR which increases LOS by at least 1 day.
Level 4B ADR was the reason for admission.
Level 5 Any level 4 ADR which requires intensive medical care.
Level 6 ADR caused permanent harm to the patient.
Level 7 ADR either directly or indirectly led to the death of the
patient.

14. • High risk opioids
– Hydromorphone ADR’s:
• Dose related (1 mg or greater)
• Opioid naïve
• Concurrent use of CNS depressants
– Causes:
• Lack of standard equianalgesic conversions
• Prescribing multiple opioids with varying dose ranges,
via multiple routes
Effective Processes

15. • Hydromorphone dose adjustment protocol
– Objective: In an effort to reduce the risk of severe
adverse events with hydromorphone and to use
the lowest analgesic dose, intravenous starting
doses of 1 mg or greater in opioid naïve patients
will be decreased as follows:
• Hydromorphone 0.5 mg IV continue same frequency as
ordered. May administer a second dose if not effective
within 30 min.
Effective Processes

16. Effective Processes

17. • Opioid Tolerant
– FDA: taking equivalent of morphine oral 60 mg/day
for 1 week or longer
– NCCN: chronically receiving opioids on a daily basis
• Process to determine
– Review current medication profile and medication
reconciliation
• Automated dispensing cabinets
– Stock only 0.5 mg dosage, remove 2 mg & 4 mg
– Restrict higher doses to Oncology unit
Effective Processes

18. • Optimizing EMR functionality to promote safe
use of opioids
– Order Set development
– Red flags for dose verification, interactions,
duplications and dosing limits
– Tallman lettering
Safe Technology

19. • Infusion Pumps for use of opioids
– PCA, PCEA, and continuous
Safe Technology

20. • Onboarding of all providers
– Policies and procedures related to pain
management
– Competencies assessed annually
• Standardized Pain Management Resources
– Focus on Cancer patients
– Opioid titration, switch, tolerance
– Equianalgesic potency & conversion methods
– Addresses ADR management
Appropriate Education and Training

21. Best Practice Recommendation
https://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Gap-Analysis-Opioid.pdf

22. Patients with sleep apnea are at higher risk of opioid-induced
respiratory depression.
True
False
Which of the following are ways that information technology can be
utilized to monitor opioid prescribing:
Use of red flags and alerts for dosing limits and/or verifications
during e-prescribing of opioids
Use of infusion smart pump with dosing safeguards when
administering patient controlled analgesia
Use of tall man lettering within the drug formulary
All of the above
Assessment Questions

23. 1. The Joint Commission Statement on Pain Management. 2001. Available at
https://www.jointcommission.org/joint_commission_statement_on_pain_manage
ment/. [Last accessed: October 2, 2016]
2. The Joint Commission Sentinel Event Alert: Safe Use of opioids in hospitals.
2012;(49). Available at
https://www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf[
Last accessed: October 2, 2016]
3. Davies EC, et al: Adverse Drug Reactions in Hospital In-Patients: A Prospective
Analysis of 3695 Patient Episodes, PLos ONE, February 2009;4(2):e4439.
4. Opioid Adverse Drug Event Prevention Gap Analysis. Minnesota Hospital
Association.
https://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-
Safety-Gap-Analysis-Opioid.pdf [Last accessed: October 2, 2016]
5. National Comprehensive Cancer Network. Adult Cancer Pain (Version 2.2016).
https://www.nccn.org/professionals/physician_gls/pdf/pain.pdf[Last accessed:
October 2, 2016]
References