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Acute Pain Crisis: Natalie Moryl, MD, discusses managing an acute pain crisis in a patient with advanced cancer.
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Acute Pain Crisis: Natalie Moryl, MD, discusses managing an acute pain crisis in a patient with advanced cancer.
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives Section. Today I have the pleasure of speaking with Dr. Natalie Moryl about managing an acute pain crisis in a patient with advanced cancer. Dr. Moryl, why don't you introduce yourself to our listeners? >> Hello, I'm Natalie Moryl. I am a physician at Memorial Sloan Kettering Cancer Center, and I'm affiliated with Cornell Medical College. >> Dr. Moryl, what is an acute pain crisis? And what steps should a clinician take in the assessment of an acute pain crisis in a patient with advanced cancer?
>> I would define a pain crisis as an event in which the patient reports pain that is severe, uncontrolled, and causing distress for the patient, family, and in some instances, for the staff. >> And in terms of assessing pain crisis in a patient with advanced cancer, what steps should a clinician take? >> The general strategy should be focused on, number one, making a pain diagnosis, and most importantly, differentiating reversible causes of pain from intractable causes of pain, and making decisions about further workup.
The second important part is selecting the opioids and monitoring and treating adverse opioids effects, while titrating and possibly rotating opioids and co-analgesics. The third issue is if in case of severe pain crisis or if the expertise of the team is not sufficient to manage the physical or emotional pain, it's important to consult experts to treat the pain crisis as quickly as possible and prevent the necessary suffering of the patient. That leads me to the last most important issue, the team needs to identify any co-op, the available institutional resources to support the team and the patient in controlling the pain crisis in the safest setting possible.
>> What are some pain and symptom assessment tools that could be used to define and quantify pain? >> General principles of pain assessment are based on believing the patient's complaint of pain. There are multiple assessment tools. At Memorial Hospital, we most commonly use Memorial Symptom Assessment Scale, and for research purposes, the Brief Pain Inventory. All of these scales focus on assessing patient's complaint, pain, pain medication history, and that helps to make an appropriate diagnosis, and ultimately leads to the best treatment plan.
>> How are opioids selected for the management of pain? >> We select the opioid drug based on the patient's analgesic history, severity of pain, and inferred pain mechanism. We also need to take into consideration the patient's age, metabolic state, presence of major organ failure, such as renal, hepatic, lung, and presence of coexisting diseases, as well as concurrent medications, such as sedating medications. >> What adverse effects may be associated with opioid use?
And what treatments should clinicians use to manage these effects? >> Opioids are frequently associated with side effects, especially during the initiation of opioids or during opioid titration, especially if it's done rapidly. Most common side effects are nausea, sedation. The most feared side effects are respiratory depression and delirium. Urinary retention and pruritus are less discussed, but also could be quite disturbing to the patient. There are multiple adjuvant analgesic medications that can counteract the effect of opioids.
However, if during opioid titration, the intolerable side effects are noted and pain is still not well controlled, instead of adding multiple medications to control side effects, we would recommend opioid rotation. >> How can adjuvant co-analgesic medications be used in pain crisis management? >> Adjunct co-analgesic medications should be considered early in pain crisis management. In general, the term "adjuvant" is used to describe different drugs and classes of drugs that may enhance the effects of opioids, or nonsteroidal anti-inflammatory medications, exerting independent analgesic activity when certain instances counteracted the adverse effects of analgesics.
Most commonly used drugs in acute uncontrolled pain are ketorolac and other nonsteroidal anti-inflammatory medications, corticosteroids. We also use ketamine in severe neuropathic pain, or if sedation is a major dose-limiting side effect in opioid management. In intractable symptoms, use of the benzodiazepines or sedating neuroleptics could be considered. >> When should clinicians consider methadone therapy? >> Methadone has been reported to have unique analgesic properties that could be due to NMDA receptor antagonism and other properties.
It does seem to be effective when other opioids are associated with extreme side effects or simply are not effective in controlling the pain and could not be further escalated because of opioid-related side effects. However, due to its long and unpredictable half-life, any rotation to methadone requires very frequent monitoring of the patient for undertreatment of pain, oversedation, withdrawal symptoms. We recommend that methadone should be used with caution and a consultation with a palliative care or pain team is recommended.
>> Dr. Moryl, is there anything else you would like to tell our listeners about managing an acute pain crisis? >> In our 2008 paper, we presented a particular challenging case because the dose of parenteral opioids that the patient required was beyond the expertise of the staff that was expected to manage the pain crisis. This case illustrated the critical need for a clinical pathway for an acute pain crisis and other symptom management. Such institutional guidelines are important for resource allocation, both of staff time and ICU bed allocation, enabling continuous monitoring of the high-dose opioid and ketamine infusions.
Such guidelines for management of acute pain crisis frame as standard of care, informing both the patient and the health care professionals of a recommended approach. The guidelines would help to distinguish an appropriate use of rapidly escalating high-dose opioids, and other agents in a dying patient or patient with advanced cancer from inappropriate strategies of euthanasia and physician-assisted suicide. >> Thank you, Dr. Moryl, for your insights into managing an acute pain crisis in a patient with advanced cancer. For additional information about this topic, JAMAevidence subscribers can consult Chapter 5 in Care at the Close of Life.
This has been Joan Stephenson of JAMA talking with Dr. Natalie Moryl for JAMAevidence.
