Monday, March 31, 2008

Pain Crisis; cure & heal; The Dreaded “D” Word.

In JAMA’s ongoing series “Perspectives on Care at the Close of Life,” the Memorial Sloan-Kettering team tackles the management of acute cancer pain crisis.

This is definitely one for the Teaching File. As always in this series, a fairly graphic or complicated case is presented with definitions, descriptions, prescriptions, strategy, and philosophy interspersed. I’ll list the salient points:

  • Pain crisis is “an event in which the patient reports pain that is severe, uncontrolled, and causing distress for the patient, family members, or both.” Pain crisis can occur anywhere in the disease trajectory. Pain crisis is a medical emergency that requires aggressive assessment and intervention.
  • Management strategy focuses on
  1. making a pain diagnosis, differentiating reversible from intractable causes of pain and making decisions about further workup,
  2. selecting the opioid and monitoring and treating adverse opioid effects,
  3. titrating and rotating opioids and coanalgesics,
  4. consulting experts to treat a pain crisis as quickly as possible to prevent unnecessary suffering, and
  5. identifying and co-opting the available institutional resources. [this is my favorite]
  • There are no epidemiologic data on the incidence of pain crisis. Approximately 20-25% of all palliative care referrals at MSKCC are for pain crisis [which strikes me as high—what’s your experience, readers?]
  • Rapid response is crucial
  • Intervention is guided by goals of care. “Reestablishing goals of care” and planning interventions “congruent with goals of care” are emphasized over & over. When possible, the patient “leads the discussion” on goals of care.
  • Provide continuous support for patient & family
  • Continuously reassess response to interventions

There are several boxes and tables that summarize and expand on information in the narrative. NOTE: there is an error in Table 4 which displays an incorrect hydromorphone-methadone ratio when the 24-hr dose of hydromorphone is less than 330 mg. The listed value is 16:1; there is a decimal point missing: it should read 1.6:1. I was hoping they had corrected it by now in the online version, but as of Monday morning it is still unchanged. The conversion values for hydromorphone and methadone are tenuous at best, anyway. Personally, I think it makes sense to convert all opioids to morphine equivalents—either IV or PO, depending on the circumstances—so that there is a familiar and consistent constant.

We sometimes forget that adjuvants and coanalgesics have a role to play in pain crisis. Several options are listed. I used to use a lot of ketorolac. Acute pain very often (almost always?) has an inflammatory component. Unless otherwise indicated, it is a great analgesic booster while trying to titrate to the effective opioid dose.

There is a brief, but good, discussion of methadone and the implications/relative risk of QTc prolongation.

Please note that there is nothing in the article about PCA. Far too often clinicians think that PCA is the answer to uncontrolled pain. It isn't. PCA is for maintaining control once reached. It would have been nice if they had made that explicit. Otherwise as thorough & worthwhile as you can find on this topic in a general medical journal.

Some of you may have seen the patient-directed periodicals cure, and heal. I’ll bet they’re in your treatment center’s waiting room or in your patient support center. They come from the same publisher. heal’s target audience is cancer survivors, and the target demographic for both magazines appears to be the well-educated, information-mining patient. On the whole, these are good, informative magazines. There is a particularly good article on palliative care in the Spring issue of cure (unfortunately, that issue is not yet available online). The only complaint I had is the use of the term “palliative medicine,” as in Betty Ferrell is “a national leader in training nurses in palliative medicine.” But that’s just a little late night whining. A good one for the patient Teaching File.

The Left Atrium is a regular column in Canadian Medical Association Journal (CMAJ). It’s sort of a non-cancer version of JCO’s “When the Tumor is Not the Topic” column. This week’s essay is by a medical student recounting an experience in her surgical rotation (I think the student is a “she.” If I have it wrong, I apologize for my cultural ignorance). The student is paged to see a patient after the surgical team has gone home for the night. The patient has decided to forego the scheduled surgery and go home to see his children—and to die. The essay is short, well-written, and open access. I recommend it. There’s an engaging image, too. The important kernel of insight: “I realized that I had come in at the tail end of what must have been a long, introspective process for Mr. Lee and his family.” By the way, this author, Pari Basharat, has honed her writing skills previously in CMAJ with both poetry and narrative. Good stuff.

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