ASCO Mod: Pain management in cancer patients

Question 1

Which 2 proteins are involved in opiate metabolism?

Answer 1

3A4 and 2D6

Question 2

What drugs could inhibit 3A4 and thus opiate metabolism?

Answer 2

Macrolides, azoles, antiretrovirals, grapefruit, Imatinib, etc

Question 3

Extended release opiates should be backbone of opiate pain regimen for cancer pain. What % of daily dose should be short-acting PRNs?

Answer 3

5-20%

remember to keep increasing if long-acting is increased

Question 4

What % should be titrated up and down when titrating opiate doses?

Answer 4

30-50% of daily dose to see differences

Question 5

Important steps when rotating opiates?

Answer 5

• Calculate MME
• Use table to find equaivalnt in new class
• dose reduce by 30-50%
• Add PRN which is 5-20% of daily dose
• Follow up with patient in 2-3 days

Question 6

Treatment of myoclonus side effect of opiates?

Answer 6

opiate rotation or benzodiazepines

Question 7

Universal precautions of opiate prescribing:

Answer 7

pain management agreements
urine drug testing
Pill counts
PMP
Assess risk of misuse, monitor behavior, respond to aberrant behavior

Question 8

55yoF w/ metastatic NSCLC. Severe pain from mets to spine. Reports fatigue, sedation, and daytime myoclonus. Next step?

Answer 8

Rotate pain meds

Follow-up within 2-3 days