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Care at the Close of Life: Evidence and Experience
Stephen J. McPhee, Margaret A. Winker, Michael W. Rabow, Steven Z. Pantilat, Amy J. Markowitz
Part B Symptom Management
Chapter 5. Managing an Acute Pain Crisis in a Patient With Advanced Cancer: "This Is as Much of a Crisis as a Code"
Natalie Moryl, MD, Nessa Coyle, NP, PhD, Kathleen M. Foley, MD
Table 5-1 Relative Single-Dose Potencies of Commonly Used Opioid Drugs for Pain and Their Oral-Intravenous Ratiosa


Topics Discussed: cancer pain, cancer, advanced, dexamethasone, diagnostic process, diagnostic studies, fentanyl, hydromorphone, ketamine, lorazepam, management of cancer pain, methadone, morphine, opioid analgesics, opioids, oxycodone, pain crisis, pain management, pain measurement

Excerpt: "The assessment and management of an acute pain crisis in the setting of advanced illness are challenging.1,2 Using Mr X's case, we outline a management strategy that 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.We define a pain crisis as an event in which the patient reports severe, uncontrolled pain that is causing the patient, family, or both severe distress. The pain may be acute in onset or may have progressed gradually to an intolerable threshold (as determined by the patient) but requires immediate intervention. The US National Comprehensive Cancer Network pain management guidelines identify a pain emergency as an event in which patients have severe pain (a numerical estimate of at least 7 on a 10-point scale) that requires rapid opioid titration to provide analgesia.3 There are no epidemiologic data to suggest how commonly pain crises occur. Our own experience at Memorial Sloan-Kettering Cancer Center suggests that of approximately 120 inpatient consultations a month, our Pain and Palliative Care Service is called for what is identified as a pain crisis by the referring physician as frequently as 20 to 30 times a month. The message usually conveyed is that the patient needs to be seen "right now." The treatment plan starts with a rapid clinical assessment, titration of analgesics, and direct supervision by a physician-nurse team. When the medications or doses are not familiar to the clinician providing direct patient care, appropriate experts and resources should be consulted to help outline a plan of care, guide medication titration, monitor the outcomes, and provide support to staff, patient, and family.3-5..."
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