CANCER PAIN REFERRAL GUIDELINES
For many cancer patients, oral analgesics may be adequate; however, those cancer patients with intractable pain who meet any of the criteria listed below may be appropriate for more advanced pain management techniques. Consider referring those patients to a pain management specialist for an evaluation, and to learn about options for chronic pain control using intrathecal opioids. Pending a successful intrathecal morphine trial, a permanent intrathecal catheter and Medtronic SynchroMed™ II programmable pump could be implanted for chronic pain control.
- Symptoms of pain due to advanced stage cancer at presentation, with a minimum life expectancy of >3 months.3,4,9,10
- Refractory to conventional pain management because of intractable drug adverse effects or unsatisfactory analgesia.3,4,9,10
- Visual analog scale (VAS) of ≥ 5, despite 200 mg/day of oral morphine or the analgesic equivalent.*3,9,10
Consider patients on lower doses if opioid side effects are refractory to conservative treatment and severe enough to prevent upward titration.3,9,10
*200 mg oral morphine or equivalent was used as enrollment criterion in a pivotal randomized clinical trial published in 20023; and has since been referenced as a criterion in additional clinical studies related to cancer pain and intrathecal drug delivery.9,10
Note: It is important to consider increased assessment and referral vigilance for women,1,2,5,7 minorities,2,5-7 and the elderly,2,5,6 who have been shown to be at increased risk for inadequate analgesia.
CONTRAINDICATIONS
Infection; implant depth greater than 2.5 cm below skin; insufficient body size; spinal anomalies; drugs with preservatives, drug contraindications, drug formulations with pH ≤3, use of catheter access port (CAP) kit for refills or of refill kit for catheter access, blood sampling through CAP in vascular applications, use of Personal Therapy Manager to administer opioid to opioid-naïve patients. See SynchroMed product labeling for more information.
1
Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994;330:592-596.
2
Cleeland CS. Undertreatment of cancer pain in elderly patients. JAMA. 1998;279(23):1914-1915.
3
Smith TJ, Staats PS, Deer T, Stearns LJ, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival. J Clin Oncol. 2002;20(19):4040-4049.
4
Stearns L, Boortz-Marx R, Du Pen S, Friehs G, et al. Intrathecal drug delivery for the management of cancer pain: a multidisciplinary consensus of best clinical practices. J Support Oncol. 2005;3(6):399-408.
5
Carr D, Goudas L, Lawrence D, et al. Management of cancer symptoms: pain, depression, and fatigue. Evidence Report/Technology Assessment No. 61 (Prepared by the New England Medical Center Evidence-based Practice Center under Contract No 290-97-0019). AHRQ Publication No. 02-E032. Rockville, MD: Agency for Healthcare Research and Quality. July 2002. Accessed at http://archive.ahrq.gov/downloads/pub/evidence/pdf/cansymp/cansymp.pdf on 02/15/17.
6
Bernabei R, Gambassi G, Lapane K, Landi F, et al. Management of pain in elderly patients with cancer. JAMA. 1998;279(23):1877-1882.
7
Cleeland CS, Gonin R, Baez L, Loehrer P, Pandya K. Pain and pain treatment in minority outpatients with metastatic cancer. Ann Intern Med. 1997;127:813-816.
8
Doleys DM, Olson K. eds. 2007. Psychological assessment and intervention in implantable pain therapies. Medtronic, Inc. Minneapolis, MN.
9
Smith TJ, Coyne PJ. Implantable drug delivery systems (IDDS) after failure of comprehensive medical management (CMM) can palliate symptoms in the most refractory cancer pain patients. J Pall Med. 2005;8(4):736-742.
10
Brogan, SE. Intrathecal therapy for the management of cancer pain. Curr Pain Head Rep. 2006;10:253-259.