Cancer Pain -- Printable Tables

TITLE:	CANCER PAIN
AUTHOR:	MELLAR P. DAVIS, MD -- Department of Hematology and Medical Oncology
PUBLISHED:	DECEMBER 6, 2002
REVIEWED:	DECEMBER 29, 2003

Table 1:

Common Causes of Pain

Bone metastases

Visceral metastases

Immobility

Neuropathic pain

Soft tissue

Constipation

Esophagitis

Lymphedema

Muscle cramps

Chronic Postoperative Scar

Adapted from reference 10.

Table 2:

Mediators Capable of
Depolarizing Nociceptors

Nerve growth factor

Bradykinin

Serotonin

Protons

Lipids (prostaglandin)

Heat

Pressure

Table 3:
Routes of Administration
Oral	Rectal	Sublingual	Spinal	Intravenous	Transdermal
Hydromorphone	Hydromorphone	Fentanyl	Fentanyl	Fentanyl	Fentanyl
Methadone	Morphine	Methadone	Hydromorphone	Hydromorphone
Morphine	Oxycodone		Methadone	Methadone
Oxycodone			Morphine	Morphine

Table 4:
Adjuvant Analgesic
Drug	Initial Dose	Maximum Dose
Acetaminophen	500 mg qid	4000 mg/day
Naprosyn	250 mg bid	500 mg tid
Dexamethasone	8 mg bid	Unknown
Rofecoxib	12.5 mg qd	50 mg qd
Nortriptyline	10 mg qhs	100-150 mg qd
Desipramine	10 mg qhs	100-150 mg qd
Valproic acid	250 mg qhs	30-60 mg per kg/day
Gabapentin	300 mg qhs	3600 mg/day

Table 5:
Analgesic Equivalents Compared to Morphine
Drug	Potency Ratio	Duration of Action
Tramadol	1/5	2-4 hours
Oxycodone	1-1.5	3-4 hours
Hydromorphone	5-7.5	4-5 hours
Fentanyl (transdermal)	100	72 hours
Methadone	4 (<90 mg morphine daily) 8 (90-300 mg morphine daily) 12 (>300 mg morphine daily)	8 hours

Table 6:
Equinanalgesic Dose and Conversions
Drug	Oral	SC/IV	Rectal
Fentanyl	---	25 ug = 1 mg morphine (parenteral)	---
Hydromorphone	6 mg	1.5 mg	6 mg
Methadone	Linear to total daily morphine	½ oral	1:1 oral/rectal
Morphine	30 mg	10 mg	30 mg

Table 7:
Side Effects and Treatment of Morphine Side Effects
Type	Initial Action	Alternative
Gastric stasis/nausea	Metoclopramide 10 mg ½ hour before meals and at bedtime Prochlorperazine 10 mg q 6 h	Opioid switch
Sedation	Reduce morphine dose if no pain	Methylphenidate 5 mg q am and 5 mg at noon Morphine dose reduction plus add an adjuvant
Cognitive Failure	Reduce morphine dose Delete psychosomatic adjuvants	Opioid switch
Myoclonus	Morphine dose reduction	Opioid switch Add clonazepam or valproic acid or gabapentin
Pruritus	Oral antihistaminic	Opioid switch

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