What are NCCN guidelines for palliative cancer pain management in opioid-tolerant patients?

Updated: Jun 01, 2019
  • Author: Winston W Tan, MD, FACP; more...
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For opioid-tolerant patients who have breakthrough pain of intensity ≥4 (on a scale of 0-10) or whose goals of pain control and function are not met, management is as follows [7] :

  • Administer a rescue dose of a short-acting opioid, equivalent to 10-20% of the total long-acting or regularly schedule oral opioid dose taken in the previous 24 hours
  • Assess efficacy and adverse effects every 60 minutes for oral opioids and every 15 minutes for IV opioids
  • If pain assessment is unchanged or increased, increase the rescue dose by 50-100%
  • If the pain score decreases, repeat the opioid dose and reassess at 60 minutes for oral opioids and 15 minutes for IV opioids
  • If the pain score remains unchanged after two to three cycles, consider changing the route of administration from oral to IV or explore alternative management strategies
  • If the pain score decreases to 0-3, give the current effective dose as needed over 24 hours before proceeding to subsequent management strategies
  • Ongoing need for repeated rescue doses may indicate a need for adjustment of the regularly scheduled opioid dose
  • Consider rapidly acting transmucosal fentanyl for brief episodes of incident pain not attributed to inadequate dosing of around-the-clock opioid

Subsequent management is based on the continued pain rating score and includes the following:

  • Regular doses of opioids, with rescue doses as needed
  • Management of constipation
  • Social support and education for patients and families

For ongoing care, if an acceptable level of comfort and function has been achieved and the patient’s 24-hour opioid requirement is stable, convert to an extended-release oral medication (if feasible) or other extended-release formulation (e, transdermal fentanyl).

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