Opioid rotation for cancer pain: rationale and clinical aspects

A new extended release formulation (OROS) of hydromorphone in the management of pain

Opioid analgesics are essential in the treatment of moderate to severe cancer-related pain. Opioids are also recognized as important in the management of other severe, persistent refractory painful conditions, such as sickle cell disease and arthritis. In the clinical practice of pain management, stable opioid dosing generally depends on achieving maximal analgesia with tolerable side effects typical of opioid analgesics. There is a wide interindividual variability of responsiveness to exogenous opioids both in terms of analgesic efficacy and side effects. Optimizing pain management for the individual patient may require sequential trials of opioid medications until the regimen with the most favorable therapeutic ratio of efficacy to side effects is determined.

Early switching from morphine to methadone is not improved by acetaminophen in the analgesia of oncologic patients: a prospective, randomized, double-blind, placebo-controlled study

OBJECTIVES

This study aims to evaluate the efficacy of methadone as substitute for morphine and to investigate if the addition of acetaminophen could reduce the time to attain an equianalgesic dose of methadone and/or to improve the level of pain control in oncologic patients.

PATIENTS AND METHODS

Fifty patients on stable doses of morphine for 1 week were switched to methadone using a "stop-start" strategy and randomized in a double-blind fashion to receive either acetaminophen (750 mg PO every 6 hours) or placebo for a 7-day period. We collected data regarding level of pain, side effects, and quality of life.

RESULTS

Substitution of morphine for methadone resulted in a significant reduction in constipation (p < 0.001) and xerostomia (p = 0.03). There was also an improvement in the numeric pain scale (p = 0.03) as well as a significant improvement in the functional level and symptomatology according to the QLQ-C30 questionnaire. Addition of acetaminophen did not improve pain control or reduce the time of stabilization of analgesia once methadone was introduced. At the end of the study, most patients (70.8%, p = 0.001) preferred methadone to morphine.

CONCLUSIONS

Early switching from morphine to methadone was a safe and efficient strategy for the reduction of side effects and improvement of analgesia, allowing for a comfortable dosing regimen. In this scenario, the association with acetaminophen did not improve pain control or reduce the time to achieve an equianalgesic dose of methadone.

Opioids switching with transdermal systems in chronic cancer pain

Background

Due to tolerance development and adverse side effects, chronic pain patients frequently need to be switched to alternative opioid therapy

Objective

To assess the efficacy and tolerability of an alternative transdermally applied (TDS) opioid in patients with chronic cancer pain receiving insufficient analgesia using their present treatment.

Methods

A total of 32 patients received alternative opioid therapy, 16 were switched from buprenorphine to fentanyl and 16 were switched from fentanyl to buprenorphine. The dosage used was 50% of that indicated in equipotency conversion tables. Pain relief was assessed at weekly intervals for the next 3 weeks

Results

Pain relief as assessed by VAS, PPI, and PRI significantly improved (p < 0.0001) in all patients at all 3 follow up visits. After 3 weeks of treatment, the reduction in the mean VAS, PPI, and PRI scores in the fentanyl and buprenorphine groups was 68, 77, 74, and 69, 79, and 62%, respectively. Over the same time period the use of oral morphine as rescue medication was reduced from 27.5 ± 20.5 (mean ± SD) to 3.75 ± 8.06, and 33.8 ± 18.9 to 3.75 ± 10.9 mg/day in the fentanyl and buprenorphine groups, respectively. There was no significant difference in either pain relief or rescue medication use between the two patient groups The number of patient with adverse events fell during the study. After the third week of the treatment the number of patients with constipation was reduced from 11 to 5, and 10 to 4 patients in the fentanyl and buprenorphine groups, respectively. There was a similar reduction in the incidence of nausea and vomiting. No sedation was seen in any patient after one week of treatment.

Conclusion

Opioid switching at 50% of the calculated equianalgesic dose produced a significant reduction in pain levels and rescue medication. The incidence of side effects decreased and no new side effects were noted. Further studies are required to provide individualized treatment for patients according to their different types of cancer.

Switching from methadone to a different opioid: what is the equianalgesic dose ratio?

INTRODUCTION

Methadone (ME) is a highly effective opioid agonist used for difficult pain syndromes. However, in the management of cancer pain with strong opioids, rotation to a different opioid (opioid rotation) may be required because of side effects or poor pain control. Rotation from methadone to another opioid has received limited study and therefore may be difficult because of the absence of a uniformly accepted dose conversion ratio.

METHODS

Retrospectively reviewed consecutive medical records of patients undergoing an opioid rotation from methadone to an alternative opioid were evaluated. For inclusion, patients were required to have received methadone for at least 3 days and have reached stable dose of the alternative opioid(s) during the 7 days following. Stable dose was defined as a 30% or less change in opioid dose from one day to the next.

RESULTS

Records of 39 patients met inclusion criteria. Excluded from analysis were 5 patients who were restarted on methadone within 7 days, 2 with irregular opioid use resulting in negligible regular opioid doses post-switch, and 3 due to concerns about reliability of multiple routes used for fentanyl. Data from 29 patients, 10 female, mean age 48 +/- 14.4 years, were evaluable. The mean dose ratio for oral methadone to oral morphine equivalent daily dose (MEDD) was 1:4.7 (95% confidence interval [CI], 3.0-6.5; n = 16), and for intravenous (IV) methadone to MEDD was 1:13.5 (95% CI, 6.6-20.5; n = 13), p = 0.06. Methadone dose was significantly correlated to stable MEDD after switching opioids for both methadone IV and oral (Spearman = 0.86, p = 0.0001 and Spearman = 0.72, p = 0.0024), respectively. Mean day of achieving stable dose was day 2.5 +/- 0.2 for IV methadone and day 2.6 +/- 0.3 for oral methadone.

CONCLUSION

These dose ratios are new findings that may assist in switching patients more safely to alternative opioids when side effects or pain problems occur when patients are receiving methadone. An important difference in analgesic potency appears to exist between IV and oral ME. Future research with prospective studies is required.

The role of methadone in opioid rotation-a Polish experience

BACKGROUND

To assess methadone analgesia, adverse effects, and calculation method of equianalgesic doses with oral morphine.

MATERIALS AND METHODS

Methadone was administered to 21 opioid-tolerant cancer patients because of pain (numerical rating scale [NRS] > 5) on morphine (ten patients), transdermal fentanyl (TF; four patients), morphine, ketamine, and TF (one patient), tramadol (one patient), pethidine (one patient), pain with drowsiness on morphine with ketamine (three patients), and pain with nausea on morphine (one patient). Dose ratios of equivalent daily dose of oral morphine (ddom) to daily dose of oral methadone (ddomet) were 4:1 (ddom to 100 mg), 6:1 (101-300 mg), 12:1 (301-1,000 mg), and 20:1 (over 1,000 mg). Previous opioid treatment was stopped completely (stop-start approach) in 19 patients; two received methadone and other opioids. The mean ddom before switch was 812 +/- 486 mg. Methadone was administered regularly three times daily; 20 patients received oral methadone, one patient received rectal suppositories. Breakthrough pain was treated with methadone (half of regular dose), morphine, fentanyl, metamizol, ketoprofen, or ketamine.

RESULTS

Mean time of methadone treatment was 38.3 +/- 27.1 days (range 3-95 days), mean daily doses: start 48.1 +/- 19.7 mg, maximal 148.5 +/- 104.1 mg, treatment completion 131.1 +/- 104.3 mg. Good analgesia (NRS < 4) was observed in 11 patients, partial (NRS 4-5) in nine patients, and unsatisfactory (NRS > 5) in one patient. Adverse effects such as drowsiness (six patients), constipation (six patients), nausea and vomiting (two patients), sweating (two patients), and respiratory depression (one patient) the last one resolved by methadone cessation and naloxone.

CONCLUSIONS

Results confirmed high analgesic efficacy, acceptable methadone adverse event profile, safety, and effectiveness of ddom to ddomet dose calculation method.

Morphine sulfate extended-release capsules for the treatment of chronic, moderate-to-severe pain

BACKGROUND

Morphine sulfate extended-release capsules (KADIAN) contain polymer-coated morphine sulfate pellets that are formulated to deliver sustained plasma morphine levels with minimal fluctuation. Morphine sulfate extended-release capsules, the only opioid formulation indicated in the US for both once- and twice-daily (every 12 and every 24 h) dosing, is approved in eight dosage strengths and is effective against pain from diverse sources in a variety of patient types. The formulation of morphine sulfate extended-release capsules allows flexible dosing options: capsules can be taken whole or the contents can be sprinkled on apple sauce or delivered via a gastrostomy tube. Morphine sulfate extended-release capsules have no immediate-release component and no components that would limit high doses.

RESULTS/CONCLUSION

The bioavailability of morphine sulfate extended-release capsules is not compromised when taken with food and dose dumping (immediate elevations in dose) does not occur when morphine sulfate extended-release capsules are taken concomitantly with alcohol. Nearly all patients taking morphine sulfate extended-release capsules for pain relief adhere to the recommended dosing frequency. The flexibility available with morphine sulfate extended-release capsules may offer clinical advantages for pain management.

Challenges in using opioids to treat pain in persons with substance use disorders

Pain and substance abuse co-occur frequently, and each can make the other more difficult to treat. A knowledge of pain and its interrelationships with addiction enhances the addiction specialist's efficacy with many patients, both in the substance abuse setting and in collaboration with pain specialists. This article discusses the neurobiology and clinical presentation of pain and its synergies with substance use disorders, presents methodical approaches to the evaluation and treatment of pain that co-occurs with substance use disorders, and provides practical guidelines for the use of opioids to treat pain in individuals with histories of addiction. The authors consider that every pain complaint deserves careful investigation and every patient in pain has a right to effective treatment.

Cognitive effects of opioids

Although opioid analgesics are safe and effective tools for the treatment of moderate to severe pain, there remain large gaps in understanding of the effects of these drugs on the many dimensions of functioning. This article summarizes the biomedical evidence addressing cognitive effects of the opioid analgesics. Current evidence indicates that cognitive function can be influenced by use of opioid analgesics, although the effects vary between drugs, are thought to be most significant with mixed-activity drugs, codeine, propoxyphene, and meperidine, and are generally most concerning during the first few days after starting opioid therapy, before tolerance develops. Blanket policies regarding the activities of driving and working are inappropriate; this issue is best addressed on a patient-specific basis.

Opioids and efflux transporters. Part 2: P-glycoprotein substrate activity of 3- and 6-substituted morphine analogs

Continuing our studies investigating opioids with reduced P-glycoprotein (P-gp) substrate activity, a series of known 3- and 6-hydroxy, -methoxy, and -desoxymorphine analogs was synthesized and analyzed for P-gp substrate activity and opioid binding affinity. 6-Desoxymorphine ( 7) showed high affinity for opioid receptors and did not induce P-gp-mediated ATP hydrolysis. Additionally, 7 demonstrated morphine-like antinociceptive potency in mice, indicating this compound as an ideal lead to further evaluate the role of P-gp in opioid analgesic tolerance development.

Challenging the equipotency calculation for transdermal buprenorphine: four case studies

AIMS

Opioids produce analgesia via different pain pathways. The aim of these case studies was to address the issue of opioid rotation or switching, raising the important issue of conversion ratios between different compounds and routes of administration.

RESULTS

We present two cases of neuropathic pain and two cases of nociceptive pain with a significant neuropathic component, which were successfully treated with transdermal buprenorphine after the failure of other opioids.

CONCLUSION

In each case, effective pain relief was produced by a lower dose than the proposed equipotency ratio of 1:75 would indicate, suggesting that a ratio of 1:110 to 1:115 may be more appropriate.

Morphine-induced analgesic tolerance, locomotor sensitization and physical dependence do not require modification of mu opioid receptor, cdk5 and adenylate cyclase activity

Acute morphine administration produces analgesia and reward, but prolonged use may lead to analgesic tolerance in patients chronically treated for pain and to compulsive intake in opioid addicts. Moreover, long-term exposure may induce physical dependence, manifested as somatic withdrawal symptoms in the absence of the drug. We set up three behavioral paradigms to model these adaptations in mice, using distinct regimens of repeated morphine injections to induce either analgesic tolerance, locomotor sensitization or physical dependence. Interestingly, mice tolerant to analgesia were not sensitized to hyperlocomotion, whereas sensitized mice displayed some analgesic tolerance. We then examined candidate molecular modifications that could underlie the development of each behavioral adaptation. First, analgesic tolerance was not accompanied by mu opioid receptor desensitization in the periaqueductal gray. Second, cdk5 and p35 protein levels were unchanged in caudate-putamen, nucleus accumbens and prefrontal cortex of mice displaying locomotor sensitization. Finally, naloxone-precipitated morphine withdrawal did not enhance basal or forskolin-stimulated adenylate cyclase activity in nucleus accumbens, prefrontal cortex, amygdala, bed nucleus of stria terminalis or periaqueductal gray. Therefore, the expression of behavioral adaptations to chronic morphine treatment was not associated with the regulation of micro opioid receptor, cdk5 or adenylate cyclase activity in relevant brain areas. Although we cannot exclude that these modifications were not detected under our experimental conditions, another hypothesis is that alternative molecular mechanisms, yet to be discovered, underlie analgesic tolerance, locomotor sensitization and physical dependence induced by chronic morphine administration.

Morphine treatment accelerates sarcoma-induced bone pain, bone loss, and spontaneous fracture in a murine model of bone cancer

Metastatic bone cancer causes severe pain that is primarily treated with opioids. A model of bone cancer pain in which the progression of cancer pain and bone destruction is tightly controlled was used to evaluate the effects of sustained morphine treatment. In cancer-treated mice, morphine enhanced, rather than diminished, spontaneous, and evoked pain; these effects were dose-dependent and naloxone-sensitive. SP and CGRP positive DRG cells did not differ between sarcoma or control mice, but were increased following morphine in both groups. Morphine increased ATF-3 expression only in DRG cells of sarcoma mice. Morphine did not alter tumor growth in vitro or tumor burden in vivo but accelerated sarcoma-induced bone destruction and doubled the incidence of spontaneous fracture in a dose- and naloxone-sensitive manner. Morphine increased osteoclast activity and upregulated IL-1 beta within the femurs of sarcoma-treated mice suggesting enhancement of sarcoma-induced osteolysis. These results indicate that sustained morphine increases pain, osteolysis, bone loss, and spontaneous fracture, as well as markers of neuronal damage in DRG cells and expression of pro-inflammatory cytokines. Morphine treatment may result in "add-on" mechanisms of pain beyond those engaged by sarcoma alone. While it is not known whether the present findings in this model of osteolytic sarcoma will generalize to other cancers or opioids, the data suggest a need for increased understanding of neurobiological consequences of prolonged opioid exposure which may allow improvements in the use of opiates in the effective management of cancer pain.

Mechanisms of Opioid-Induced Tolerance and Hyperalgesia

Opioid tolerance and opioid-induced hyperalgesia are conditions that negatively affect pain management. Tolerance is defined as a state of adaptation in which exposure to a drug induces changes that result in a decrease of the drug's effects over time. Opioid-induced hyperalgesia occurs when prolonged administration of opioids results in a paradoxic increase in atypical pain that appears to be unrelated to the original nociceptive stimulus. Complex intracellular neural mechanisms, including opioid receptor desensitization and down-regulation, are believed to be major mechanisms underlying opioid tolerance. Pain facilitatory mechanisms in the central nervous system are known to contribute to opioid-induced hyperalgesia. Recent research indicates that there may be overlap in the two conditions. This article reviews known and hypothesized pathophysiologic mechanisms surrounding these phenomena and the clinical implications for pain management nurses.

Prescribing patterns and purchasing costs of long-acting opioids over nine years at an academic oncology hospital

PURPOSE

The prescribing patterns and purchasing costs of long-acting opioids over nine years at an academic oncology hospital were studied.

METHODS

Data were collected for doses of transdermal fentanyl, methadone (all routes of administration), and oral sustained-release morphine and oxycodone dispensed for individual inpatient use for the month of October for each year between 1996 and 2004. The dates included in the retrieval were selected to document long-acting opioid use before and after the establishment of the palliative care and rehabilitation medicine department. For each opioid the number of milligrams dispensed daily per patient was determined and converted into a morphine-equivalent daily dose (MEDD). The average wholesale price per dosing unit of each drug during each period studied was obtained from internal databases. Costs were calculated by multiplying the number of units dispensed by the average wholesale price per unit and then normalized to 1996 U.S. dollars. The mean aggregate cost for a single MEDD in a month was determined by multiplying the mean cost per MEDD for each agent by that agent's percent contribution to the total MEDDs dispensed in that month.

RESULTS

Long-acting opioid and methadone usage increased from 1996 to 2004. Between 1996 and 2004, the mean cost of a single MEDD dropped from $0.0738 to $0.0330. During the study period, the median daily cost to treat one patient dropped from $5.96 to $2.80.

CONCLUSION

Long-acting opioid use increased and cost per MEDD decreased at an academic oncology hospital between 1996 and 2004. The decreased cost of purchasing opioids was attributed to the increased proportional use of methadone.

Opioid rotation from high-dose morphine to transdermal buprenorphine (Transtec) in chronic pain patients

Opioid rotation is increasingly becoming an option to improve pain management especially in long-term treatment. Because of insufficient analgesia and intolerable side effects, a total of 42 patients (23 male, 19 female; mean age 64.1 years) suffering from severe musculoskeletal (64%), cancer (21%) or neuropathic (19%) pain were converted from high-dose morphine (120 to >240 mg/day) to transdermal buprenorphine. The dose of buprenorphine necessary for conversion (at least 52.5 microg/h) was titrated individually by the treating physician. No conversion recommendations were given and the treating physician used his or her own judgment for dose adjustment. Pain relief, overall satisfaction and quality of sleep (very good, good, satisfactory, poor, or very poor), and the incidence and severity of adverse drug reactions over a period of at least 10 weeks and up to 1 year was assessed. Following rotation, patients experiencing good/very good pain relief increased from 5% to 76% (P < 0.001). Only 5% reported insufficient relief. Relief was achieved with buprenorphine alone in 77.4%, while 17% needed an additional opioid for breakthrough pain. Sleep quality (good/very good) increased from 14% to 74% (P < 0.005). Adverse effects were reported in 11.9%, mostly because of local irritation, did not result in termination of therapy. Neither tolerance nor refractory effect following rotation from morphine to buprenorphine was noted. Conversion tables with a fixed conversion ratio are of limited value in patients treated with high-dose morphine.

Ketamine as an adjuvant for treatment of cancer pain in children and adolescents

In children with advanced stages of cancer, pain control remains inadequate in many patients and a solution to this problem is sorely lacking. Factors related to progression of the primary disease and side-effects of high doses of opioids, the mainstay of pain therapy, contribute to the inadequacy of pain control. In addition, few studies suggest that opioids, by inducing tolerance, having pronociceptive effects and producing hyperalgesia in some patients, can also contribute to inadequacy of pain control. Researchers have shown that N-methyl-D-aspartate (NMDA) receptor antagonists may have a role in mitigating opioid-induced tolerance and hyperalgesia in adults. However, literature on NMDA antagonists to treat cancer pain in children and adolescents is scarce. We used subanesthetic doses of ketamine to treat 11 children and adolescents who were on high doses of opioids and yet had uncontrolled cancer pain. A low-dose ketamine infusion was administered to all patients to modulate the need for rapidly escalating opioid therapy. We found that in 8 of 11 patients, ketamine infusions used as an adjuvant to opioid analgesia was associated with opioid-sparing effects and apparent improvement in pain control and in the children's ability to interact with their family. This study suggests that infusions of ketamine may offer a promising therapeutic option in the treatment of appropriately selected children and adolescents with intractable cancer pain.

PERSPECTIVE

In many children with advanced stages of cancer, pain control remains inadequate. We used subanesthetic doses of ketamine to treat 11 children and adolescents who were on high doses of opioids and had uncontrolled cancer pain. In the majority of patients, ketamine appeared to improve pain control and to have an opioid-sparing effect.

Opioid Plasma Concentrations during a Switch from Transdermal Fentanyl to Methadone

Opioid switching is often used to improve the opioid response in patients with cancer experiencing poor analgesia or adverse effects. When switching between drugs with delayed effect because of pharmacokinetics or type of delivery, concerns exist about the correct timing of introducing the second drug after stopping the previous one. The aim of this study was to assess plasmatic changes of fentanyl and methadone underlying the clinical events occurring during opioid switching. Eighteen patients with cancer receiving transdermal fentanyl with uncontrolled pain and/or moderate to severe opioid adverse effects, were switched to oral methadone using an initial fixed ratio of 1:20. Fentanyl patches were removed and the first of three daily doses of methadone was started concurrently. Blood samples were obtained at intervals after removing the fentanyl patch, and at 5-hour intervals for the first 25 hours. The intensity of pain and the adverse effects were assessed before switching, the day after, and then daily up to dose stabilization. A successful switch was considered when the intensity of pain and distress score decreased at least of 33% of the basal value recorded before the switch, within a reasonable period of time. Complete blood samples were obtained in 16 patients. Methadone plasma concentration increased from 2 to 245 ng/mL, and fentanyl plasma concentration decreased from 15 to 8 ng/mL, 25 hours after. A successful switch was determined the day after in 7 patients, while 4 patients did not respond favorably (effective switching, 63%). Five patients were considered too terminal for an appropriate evaluation. No differences in plasma concentration pattern of the two opioids were found between patients considered responders and nonresponders. Conversion ratios between opioids at time of stabilization did not significantly change in comparison with the initial conversion ratio chosen. Starting methadone soon after removing fentanyl patches results in a rapid increase of methadone concentration, while the half-life of transdermal fentanyl is reached after 25 hours. As a result, the rapid achievement of a clinical effect is obtained avoiding distressing therapeutic holes in patients with a clinical condition, mainly characterized by poor pain control and severe adverse effects, requiring an immediate intervention.

The impact of opioid-induced hyperalgesia for postoperative pain

Clinical evidence suggests that--besides their well known analgesic activity - opioids can increase rather than decrease sensitivity to noxious stimuli. Based on the observation that opioids can activate pain inhibitory and pain facilitatory systems, this pain hypersensitivity has been attributed to a relative predominance of pronociceptive mechanisms. Acute receptor desensitization via uncoupling of the receptor from G-proteins, upregulation of the cAMP pathway, activation of the N-methyl-D-aspartate (NMDA)-receptor system, as well as descending facilitation, have been proposed as potential mechanisms underlying opioid-induced hyperalgesia. Numerous reports exist demonstrating that opioid-induced hyperalgesia is observed both in animal and human experimental models. Brief exposures to micro-receptor agonists induce long-lasting hyperalgesic effects for days in rodents, and also in humans large-doses of intraoperative micro-receptor agonists were found to increase postoperative pain and morphine consumption. Furthermore, the prolonged use of opioids in patients is often associated with a requirement for increasing doses and the development of abnormal pain. Successful strategies that may decrease or prevent opioid-induced hyperalgesia include the concomitant administration of drugs like NMDA-antagonists, alpha2-agonists, or non-steroidal anti-inflammatory drugs (NSAIDs), opioid rotation or combinations of opioids with different receptor/selectivity.

Opioids for chronic nonterminal pain

This article first reviews the evidence for and against chronic opioid therapy. Evidence supporting the opioid responsiveness of chronic pain, including neuropathic pain, includes multiple randomized trials conducted over months (up to 8 months). Observational studies are conducted for longer, and many also support opioid analgesic efficacy. Concerns have arisen about loss of efficacy with prolonged use, possibly related to tolerance or opioid-induced hyperalgesia. Mechanisms of tolerance and opioid-induced hyperalgesia are explored. Evidence on other important outcomes such as improvement in function and quality of life is mixed, and is less convincing than evidence supporting analgesic efficacy. It is clear from current evidence that many patients abandon chronic opioid therapy because of the unacceptability of side effects. There are also concerns about toxicity, especially when opioids are used in high doses for prolonged periods, related to hormonal and immune function. The issue of addiction during opioid treatment of chronic pain is also explored. Addiction issues present many complex questions that have not been satisfactorily answered. Opioid treatment of pain has been, and remains, severely hampered because of actual and legal constraints related to addiction risk. Pain advocacy has focused on placing addiction risk into context so that addiction fears do not compromise effective treatment of pain. On the other hand, denying addiction risk during opioid treatment of chronic pain has not been helpful in terms of providing physicians with the tools needed for safe chronic opioid therapy. Here, a structured goal-directed approach to chronic opioid treatment is suggested; this aims to select and monitor patients carefully, and wean therapy if treatment goals are not reached. Chronic opioid therapy for pain has not been a universal success since it was re-established during the last two decades of the twentieth century. It is now realized that the therapy is not as effective or as free from addiction risk as was once thought. Knowing this, many ethical dilemmas arise, especially in relation to patients' right to treatment competing with physicians' need to offer the treatment selectively. In the future, we must learn how to select patients for this therapy who are likely to achieve improvement in pain, function and quality of life without interference from addiction. Efforts will also be made in the laboratory to identify opioids with lower abuse potential.

Optimizing use of opiates in the management of cancer pain

Cancer pain is often suboptimally managed. The underestimation and undertreatment continues to be a problem despite the availability of consensus-based guidelines. Most patients with cancer develop pain. The prevalence and severity of pain among cancer patients varies according to primary and metastatic sites and stage of disease. Opioid therapy is the cornerstone of management of severe chronic pain in the field of cancer patients and in general in palliative care medicine. Since this class of drugs is the cornerstone of the treatment, optimizing its use may be useful in clinical practice. For this purpose we focused on 4 distinct issues: 1) How to implement the use the opioids in cancer patients; 2) How to optimise the use of morphine in cancer patients; 3) The management of side effects and opioid switching; 4) What is the role of other potent opioids. A holistic approach including an appropriate use of opioids may improve pain control in most cancer patients, particularly for those with advanced disease.

Managing Cancer Pain and Symptoms of Outpatients by Rotation to Sustained-release Hydromorphone

PURPOSE

In this prospective clinical trial we examined the technique of opioid rotation to oral sustained-release hydromorphone for controlling pain and symptoms in outpatients with cancer pain.

METHODS

Before and after rotation, 50 patients were assessed by Numerical Analog Scales [Numerical Rating Scales (NRS)], or as categorical parameters, and analyzed by descriptive and confirmatory statistics (ANOVA, Wilcoxon, chi).

RESULTS

Rotation was successful in 64% of patients experiencing pain (60%), and gastrointestinal (32%) and central (26%) symptoms under oral morphine (38%), transdermal fentanyl (22%), tramadol (20%), oxycodone (12%), or sublingual buprenorphine (8%). NRS of pain (4.1 to 3.2; P=0.015), gastrointestinal symptoms, especially defecation rates (P=0.04), and incidence of insomnia improved after an increase in morphine-equivalent doses from 108.9 to 137.6 mg/d without modifying concomitant analgesics or coanalgesics.

CONCLUSIONS

Switching the opioid to oral hydromorphone may be a helpful technique to alleviate pain and several symptoms, but it is still not clear to what extent the underlying mechanisms, such as the technique of rotation itself, better dose adjustment, or using a different opioid have an impact.

Patterns of Dosage changes with transdermal buprenorphine and transdermal fentanyl for the treatment of noncancer and cancer pain: A retrospective data analysis in Germany

BACKGROUND

Previous studies have suggested that buprenorphine may have a low association with tolerance development compared with other strong opioids. In a previous study by our group, mean cohort and intraindividual dosage increases over an entire course of treatment and on a per-day basis were significantly lower with transdermal (TD) buprenorphine than with TD fentanyl. However, no information concerning the relationship between qualitative and quantitative dose changes is available.

OBJECTIVE

The aim of this study was to compare TD buprenorphine and TD fentanyl with respect to dosage increases, dosage stability, and the nature of dosage changes.

METHODS

This retrospective analysis used data from the IMS Disease Analyzer-Mediplus database, which contains patient-related data documented by 400 medical practices in Germany. Data from patients with noncancer or cancer pain treated with TD buprenorphine or TD fentanyl for at least 3 months between May 2002 and April 2005 were analyzed. Daily dosages were directly determined from the prescribed patch strength, taking into account the possibility of multiple patches applied simultaneously. To determine dosage stability, patients were classified based on the type of dosage change (stable, increase, alternating, or decrease) of the prescribed dosages. From the prescribed daily dosages, mean percentage increases were calculated on a per-patient basis for the entire treatment period and per day, and these were assessed in relation to the type of dosage change.

RESULTS

In total, 631 patients with noncancer pain and 605 patients with cancer pain were included in the analysis (782 women, 454 men; mean age, 76.3 years [range, 29-100 years]). Treatment indications included osteoarthritis, low back pain, osteoporosis (noncancer groups), and neoplasm (cancer groups). Patients had similar analgesic premedication requirements based on steps 1 to 3 of the World Health Organization analgesic ladder. Comedication requirements for breakthrough pain were also similar between the TD buprenorphine and TD fentanyl groups. The mean percentage increases per day were 0.10% (TD buprenorphine) and 0.25% (TD fentanyl) in the noncancer groups and 0.19% (TD buprenorphine) and 0.47% (TD fentanyl) in the cancer groups (both, P < 0.05). A significantly larger proportion of patients receiving TD buprenorphine had stable dosages over the entire treatment period compared with patients receiving TD fentanyl (noncancer groups: 56.9% vs 41.6%; cancer groups: 50.0% vs 26.2% [both, P < 0.05]). Compared with TD buprenorphine, the proportion of patients with alternating dosage changes was significantly greater in patients receiving TD fentanyl (noncancer groups: 22.7% vs 13.1%; cancer groups: 30.6% vs 11.8% [both, P < 0.05]).

CONCLUSIONS

In this retrospective data analysis, compared with TD buprenorphine, the increase in mean daily dosage was significantly greater in patients treated with TD fentanyl. Also, compared with TD buprenorphine, alternating dosage changes were seen in a significantly greater proportion of patients receiving TD fentanyl. On the other hand, a significantly greater proportion of patients treated with TD buprenorphine had stable dosages over their entire treatment periods.

Opioid switching: a systematic and critical review

Cancer patients with pain may not respond to increasing doses of opioids because they develop adverse effects before achieving an acceptable analgesia, or the analgesic response is poor, despite a rapid dose escalation. Opioid switching may significantly improve the balance between analgesia and adverse effects. We conducted a systematic review of existing literature on opioid switching. According to available data, opioid switching results in clinical improvement in more than 50% of patients with chronic pain with poor response to one opioid. However, data are based on open studies or small case series. Reasons for switching may influence the dose of the alternative drug. Opioid conversion should not be a mere mathematical calculation, but just a part of a more comprehensive evaluation of pain, adverse effect intensity, comorbidities, and concomitant drugs. The process of reaching an optimal dose should be highly individualized, particularly when patients are switched from high doses of opioids, given the wide conversion ratios reported in literature.

Opioids in pain management of blood-related malignancies

Opioids are basic analgesics used in the treatment of moderate to severe pain in patients affected by blood-related malignancies. They should be sequentially administered according to the World Health Organisation scale for cancer pain. Initial treatment and titration with opioids should be based on immediate-release preparations, to be administered at appropriate intervals in order to relieve pain and to satisfy the individual opioid requirement. Once a relatively good pain control has been achieved, a slow release formulation at equivalent doses can be given. Most patients can be adequately managed using oral formulation opioids. However, a small group, such as those presenting severe mucositis or requiring a rapid pain relief, should be managed by intravenous continuous infusion and/or by a patient-controlled analgesia system; while for patients in the community, there are distinct advantages to using the subcutaneous route. Other available routes of administration for opioids, can be used in selected circumstances, including rectal, transdermal, epidural, intrathecal and intramuscular. The invasive neuraxial route has a very limited role in patients with haematological malignancies, given the high risk of infection and bleeding. Through a close observation and a careful management, opioid-related side effects can be effectively prevented and treated. This article reviews the principles of opioid therapy and how opioids can be adapted for patients with pain due to haematological malignancies.

Treatment of chronic moderate-to-severe non-malignant pain with polymer-coated extended-release morphine sulfate capsules

OBJECTIVE

To demonstrate the efficacy and tolerability of polymer-coated extended-release morphine sulfate (P-ERMS)(KADIAN) for the treatment of chronic, moderate-to-severe, non-malignant pain in a community-based outpatient population not satisfactorily relieved with their current therapies.

DESIGN

Phase IV, prospective, randomized, open-label, blinded endpoint.

PARTICIPANTS

Adults (N = 1428) with chronic, moderate-to-severe, non-malignant pain with visual numeric scale scores >or= 4 (0 = no pain; 10 = worst pain).

INTERVENTIONS

Patients were randomized to P-ERMS once daily in AM or PM for a 4-week treatment period. Dose increases were allowed; however, switching to twice-daily dosing was reserved until week 2.

MAIN OUTCOME MEASURES

Improvement from baseline in pain and sleep scales (0-10) (after weeks 2 and 4), quality of life (physical and mental component summary scores of the SF-36v2 Health Survey) (week 4), and patient (weeks 2 and 4) and clinician (week 4) assessments of current therapy (-4 to +4). Patient satisfaction was assessed again 1 month after the study.

RESULTS

Approximately 70% of patients completed the study, with 2.4% (n = 34) discontinuing due to lack of efficacy, and 9.6% (n = 136) discontinuing due to an adverse event. Improvements were seen in pain and sleep scores, physical and mental component scores of the SF-36v2, and patient and clinician global assessment scores (p < 0.0001, all assessments). Patients attained similar results regardless of AM vs. PM dosing. More than half (55.4%) of patients were maintained on once-daily therapy, with the remainder on a twice-daily regimen, in accordance with the prescribing information. Most adverse events (71.6%) were mild to moderate in severity, the most common being constipation (11.6%) and nausea (9.2%). One-month follow-up indicated continued satisfaction with P-ERMS vs. previous medication (p < 0.0001).

CONCLUSIONS

P-ERMS was efficacious and well tolerated in patients with chronic, moderate-to-severe, non-malignant pain when used once or twice daily.

Acute pain management for opioid dependent patients

Patients requiring acute pain management may be opioid dependent as a result of either recreational or therapeutic opioid use, including those in opioid addiction programmes. Pain in these patients is often under-estimated and under-treated. In addiction, drug-seeking behaviour differentiates it from simple dependence. With few randomised controlled trials, current evidence predominantly consists of guidelines based on case reports, retrospective studies and expert opinion. Consensus recommendations include maintaining regular provision of the patient's pre-existing opioid requirement, with additional analgesia, ideally multimodal, in appropriate combinations of short-acting opioid (as required), local anaesthesia, and adjuvant anti-inflammatory analgesics and paracetamol. Patient controlled analgesia with higher bolus doses and shorter lock-out intervals is a recommended strategy. Transdermal opioid patches and implantable pumps will continue to deliver opioid, to which non-opioid and short-acting opioids may be added. Re-exposure to opioid is ideally avoided in previously addicted patients, but if not feasible, opioid therapy should be prescribed.

Opioid switching from oral slow release morphine to oral methadone may improve pain control in chronic non-malignant pain: a nine-month follow-up study

Twelve patients with poor pain control or unacceptable side effects during treatment with morphine were switched to methadone and followed for nine months in this open prospective study. Primary outcomes were patient preference for opioid and pain control while physical, cognitive and role functioning were secondary outcomes. The morphine dose was decreased by 1/3 daily and was replaced with an equianalgesic dose of methadone over a three-day period. During switching and a one-week dose titration period, patients were given additional methadone if required. During dose titration one patient experienced sedation requiring naloxone. Four patients were switched back to morphine due to poor pain control, drowsiness or sweating. Seven patients preferred long-term (>nine months) treatment with methadone and reported reduced pain and improved functioning while cognition was not improved. This study brings novel information on the long-term consequences for pain control, health-related quality of life and cognitive functioning with a switch from morphine to methadone in the treatment of chronic non-malignant pain.

Opioidvermittelte Analgesie und Hyperalgesie

Opioids are frequently used for the treatment of moderate to severe acute and chronic pain. However, clinical evidence suggests that opioids can elicit increased sensitivity to noxious stimuli suggesting that administration of opioids can activate both, pain inhibitory and pain facilitatory systems. Acute receptor desensitization via uncoupling of the receptor from G proteins, upregulation of the cAMP pathway, activation of the N-methyl-D-aspartate (NMDA) receptor system and descending facilitation have been proposed as potential mechanisms underlying opioid-induced hyperalgesia. The tolerance results from a pain sensitization process more than from a decrease in the opioid effectiveness. Opioid-induced hyperalgesia and tolerance are observed both in animal and human experimental models. Brief exposures to mu-receptor agonists induce long-lasting hyperalgesic effects for days. Furthermore, the prolonged use of opioids in patients often requires increasing doses and may be accompanied by the development of abnormal pain. Successful strategies that may decrease or prevent opioid-induced hyperalgesia include the concomitant administration of drugs such as NMDA antagonists, alpha(2)-agonists, or nonsteroidal anti-inflammatory drugs (NSAID), opioid rotation, or combinations of opioids with different receptor selectivity.

Rapid Switching Between Transdermal Fentanyl and Methadone in Cancer Patients

Purpose

The aim of this study was to examine the clinical effects of switching from transdermal (TTS) fentanyl to methadone, or vice versa, in patients with a poor response to the previous opioid.

Patients and Methods

A prospective study was carried out on 31 patients who switched from TTS fentanyl to oral methadone, or vice versa, because of poor opioid response. A fixed conversion ratio of fentanyl to methadone of 1:20 was started and assisted by rescue doses of opioids, and then doses were changed according to clinical response. Pain and symptom intensity, expressed as distress score, were recorded before switching doses of the two opioids and after subsequent doses. The number of changes of the daily doses, time to achieve stabilization, and hospital stay were also recorded.

Results

Eighteen patients were switched from TTS fentanyl to methadone, and seven patients were switched from methadone to TTS fentanyl. A significant decrease in pain and symptom intensity, expressed as symptom distress score, was found within 24 hours after switching took place in both directions. Unsuccessful switching occurred in six patients, who were subsequently treated with an alternative therapy.

Conclusion

A rapid switching using an initial fixed ratio of fentanyl to methadone of 1:20 is an effective method to improve the balance between analgesia and adverse effects in cancer patients with poor response to the previous opioid. No relationship between the final opioid dose and the dose of the previous opioid has been found.

Long-term use of clonidine in a critically-ill infant

We report the use of clonidine in an infant as an adjunct to sedation and analgesia for 4.5 months in the critical care setting. Advantages, potential side effects, and dosing for multiple modes of delivery are discussed.

Changes in the Prescribed Daily Doses of Transdermal Fentanyl and Transdermal Buprenorphine During Treatment of Patients with Cancer and Noncancer Pain in Germany: Results of a Retrospective Cohort Study

BACKGROUND

During long-term therapy with strong opioids (step III opioids according to the World Health Organization [WHO] analgesic ladder), dose increases are often necessary because of deterioration of the primary disease or development of tolerance.

OBJECTIVE

The purpose of this study was to compare changes in dosages of transdermal (TD) fentanyl and TD buprenorphine in patients with cancer and non-cancer pain.

METHODS

In a retrospective study, patients with cancer and noncancer pain being treated with TD fentanyl or TD buprenorphine for at least 3 months between January 2001 and December 2003 were identified from the IMS Disease Analyzer-mediplus database, which contains all patient-related data documented from 400 medical practices in Germany. The indications for treatment were defined according to the International Classification of Diseases, 10th Revision, and included neoplasm (cancer groups), and osteoarthritis, low back pain, and osteoporosis (noncancer groups). The cohort patients were considered to have comparable pain intensity because they had received similar analgesic premedication classified according to steps I to III of the WHO analgesic ladder (cohort groups). The mean prescribed daily doses on first and last prescription were documented, and the mean percentile increases were calculated over the whole treatment duration and per day. Additionally, the mean percentile intraindividual increases (on a per-patient basis) were estimated.

RESULTS

The cohort groups consisted of 448 patients with noncancer pain and 446 patients with cancer pain (552 women and 342 men; mean age, 74 years; range, 25-101 years). The mean percentile increases in dosages over the whole treatment duration and adjusted per day were significantly higher in patients taking TD fentanyl (P < 0.05). Differences were even greater for the mean percentile intraindividual increases per day, which totaled 0.42%and 0.17% for cancer patients taking TD fentanyl and TD buprenorphine, respectively; corresponding values were 0.25% and 0.09%in noncancer patients (P < 0.001).

CONCLUSIONS

This retrospective analysis showed a significantly higher increase in the mean daily doses of TD fentanyl as compared with TD buprenorphine. The results must be verified in prospective, randomized clinical studies.

Opioid rotation from morphine to fentanyl in delirious cancer patients: an open-label trial

Although recent studies suggest that opioid rotation could be an effective treatment strategy for morphine-induced delirium, there have been no prospective studies to investigate the treatment effects of opioid rotation using fentanyl. The primary aim of this study was to clarify the efficacy of opioid rotation from morphine to fentanyl in symptom palliation of morphine-induced delirium. Twenty-one consecutive cancer patients with morphine-induced delirium underwent opioid rotation to fentanyl. Physicians recorded the symptom severity of delirium (the Memorial Delirium Assessment Scale, MDAS), pain, and other symptoms (categorical verbal scale from 0: none to 3: severe) and the Schedule for Team Assessment Scale (STAS) (from 0: none to 4: extreme); and performance status at the time of study enrollment and three and seven days after. Of 21 patients recruited, one patient did not complete the study. In the remaining 20 patients, morphine was substituted with transdermal fentanyl in 9 patients and parenteral fentanyl in 11 patients. Total opioid dose increased from 64 mg oral morphine equivalent/day (Day 0) to 98 mg/day (Day 7), and the median increase in total opioid dose was 42%. Treatment success, defined as an MDAS score below 10 and pain score of 2 or less, was obtained in 13 patients on Day 3 and 18 patients on Day 7. The mean MDAS score significantly decreased from 14 (Day 0) to 6.4 and 3.6 (Days 3 and 7, respectively, P < 0.001). Pain scores significantly decreased from 2.2 (Day 0) to 1.3 and 1.1 on the categorical verbal scale (Days 3 and 7, respectively, P < 0.001); from 2.6 (Day 0) to 1.6 and 1.3 on the STAS (Days 3 and 7, respectively, P < 0.001). Symptom scores of dry mouth, nausea, and vomiting significantly decreased, and performance status significantly improved. Opioid rotation from morphine to fentanyl may be effective in alleviating delirium and pain in cancer patients with morphine-induced delirium.

Age-dependent opioid escalation in chronic pain patients

Rapid opioid dose escalation, possibly caused by tolerance, has been observed in some patients on daily opioid therapy, although clinically identifiable characteristics of these patients are unknown. In this retrospective chart review of 206 patients, we examined whether the age of the patient was related to opioid escalation. Initial starting doses of long-acting opioids were similar in younger patients (< or =50 yr; 49 +/- 3 mg/d oral morphine-equivalent dose) versus older patients (> or =60 yr; 42 +/- 3 mg/d). Younger patients reached a maximum dose of 452 +/- 63 mg/d over 15.0 +/- 1.3 mo, whereas older patients achieved a maximum dose of 211 +/- 23 mg/d over 14.4 +/- 1.5 mo (P < 0.0001). At the last clinic visit, younger-patient dosing averaged 365 +/- 61 mg/d, with older patients averaging 168 +/- 18 mg/d (P < 0.0001). Only older patients demonstrated a reduction in visual analog scale scores from start of opioid therapy until discharge from the clinic (6.9 +/- 0.3 to 5.6 +/- 0.3; P < 0.01). These clinical data suggest that age is an important variable in opioid dose escalation. Although factors other than opioid tolerance can result in dose escalation, it is possible that older patients may have a reduced rate of tolerance development.

No pain relief from morphine? Individual variation in sensitivity to morphine and the need to switch to an alternative opioid in cancer patients

GOALS OF WORK

The aims of this study were (1) to prospectively evaluate the clinical benefits of switching from morphine to an alternative opioid, using oxycodone as first-line alternative opioid, in patients with cancer, (2) to evaluate the consistency of the clinical decision for the need to switch by comparing two hospital sites, and (3) to evaluate whether there were objective predictors that would help identify morphine non-responders who require switching to an alternative opioid and from this to construct a clinical model to predict the need to switch.

PATIENTS AND METHODS

One hundred eighty-six palliative care patients were prospectively recruited from two hospital sites. Responders were patients treated with morphine for more than 4 weeks with good analgesia and minimal side effects. Non-responders (switchers) were patients who had either uncontrolled pain or unacceptable side effects on morphine and therefore required an alternative opioid. The differentiation between responders and switchers was made clinically and later confirmed by objective parameters.

RESULTS

In this prospective study 74% (138/186) had a good response to morphine (responders). One patient was lost to follow up. Twenty-five percent (47/186) did not respond to morphine. These non-responders were switched to alternative opioids (switchers). Furthermore, of 186 patients, 37 achieved a successful outcome when switched to oxycodone and an additional 4 were well controlled when switched to more than one alternative opioid. Overall successful pain control with minimal side effects was achieved in 96% (179/186) of patients. There were no significant differences in the need to switch between the two hospital sites.

CONCLUSIONS

This study has shown that proactive clinical identification and management of patients that require opioid switching is reproducible in different clinical settings and significantly improves pain control. Further studies are required to develop and test the predictive model.

Stark wirksame Opioidanalgetika und Obstipation

In cancer pain therapy treatment with strong opioids is essential. However, it may be accompanied by the occurrence of various adverse effects. The most frequent and persistent side effect in the course of opioid treatment is constipation. It is mainly caused by linkage of the opioid to the peripheral mu-receptors in the bowel and may increase as a result of certain concomitant circumstances, such as poor intake of fluids or electrolyte disorder. Present research indicates that there is a relation between type of opioid and degree of constipation, i.e. treatment with transdermal fentanyl or methadone tends to cause less constipation compared to morphine or hydromorphone. The route of administration of morphine--oral vs. subcutaneous--does not seem to affect the incidence of opioid-induced constipation. Furthermore, prophylaxis and efficient control of opioid-induced constipation still fail to be part of the routine in pain treatment.

Pharmacologic Treatment of Opioid-Induced Sedation in Chronic Pain

OBJECTIVE:

To review the literature for pharmacologic management of opioid-induced sedation (OIS) in patients with chronic pain.

DATA SOURCES:

A search of MEDLINE (1966–October 2004) for English-language literature and selected bibliographies was completed. Search terms included pain, opioid, sedation, psychostimulants, amphetamines, modafinil, and donepezil.

DATA SYNTHESIS:

Amphetamines and amphetamine-like agents, caffeine, donepezil, and modafinil have been evaluated for OIS. Available literature is limited by numbers of subjects, duration, and trial design; however, there is limited support for the use of methylphenidate, donepezil, and modafinil.

CONCLUSIONS:

Pharmacologic treatment of OIS should be utilized selectively, given the available literature. Methylphenidate, donepezil, and modafinil may be considered in appropriate patients.

The Role of Opioids in Cancer Pain Management

Opioids remain an important cornerstone in the treatment of cancer pain. Effective analgesia is obtained in the majority of cancer pain patients with the application of fairly straightforward algorithms using opioids as the main therapy. Many rational treatment algorithms exist. In this tutorial we will describe the role of opioids in the treatment of cancer pain, including a brief overview of cancer pain syndromes, essential aspects of opioid therapy, opioid pharmacology, opioid rotation, properties of the individual opioids, and management of common side effects of opioids.

Management of opioid-induced bowel dysfunction in cancer patients

The gastrointestinal (GI) effects of morphine and other opioids may result in opioid-induced bowel dysfunction (OBD) and the need for treatment. Although OBD is very common in morphine-treated patients, it is usually under-diagnosed. Opioids deliver their GI effect through central and peripheral mechanisms. Laxatives are the pharmaceuticals prescribed most in this area. Prokinetics as well as cholinergic agonists have been used satisfactorily. One-third of patients with OBD have to be treated rectally. The use of opioid antagonists has been favored, but the bioavailability of oral forms is poor. Opioid antagonists with a quaternary structure have a high affinity for peripheral opioid receptors and therefore do not interfere with the analgesia, nor do they generate alkaloid withdrawal syndrome. Opioid rotation is another strategy for maintaining or improving analgesic quality directed toward decreasing the effects of previous opiates on the GI tract.

Underutilisation of Opioids in Elderly Patients with Chronic Pain

The impact of poorly managed chronic pain on the quality of life of elderly patients and the problems related to its management are widely acknowledged. Underutilisation of opioids is a major component of poor pain management in this group of patients, despite good evidence for the effectiveness of opioids and published guidelines directing their usage. Reasons for this underutilisation are, among others, poor assessment of pain in this age group; fear of polypharmacy and opiophobia; and avoidance of opioids because of concerns about tolerance, physical dependence, addiction and adverse effects. This review suggests approaches to overcome these barriers to opioid usage, such as regular pain assessments, education to overcome opiophobia, rational prescribing, utilisation of less conventional opioids and non-oral routes of administration, avoidance of inappropriate opioids, opioid rotation, and education about managing or preventing adverse effects, the reasons why opioid therapy may be unsuccessful, and the effects of psychological factors on the pain experience. This more rational and knowledge-based approach to the use of opioids in the management of chronic pain in the elderly population should correct the current problems with underprescribing in this age group.

Management of common symptoms of advanced lung cancer

Disease-directed treatment of lung cancer reduces the morbidity and extends life for patients. However, as providers we must recognize that treating the symptoms of the disease may be as important as the treatment of the disease itself. This is particularly true in advanced disease and after disease-directed therapies have been exhausted. Aggressive assessment of symptoms and use of palliative therapies can significantly reduce the symptomatology of advanced lung cancer. Though the impact of these symptoms (ie, pain, dyspnea, and cachexia) are well known, they tend to be under-treated. In addition, simple maneuvers such as opiate rotation for pain relief are underutilized. The diagnosis of lung cancer and its associated symptoms may result in severe psychosocial stress for the patient and further exacerbate the symptoms in a vicious cycle. Understanding of coping strategies may aid the medical provider in assisting the patient during his or her illness.