Author: scott

Members in the News

Members in the News

 Dr. Newman“The American Academy of Pediatrics Section on Oral Health presents the 2016 Oral Health Service Award to C. Eve Jensen Kimball, MD, FAAP, for working to advance children’s oral health through education, medical/dental collaboration, and advocacy.” It was presented at the AAP National Conference & Exhibition Meeting in San Francisco, CA on 23 October 2016. This award is given to a member of the Section on Oral Health that has contributed significantly to the mission of the Section to improve children’s oral health and medical/dental collaboration.


 

Dr. Mele

It was recently announced that Dr. Aparna Mele is being honored by the Girl Scouts of Eastern Pennsylvania at their annual Take the Lead banquet being held on March 30, 2017. The honorees are positive role models for the girls of today, providing them with the courage, confidence and character necessary to make an impact on our community. Dr. Mele was selected for the impact the educational event she founded, “Guts and Glory,” has on our community. Anyone interested in attending the Take the Lead banquet, please call the BCMS office.

Penn State Health St. Joseph elevates Chris Newman, MD, to Chief Medical Officer Christopher Newman, MD, has been named the Chief Medical Officer of Penn State Health St. Joseph following the retirement of Gary Lattin, MD. In his role, Dr. Newman has primary accountability for clinical leadership and clinical quality and medical staff relations. He serves as the key administrative liaison to the employed and independent medical staffs. He also oversees physician governance and has a significant strategic responsibility for developing clinical integration strategies.

Dr. Newman joined Penn State Health St. Joseph as Associate Chief Medical Officer 18 months ago from Lehigh Valley Health Network’s Physician Group. Prior to joining Lehigh Valley, Dr. Newman was the President and a managing partner for Lehigh Area Medical Associates, a large, private internal medicine practice in Lehigh County.

Dr. Newman is a graduate of the University of Scranton, where he earned his bachelor’s degree in biology. He completed medical school at Georgetown University School of Medicine, Washington, DC, and his residency at Georgetown University Medical Center. In the spring of 2016, he received an MBA from the prestigious University of Virginia’s Darden School of Business.

Opioid Poorly-Responsive Cancer Pain

by Tamara Sacks, MD, David E Weissman, MD, and Robert Arnold, MD


Background

Relief of cancer pain from opioids is rarely all or nothing; most patients experience some degree of analgesia alongside opioid toxicities. When the balance of analgesia versus toxicity tips away from analgesia, the term ‘opioid poorly-responsive pain’ is invoked. While opioid poorly-responsive pain is not a discreet syndrome, it is a commonly encountered clinical scenario. This Fast Fact reviews key points in its assessment and management.

Differential Diagnosis of Opioid Poorly-Responsive Pain

  1. Cancer-related pain
    1. Cancer progression (new fracture at site of known bone metastases).
    2. Causes of pain (eg. neuropathic pain, skin ulceration, rectal tenesmus, muscle pain) that are known to be less responsive to systemic opioids or opioid monotherapy.
    3. Psychological/spiritual pain related to the cancer experience (existential pain of impending death).
    4. Opioid pharmacology/technical problems
    5. Opioid tolerance (rapid dose escalation with no analgesic effect).
    6. Dose-limiting opioid toxicity (sedation, delirium, hyperalgesia, nausea – see Fast Facts #25, 142).
    7. Poor oral absorption (for PO meds) or skin absorption (e.g. transdermal patch adhesive failure).
    8. Pump, needle, or catheter problems (IV, subcutaneous, or spinal opioids).
  2. Non-cancer pain
    1.  Worsening of a known non-cancer pain syndrome (diabetic neuropathy).
    2. New non-cancer pain syndrome (dental abscess).
    3. Other psychological problems
    4. Depression, anxiety, somatization, hypochondria, factitious disorders.
    5. Dementia and delirium both can affect a patient’s report of and experience of pain.
    6. Opioid substance use disorders or opioid diversion.

Management Strategy

  1. Initial Steps
    1. Complete a thorough pain assessment including questions exploring psychological and spiritual concerns. If substance abuse or diversion is suspected, complete a substance abuse history (see Fast Facts #68, 69).
    2. Complete a physical examination and order diagnostic studies as indicated.
    3. Escalate a single opioid until acceptable analgesia or unacceptable toxicity develop, or it is clear that additional analgesic benefit is not being derived from dose escalation. If this fails, consider:
      i. Rotating to a different opioid (e.g. morphine to methadone).
      ii. Changing the route of administration (e.g. oral to subcutaneous).
    4. Treat opioid toxicities aggressively.
    5. Use (start or up-titrate) adjuvant analgesics, especially for neuropathic pain syndromes.
    6. Integrate non-pharmacological treatments such as behavioral therapies, physical modalities like heat and cold, and music and other relaxation-based therapies – see Fast Fact #211.
  2. Additional steps – Pain refractory to the initial steps requires multi-disciplinary input and care coordination.
    1. Hospice/Palliative Medicine consultation to optimize pain assessment, drug management, and assessment of overall care goals.
    2. Mental health consultation for help in diagnosis and management of suspected psychological factors contributing to pain.
    3. Chaplain/Clergy assistance for suspected spiritual factors contributing to pain.
    4. Interventional Pain and/or Radiation Oncology consultation.
    5. Rehabilitation consultations (Physiatry, Physical and Occupational Therapy) to maximize physical analgesic modalities.
    6. Pharmacist assistance with drug/route information.

References

  1. Mercadante F, Portenoy RK. Opiate Poorly Responsive Cancer Pain Parts 1-3. J Pain Symptom Management. 2001; 21(2):144-150, 21(3):255-264, 24(4):338-354.
  2. Smith TJ, Staats PS, Deer T, 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):4040-9.
  3. Fallon M. When morphine does not work. Support Care Cancer. 2008; 16(7):771-5.
  4. Quigley C. Opioid switching to improve pain relief and drug tolerability. Cochrane Database of Systematic Reviews. 2004, Issue 3. Art. No.: CD004847. DOI: 10.1002/14651858.CD004847.
  5. Hanks GW. Opioid-responsive and opioid-non-responsive pain in cancer. Br Med Bull. 1991; 47(3):718-31.
  6. Hanks G, Forbes K. Opioid responsiveness. Acta Anaesthesiologica Scand.1997; 41:154-158.Author Affiliations: University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (TS, RA), and Medical College of Wisconsin, Milwaukee, Wisconsin (DEW).

    Version History: Originally published May 2009; copy-edited August 2015.

    Fast Facts and Concepts are edited by Sean Marks, MD (Medical College of Wisconsin) and associate editor Drew A Rosielle, MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made is available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact’s content. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts.

Copyright: All Fast Facts and Concepts are published under a Creative Commons Attribution-NonCommercial 4.0 International Copyright (http://creativecommons.org/licenses/by-nc/4.0/). Fast Facts can only be copied and distributed for non-commercial, educational purposes. If you adapt or distribute a Fast Fact, let us know!

Disclaimer: Fast Facts and Concepts provide educational information for health care professionals. This information is not medical advice. Fast Facts are not continually updated, and new safety information may emerge after a Fast Fact is published. Health care providers should always exercise their own independent clinical judgment and consult other relevant and up-to-date experts and resources. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Administering Naloxone

In this edition of HealthTalk.net, Kristen M. Sandel, MD, discusses opioid addition and the use of Naloxone. She provides some essential tips on administering and prescribing Naloxone. Click the read more link to watch this episode.