Opioid-Based Treatment Strategies for Persistent and Breakthrough Cancer Pain—A CME Resource Compendium for Physicians
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Jointly sponsored by Albert Einstein College of Medicine of Yeshiva University,
Montefiore Medical Center, and Asante Communications, LLC.
This is a knowledge-based continuing education activity of Purdue University,
an equal access/equal opportunity institution.
This continuing nursing education activity was approved by the
Oncology Nursing Society (ONS), an accredited approver by the
American Nurses Credentialing Center’s Commission on Accreditation (COA).
This activity is supported by an educational grant from ProStrakan, Inc.
The goal of this knowledge-based activity is to enhance diagnostic and clinical skills of healthcare professionals who treat patients with persistent and breakthrough cancer pain.
This activity is intended for oncologists, pain specialists, pharmacists, nurses, and other clinicians dedicated to the collaborative management of cancer pain.
There are no prerequisites for this educational activity.
At the conclusion of this educational activity, participants should be better prepared to:
- Comprehensively assess pain and associated functional impairment in patients with cancer
- Diagnose breakthrough pain and its subtypes across cancer patient populations
- Explain the respective roles of long-acting, short-acting, and rapid-onset opioids in the management of cancer pain
- Structure opioid therapy for cancer pain based on comprehensive and continual assessment of patient-specific risks associated with opioid pharmacology and the potential for inappropriate medication use
- Tailor opioid-based therapy for breakthrough cancer pain based on temporal profile of the episodes, predictability, relationship with the baseline opioid regimen, and evaluation of potential benefits and risks of treatment
Statement of Need and Learner’s Gap
Cancer pain is prevalent, often originating from the neoplasm or anticancer treatment, and frequently impairing multiple dimensions—physical, affective, and cognitive, among others.1-3 Despite a range of pharmacologic, nonpharmacologic, and interventional analgesic options, effective management is complicated by the intrinsically subjective nature of pain. Indeed, the cancer patient’s pain experience reflects nociceptive signaling filtered through genetic background, disease progression, activity levels, current psychological status, sociocultural influences, and existential concerns.4 These and other factors contribute to a dynamic condition in which pain levels and associated disability fluctuate over days, hours, and even minutes. At times, pain will rapidly spike despite otherwise effective around-the-clock treatment regimens. The result is transient, severe episodes of breakthrough pain that negatively affect patient mood, function, and/or quality of life.5 To optimize symptom control and maximize functional outcomes for patients with cancer, both persistent and breakthrough pain should be specifically assessed, differentially diagnosed, and treated.6 In the oncology setting, pain management frequently relies on opioid agonists, potentially in combination with nonopioid analgesics, behavioral therapies, and, in some cases, interventional approaches.7-9 Implementing and tailoring opioid-based treatment strategies require detailed evaluations of potential pain etiologies and patient-specific treatment goals and risks, a challenging proposition when combined with the myriad issues faced by oncologists and other healthcare providers who treat cancer patients.6,10,11 Therefore, educational programs are needed to disseminate evidence-based and practical approaches for assessing cancer-related persistent and breakthrough pain, prescribing opioids responsibly, tailoring therapy based on patient response, integrating palliative care, and coordinating multidisciplinary, collaborative care.
- Cohen MZ, Easley MK, Ellis C, et al. Cancer pain management and the JCAHO’s pain standards: an institutional challenge. J Pain Symptom Manage. 2003;25(6):519-527.
- Goudas LC, Bloch R, Gialeli-Goudas M, Lau J, Carr DB. The epidemiology of cancer pain. Cancer Invest. 2005;23(2):182-190.
- Svendsen KB, Andersen S, Arnason S, et al. Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms. Eur J Pain. 2005;9(2):195-206.
- Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133(4):581-624.
- Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain. 1999;81(1-2):129-134.
- Swarm R, Abernethy AP, Anghelescu DL, et al. Adult cancer pain. J Natl Compr Canc Netw. 2010;8(9):1046-1086.
- National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain. Fort Washington, PA: NCCN; 2010.
- Nalamachu S, Hassman D, Wallace MS, Dumble S, Derrick R, Howell J. Long-term effectiveness and tolerability of sublingual fentanyl orally disintegrating tablet for the treatment of breakthrough cancer pain. Curr Med Res Opin. 2011;27(3):519-530.
- Fine PG, Portenoy RK. A Clinical Guide to Opioid Analgesia. 2nd ed. New York, NY: Vendome Group, LLC; 2007.
- Starr TD, Rogak LJ, Passik SD. Substance abuse in cancer pain. Curr Pain Headache Rep. 2010;14(4):268-275.
- Breuer B, Fleishman SB, Cruciani RA, Portenoy RK. Medical oncologists’ attitudes and practice in cancer pain management: a national survey. J Clin Oncol. 2011 [Epub ahead of print].
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Albert Einstein College of Medicine and Montefiore Medical Center, and Asante Communications, LLC. Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Albert Einstein College of Medicine designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Credit for pharmacists is available here.
Credit for nurses is available here.
Method of Participation
There are no fees for participating in and receiving credit for this activity. Participants must read the learning objectives and enduring material, and answer the multiple-choice post-questionnaire. Please complete the evaluation form and provide your comments on the quality of the instructional process, the perception of enhanced professional effectiveness and commercial bias, and future educational needs. After completion of the posttest and evaluation form you will be prompted to print your certificate. Credit is available through February 28, 2013.
Conflict of Interest Statement
The Conflict of Interest Disclosure Policies of Albert Einstein College of Medicine, Purdue University College of Pharmacy, and Oncology Nursing Society (ONS) require that faculty participating in any CME/CPE/CE activities disclose to the audience any relationship(s) with a pharmaceutical product or device company. Faculty whose disclosed relationships prove to create a conflict of interest with regard to their contribution to the activity will not be permitted to participate.
Albert Einstein College of Medicine, Purdue University College of Pharmacy, and ONS also require that faculty participating in any CE activity or anyone in a position to influence content disclose to the audience when discussing any unlabeled or investigational use of any commercial product or device not yet approved for use in the United States.
This activity contains information about off-label, experimental, or investigational use of drugs or devices.
Faculty/Planning Committee members of this program have indicated the following disclosure information:
Sanjiv S. Agarwala, MD: Meda Pharmaceuticals Inc. (Consultant)
Keith D. Eaton, MD, PhD: Genentech, Inc. (Grant/Research); Novartis AG (Grant/Research); NovaRx (Grant/Research); OSI Pharmaceuticals, Inc. (Grant/Research); Pfizer Inc. (Grant/Research)
Paul Glare, MD: Has no relevant financial relationships to disclose.
Jeffrey A. Gudin, MD: Ortho-McNeil-Janssen Pharmaceuticals, Inc. (Speakers Bureau); Pfizer Inc. (Speakers Bureau); ProStrakan, Inc. (Speakers Bureau)
David M. Kaufman, MD: Has no relevant financial relationships to disclose.
Cynthia P. Koh-Knox, PharmD, RPh: Has no relevant financial relationships to disclose.
Keela Herr, PhD, RN, FAAN, AGSF: Has no relevant financial relationships to disclose.
Planning Committee Members
Jim Kappler, PhD, and Poshala Aluwihare, PhD, of Asante Communications helped draft the chapters and have no relevant financial relationships to disclose.
The staff of Albert Einstein College of Medicine and Montefiore Medical Center and the staff of Asante Communications, LLC, have no conflicts of interest with commercial interests related directly or indirectly to this educational activity.
The CCME staff at Albert Einstein College of Medicine has no disclosures to report other than the following:
Steven Jay Feld of Albert Einstein College of Medicine, or a member of his household, owns securities in Bioheart, Inc., Chelsea Therapeutics, Inc., and Pharmacopeia, Inc.
The opinions, ideas, recommendations and perspectives expressed in this program and accompanying materials are those of the faculty only and do not necessarily reflect the opinions, ideas, recommendations, or perspectives of their affiliated institutions, Albert Einstein College of Medicine and Montefiore Medical Center, Asante Communications, LLC, or the activity’s commercial supporter.
© 2012 Albert Einstein College of Medicine and Montefiore Medical Center, and Asante Communications, LLC. All rights reserved. No part of this syllabus may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embedded in articles or reviews.