Dr. Josephine Sasu-Tenkoramaa collaboratively with Dr. Jeffrey Fudin
The World Health Organization’s (WHO) 3-Step Analgesic Ladder adopted in the 1980’s for cancer pain relief provides guidelines for initiating pain therapy. It essentially divides the pharmacological management of pain into three steps. The first step involves the use of non-opioid medications such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, and/or antidepressants and others. Step 2 uses medications often referred to as “mild opioids” for persistent or increasing pain. “Mild opioids” generally include combination products containing acetaminophen, ibuprofen, or aspirin combined with codeine, codeine-related products, or hydrocodone; essentially these are the schedule III opioids. If the pain persists or increases while on “mild opioids”, schedule II opioids are then considered in step-3. These generally include morphine, fentanyl, hydromorphone, oxycodone, oxymorphone, etc. During each step of the pain ladder management process, adjuvant medications can be added. Adjuvant medications are pharmacological agents with indications generally other than pain, but they have analgesic properties that make them suitable for the management of specific pain types.
Neuropathic pain is quite common in cancer patients, a pain type that often responds best to non-opioid adjuvant analgesic therapy. Two papers have just been published in succession with a focus on these adjuvant medications with neuropathy-relieving properties that increases their likelihood to be successful for this pain type.
The development of oral chemotherapy has provided an opportunity to avoid intravenous treatment in a cancer infusion center, however, a conundrum exists for cancer patients and those that provide medical management for their pain. The reason for this is the significant potential for drug interactions with some of the maintenance medications used to treat cancer.
Very little is known about significant drug interactions among oral cancer drugs and pain medications. Data is still lacking to fully elucidate the extent of these presumed interactions. Unfortunately most, if not all in-hospital and retail pharmacy computer systems are not programmed to identify and acknowledge these drug interactions. Presumably therefore, a significant majority of providers and pharmacists are not aware of these potential interactions. The second paper provides a detailed analysis of both known and potential drug interactions between concurrent use of certain oral chemotherapy agents and select pain medications.
We are happy to provide links to these recently published articles which appeared in Practical Pain Management (PPM) in April and May 2013. For now, these are linked to PDF’s. As soon as they appear on the PPM Website, we will link them directly there.
- Sasu-Tenkoramaa J, Fudin J. Neuropathy in the Cancer Patient: Causes and Cures. Practical Pain Management. 2013 April; 13(3):53-67.
- Sasu-Tenkoramaa J, Fudin J. Drug Interactions in Cancer Patients Requiring Concomitant Chemotherapy and Analgesics. Practical Pain Management. 2013 May; 13 (4):50-64. See PPM Website post HERE.
As always, comments are welcome.
Josephine Sasu-Tenkoramaa, PharmD. received her doctorate from Rutgers,The State University of New Jersey-New Brunswick. She is currently a PGY-1 Pharmacy Practice Resident at the Stratton Va Medical Center in Albany NY, and has accepted a PGY-2 Residency in Hematology/Oncology Pharmacy at the VA San Diego Healthcare System beginning July 1, 2013