Essential Links — Pain Managment Resources
Although there are several Web sites related to pain management, the following were chosen for their broad approach and user-friendly style.
National Guideline Clearinghouse
The National Guideline Clearinghouse (NGC) makes evidence-based clinical practice guidelines and related abstracts, summary, and comparison materials widely available.
NGC is operated by the Agency for Healthcare Research and Quality (AHRQ), a branch of the Department of Health and Human Services in partnership with the American Medical Association and the American Association of Health Plans. The NGC database contains evidence-based clinical practice guidelines as defined by the Institute of Medicine:
“Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” ( IOM, 1990 ; p. 38).
Searches can be conducted for guidelines by Disease/Condition, Treatment/Intervention, Organization, or Key Word(s), and results may be viewed by Brief Summary or Complete Summary. For example, users can go to the “Acute pain management” Web page at the University of Iowa Gerontological Nursing Interventions Research Center or to the “Chronic pain management in the long-term care setting” Web page at the American Medical Directors Association—to find pain management guidelines.
Agency for Healthcare Research and Quality
http://www.ahrq.gov/clinic/cpgonline.htm
Includes guides for acute pain/post-operative pain (either adult or pediatric) and a descriptive overview of pharmacologic and nonpharmacologic interventions with treatment guidelines, as well as tables that include samples of assessment tools and interventions for cancer pain management. These documents are for nursing and medical professionals, are clearing written, and include thorough citations.
University of Texas M. D. Anderson Cancer Center
http://prg.mdanderson.org/symptom_assmt.htm or search at http://www.mdanderson.org/search
Visitors at this site can review the Brief Pain Inventory (BPI), the Brief Fatigue Inventory (BFI), and the M. D. Anderson Symptom Inventory, including current validity for the instruments among various ethnic/clinical groups and in multiple languages. PDF copies of the BPI or BFI are available as free down-loads; free copies of the Symptom Inventory can be ordered.
WebMD Health is a national newscenter on the Web, with a content focus on health. The search engine’s results of the key word “pain management” includes many full-text links to online copies of resources such as the NIH “Quick Reference Guide” on Pain Management in Cancer Therapy (coauthored by Ada Jacox, RN) and the recent article, “Describing Pain,” by Haylock & Curtiss (both RNs).
National Foundation for the Treatment of Pain
This site provides five main sections: Perspectives in Intractable Pain Management, Essential Considerations in the Treatment of Intractable Pain, Pain Treatment Advocacy, Correspondence and Outreach, and News on Pain Issues. Links with various sites specific to different types of pain, including migraine headaches, are available.
http://www.mayohealth.org/mayo/9606/htm/painmgmt.htm
The Mayo Clinic site provides a good generic, nonprofessional overview of pain management, as well the option to condut searches.
A Stepwise Guide to Cancer: Pain Management in the Home
Louise Plaisance, RN, C, DNS, and Theresa F. Price, MSN, RN, OCN Cancer pain has multiple causes, and the most frequent and most feared symptom reported by patients with advanced cancer is pain (Donnelly & Walsh, 1995; Foley, 1985). Homebound patients and caregivers cite pain management as a major home care need (Hileman & Lackey, 1990).
Pain is caused by the malignancy itself, by treatment for
cancer, or by preexisting conditions. Pain from the malignancy may be related
to bone metastasis, nerve compression, infiltration or occlusion of blood vessels,
bowel obstruction, lymphedema, increased intracranial pressure, soft tissue
infiltration and necrosis, myopathy, or muscle spasm. Treatment-related pain
may result from the residual effects of surgery, chemotherapy, biotherapy, or
radiation. Cancer pain also can be associated with other conditions such as
constipation, immobility, infection, or concomitant illnesses. Finally, pain
may stem from preexisting conditions such as arthritis or sciatica (Curtiss,
1995).
Cancer Pain Assessment
Assessment of cancer pain is necessary to determine appropriate treatment.
Because pain is a subjective experience, the client�s complaint of pain intensity
should be documented as whatever the client reports (McCaffery & Beebe, 1989).
Assessment of chronic pain is different from evaluation of acute pain. Patients
with chronic pain may not exhibit the physiologic signs of pain.
The
initial assessment of pain should include a detailed physical and psychosocial
examination unless the patient is in severe pain (Agency for Health Care Policy
and Research [AHCPR], 1994).
Components of the physical examination include the site, onset, duration, and
intensity of pain, as well as the referral (radiating) patterns, and factors
that aggravate or relieve the pain. There are many pain assessment tools in
the literature designed to help clinicians assess various aspects of cancer
pain.
The psychosocial assessment should determine the following:
During the psychosocial assessment, the home health nurse should elicit information
about the patient�s knowledge, preferences, and expectations of pain management.
The patient should be assessed for mood changes such as depression and anxiety
that are commonly associated with chronic pain (AHCPR, 1994). Finally, the cost
of the pain management regimen should be ascertained to determine the most successful
and cost-effective method for the patient. Once the presence of cancer pain
has been ascertained and quantified, timely ongoing intervention is imperative.
Assessment of cancer pain must be a regular, systematic part of each home visit.
Pain management interventions and changes in this part of the care plan should
respect the wishes of the patient and family as much as possible. Several major
considerations for ongoing successful cancer pain management according to the
AHCPR (1994) guidelines are summarized in Table 1.
|
Table
1
Agency for Health Care Policy and Research (AHCPR): Pain Assessment and Management Tips |
|
A. Ask about
pain regularly. Assess pain systematically. B. Believe the client and family in their reports of pain and what relieves it. C. Choose pain control options appropriate for the client, family, and setting. D. Deliver interventions in a timely, logical, and coordinated fashion. E. Empower patients and their families. Enable them to control their course to the greatest extent possible. |
| Adapted from Jacox A., Carr, D. B., Payne, R., et al. (1994). Management of Cancer Pain: Clinical Practice Guideline No. 9. (AHCPR Pub. No. 94-D0592). Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service. p. 24. |
Approach to Pain Management
There are several approaches to pain management. The World Health Organization
(WHO) has developed one approach to the management of chronic malignant pain.
It consists of a three-step analgesic hierarchy, or ladder, to guide pain management
(Figure 1).
In advocating an individualized approach to pain
management, WHO emphasizes five essential components within the three-step ladder.
The components �are by the mouth, by the clock, by the ladder, for the individual
and with attention to detail� (AHCPR, 1994, p. 41). That is, the WHO approach
advocates individualized administration of appropriate oral analgesics given
around the clock (ATC) instead of �as needed� (PRN) whenever possible to avoid
peaks and valleys of pain management. The World Health Organization also advocates
paying attention to details that may exacerbate pain.
The first step in the WHO ladder is the use of nonopioid
analgesics such as acetaminophen (Tylenol) or nonsteriodal anti-inflammatory
drugs (NSAIDs). Some examples of NSAIDs are aspirin and other salicylates, ibuprofen
(Motrin), indomethacin (Indocin), ketoprofen (Orudis), and naproxen sodium (Anaprox).
With the exception of acetaminophen, most of the nonopioid analgesics exert
a systemic anti-inflammatory and antiplatelet effect. All the nonsteroidal analgesics
are antipyretic. Unlike opioids, they do not produce physical or psychological
dependence or tolerance.
Unfortunately, these analgesics have
a ceiling effect, which means that giving a larger dosage of a nonopioid does
not produce greater analgesia. Instead, larger dosages are likely only to cause
gastrointestinal or hematologic side effects (American Pain Society [APS], 1996).
The therapeutic effect of NSAIDs results from blocking the formation of eicosanoids
such as prostaglandins. Eicosanoids are phospholipids found in almost every
tissue and body fluid. Typically, NSAIDs inhibit the enzyme cyclo-oxygenase,
thereby stopping the synthesis of certain prostaglandins (Campbell & Halushka,
1996). Prostaglandins and other substances that cause inflammation are produced
in response to malignant tumors or tissue injury (Lewis, 1996).
Consequently,
the salicylates and NSAIDs effectively interrupt pain transmission in the peripheral
nervous system. These nonopioid analgesics, with or without adjuvant medications,
are indicated for mild to moderate pain.
The adjuvant medications are used to potentiate analgesia
or to reduce the side effects of analgesia. They can be used in conjunction
with analgesia at any step of the WHO ladder. Some examples of adjuvant medications
are tricyclic antidepressants, antihistamines, benzodiazepines, caffeine, dextroamphetamine,
steroids, and anticonvulsants (APS, 1996) (Table 2).
|
Table
2
Adjuvant Analgesic Drugs for Cancer Pain |
|||
| Drug | Approximate Adult Daily Dose Range | Route of Administration 1 | Type of Pain |
| Corticosteriods | |||
| Dexamethasone2 | 16�96 mg | PO, IV | Pain associated with brain metastases and epidural spinal cord compression |
| Prednisone | 40�100 mg | PO | |
| Anticonvulsants | |||
| Carbamazepine3 | 200�1,600 mg | PO | Neuropathic pain |
| Phenytoin4 | 300�500 mg | PO | |
| Antidepressants | |||
| Amitriptyline5 | 25�150 mg | PO | Neuropathic pain |
| Doxepin6 | 25�150 mg | PO | |
| Imipraine7 | 20�100 mg | PO | |
| Trazodone8 | 75�225 mg | PO | |
| Neuroleptics | |||
| Methotrimeprazine9 | 40�80 mg | IM | Analgesia, sedation, antiemetic |
| Antihistamines | |||
| Hydroxyzine10 | 300�450 mg | IM | Adjuvant to opioids in postoperative and other types of pain; relief of complicating symptoms including anxiety, insomnia, nausea |
| Local Anesthestics/ Antiarrythmics | |||
| Lidocaine11 | 5 mg/kg | IV/SC | Neuropathic pain |
| Mexiletine12 | 450�600 mg | PO | |
| Tocainide13 | 20 mg/kg | PO | |
| Psychostimulants | |||
| Dextroamphetamine14 | 5�10 mg | PO | Improve opioid analgesia, decrease sedation |
| Methylphenidate15 | 10�15 mg | PO | |
|
|||
| Adapted from Jacox A., Carr, D. B., Payne, R., et al. (1994). Management of Cancer Plan. Clinical Practice Guideline No. 9 (AHCPR Pub. No. 94�0592). Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, pp. March, 1994. | |||
If pain persists or escalates while the patient is on nonopioid
and adjuvant therapy, the second step in the WHO ladder should be implemented,
which recommends giving a mild opioid. Adjuvant medications also may be needed
to control troubling symptoms such as nausea or dry mouth, or to potentiate
analgesics (APS, 1996). Examples of mild opioids are hydrocodone hydrochloride
(Vicodin and Lortab), oxycodone (Tylox) and controlled-release oxycodone (Oxycontin),
propoxyphene napsylate (Darvocet N-100), and codeine. Nonopioid analgesia such
as aspirin or acetaminophen is combined with many of the milder opioid preparations
to potentiate analgesia.
Although these preparations may be effective in controlling moderate pain,
a major drawback is the maximum ceiling limit of the dosage. When the dosage
of a mild opioid must be increased to relieve escalating pain, the maximum amount
that can be prescribed is limited by two conditions. First, dosage increases
are restricted by the amount of nonopioid additives combined with the mild opioids
in preparations such as Tylox or Lortab (hydrocodone hydrochloride). A larger
dosage of these preparations may cause toxicity due to an excessive dosage of
aspirin or acetaminophen (AHCPR, 1994).
Second, beyond a
certain point, giving a greater amount of mild opioids does not produce greater
pain relief, but only increases side effects. For instance, an oral dosage of
codeine larger than 65 mg instead of producing greater analgesia, drug-induced
constipation only worsens (Lipman, 1989; McCaffery & Beebe, 1989). Therefore,
when a larger dosage of an opioid is needed to achieve pain relief, the next
step in the WHO ladder should be implemented (AHCPR, 1994).
The third step of the WHO ladder recommends managing moderate to severe pain
with strong opioid analgesia.
Strong opioids should be administered
ATC rather than PRN. Only one of the opioids on this rung of the WHO ladder
should be used at a time for the patient�s primary routine analgesia (Ashburn
& Lipman, 1993).
|
Table
3
Dose Equivalents for Opioid Analgesics in Opioid�Naive Adults and Children Weighing 50 kg or More |
||||
| Drug | Approximate Equianalgesic Dosage | Usual Starting Dose for Moderate to Severe Pain | ||
| Oral | Parenteral | Oral | Parenteral | |
| Opioid Agonist | ||||
| Morphine |
30
mg q 3�4 h (repeat around- the-clock dosing) 60 mg q 3�4 h (Single dose or intermittent dosing) |
10 mg q 3�4 h | 30 mg q 3�4 h | 10 mg q 3�4 h |
| Morphine, controlled-release (MS Contin, Oramorph) | 90�120 mg q 12 h | N/A | 90�120 mg q 12 h | N/A |
| Hydromophone (Dilaudid) | 7.5 mg q 3�4 h | 1.5 mg q 3�4 h | 6 mg q 3�4 h | 1.5 mg q 3�4 h |
| Levorphanol (Lovo�Dromoran) | 4 mg q 6�8 h | 2 mg q 6�8 h | 4 mg q 6�8 h | 2 mg q 6�8 h |
| Meperidine (Demerol) | 300 mg q 2�3 h | 100 mg q 3 h | N/R | 100 mg q 3 h |
| Methadone (Dolophine, other) | 20 mg q 6�8 h | 10 mg q 6�8 h | 20 mg q 6�8 h | 10 mg q 6�8 h |
| Oxymorphone (Numorphan) | N/A | 1 mg q 3�4 h | N/A | 1 mg q 3�4 h |
| Combination opioid/NSAID preparations | ||||
| Codeine (with aspirin or acetaminophen) | 180�200 mg q 3�4 h | 130 mg q 3�4 h | 60 mg q 3�4 h | 60 mg q 2 h (IM/SC) |
| Hydrocodone (in Lorcet, Lortab, Vicodin, others) | 30 mg q 3�4 h | N/A | 10 mg q 3�4 h | N/A |
| Oxycodone (Roxicodone, also in Percocet, Percodan Tylox, others) | 30 mg q 3�4 h | N/A | 10 mg q 3�4 h | N/A |
| Adapted from Jacox, A., Carr, D. B., Payne, R., et al. (1994). Management of Cancer Plan. Clinical Practice Guideline No. 9 (AHCPR Pub. No. 94�0592). Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, p. 52. | ||||
Examples of these more potent analgesics are morphine and controlled-release
morphine (MS Contin), hydromorphone (Dilaudid), methadone, fentanyl (Duragesic
Transdermal System), levorphanol, and heroin (Table 3).
Morphine
often is the drug of choice for severe cancer pain on this rung of the analgesic
ladder (Table 4). Heroin is not commercially available in this country, although
it is used commonly for cancer pain control in Great Britain.
Meperdine (Demerol) is not indicated for cancer pain management, but primarily
for short-term control of severe postoperative pain. Meperidine is a poor choice
for chronic cancer pain because it breaks down into a toxic metabolite, normeperidine,
that can cause excitability of the central nervous system. Symptoms of normeperidine
toxicity include tremors, multifocal myoclonus, and occasional seizures (Watt-Watson
& Donovan, 1992).
Likewise, the mixed agonist�antagonist opioids and the partial agonist opioids
also are poor choices for cancer pain control. These drugs have a dosage ceiling
limit, and they also can precipitate acute withdrawal in patients who are physically
dependent on opioid agonists (Cherny & Portenoy, 1994). Most of the opioids
in this class are available only in parenteral form. Examples of agonist�antagonist
opioids include butorphanol tartrate (Stadol), buprenorphine hydrochloride (Buprenex),
and pentazocine hydrochloride (Talwin).
The opioids relieve pain by acting on several sites in the central nervous system rather than on the peripheral nervous system as do the NSAIDs. Instead, opioids alter the release of neurotransmitters such as substance P, serotonin, norepinephrine, and the enkephalins. Consequently, the transmission of pain impulses is interrupted at several sites in the central nervous system, resulting in an altered perception of and response to pain.
Adjusting or Titrating Analgesia
Unfortunately, the severity of cancer pain fluctuates. Thus, PRN in addition
to ATC analgesia may sometimes be needed. Although cancer pain can generally
be controlled with regular administration of opioids, an additional rescue dosage
for breakthrough pain of either immediate-release morphine or a mild opioid
analgesic should be available (AHCPR, 1994). Breakthrough pain episodes are
'intermittent exacerbations of pain that can occur spontaneously or in relation
to specific activity' (AHCPR, 1994, p. 185). Typically, the rescue dosage should
be sufficient to relieve pain without causing undesirable side effects-usually
25% of the daily baseline analgesia dosage (Cherny & Portenoy, 1994). If pain
is worsening and the patient requires repeated rescue dosages, then the routine
dosage of analgesia should be increased.
|
Table
4
Advantages of Morphine Analgesia |
|||||
|---|---|---|---|---|---|
| Available in many dosage concentrations | |||||
| Available in many forms | |||||
|
|||||
Available in a variety
of time-release preparations
|
|
No ceiling limit on
the dose (i.e., increasingly larger doses can be given with no limit on
the maximum dose) unless side effects are problematic
|
Ease in titration to
increase or decrease the dose
|
Inexpensive
|
Gold standard to which
other analgesics are compared
|
|
When the analgesic dosage is increased, the total daily amount of the routine and rescue analgesia for breakthrough pain received by the patient should be calculated. For example, if the patient has been receiving 60 mg of oral time-release morphine every 12 hours, then the daily baseline analgesic dosage is 120 mg. However, if the patient has required an additional 15 mg of immediate-release oral morphine solution about four times a day to control breakthrough pain, then the actual dosage of morphine is about 180 mg/day or 120 mg + 15 mg + 15 mg + 15 mg + 15 mg. Consequently, the routine analgesic dosage would need to be increased to 180 mg/day, with additional analgesia available as a rescue dosage for exacerbation of pain.
When a patient's analgesia is titrated (adjusted), equianalgesic tables are helpful because they compare the oral, parenteral, and dermal dosage equivalent of one analgesic to another (see Tables 3 and 5).
Equianalgesic Tables
There are numerous equianalgesic tables in the pain management literature, and the reader is encouraged to seek the appropriate table for managing patients' pain. Many of these tables compare the various analgesics to a 10-mg intramuscular (IM) dosage of morphine, which is considered the standard dosage for comparisons of analgesic effectiveness (APS, 1996). A table also is available to help the clinician convert a dosage of morphine to a time-release premeasured dermal patch containing fetanyl (Duragesic transdermal; see Table 5), although Duragesic is somewhat more difficult to titrate than morphine.
Equianalgesic tables can be used for several purposes. For
example, if the patient has achieved adequate pain control from an opioid but
has undesirable side effects, then the medication should be switched. To substitute
an adequate dosage in the switch from one opioid to another, an equianalgesic
chart should be consulted.
Typically, for a patient with good pain control but undesirable
side effects, the dosage of the new opioid should be titrated downward (decreased)
to between 50% and 75% of the new equianalgesic dosage. For patients with poor
pain control and mild undesirable side effects, the starting dosage of the new
opioid generally should be 75% to 100% of the new equianalgesic dosage (Cherny
& Portenoy, 1994). In this instance, if the patient receives 60 mg of codeine
orally, but needs to be switched, an equivalent dosage of hydrocodone is 10
mg orally, according to Table 3. Initially, the dosage of hydrocodone could
be halved to 5 mg and titrated upward (increased)
Equianalgesic tables also can facilitate a change from a mild
to a strong opioid. For example, if a patient is taking 30 mg of hydrocodone
without adequate relief, then an equianalgesic chart should be consulted for
an equivalent dosage of a strong opioid. Typically, when switching from a mild
to a strong opioid, the equivalent dosage is halved, then titrated upward (increased)
until pain relief is achieved.
Likewise, when analgesia must be increased, it should be titrated
upward by 30% to 50% (Cherny & Portenoy, 1994; Ashburn & Lipman, 1993). Although
this may sound like a large increase, it should be considered that morphine
12 mg IM may provide substantially more pain relief than morphine 8 mg IM, and
that this is a 50% increase in dosage.
General Considerations
It is important to educate patients and families about the
differences between dependence, tolerance, and addiction, especially if the
patient appears reluctant to take opioid analgesia. Physical dependence is a
physiologic property that is noted when opioids are abruptly discontinued (Fulton
& Johnson, 1993). Abrupt cessation in the opioid-tolerant patient will result
in abstinence (withdrawal) syndrome. Consequently, opioid analgesia should be
tapered gradually if a lesser dosage is sufficient for pain control. Tolerance,
a common physiologic condition, occurs when a larger dosage of opioid is needed
to maintain the same level of analgesia (AHCPR, 1994). Addiction, however, is
a psychological dependence on a drug. It is characterized by drug-craving and
drug-seeking behaviors. Addiction rarely occurs in patients taking opioids for
cancer pain (Cherny & Portenoy, 1994; Fulton & Johnson, 1993), and the home
health nurse should allay this concern when the patient appears to be reluctant
to take analgesia as prescribed.
Anaprox (naproxen sodium), Roche Laboratories, Hoffman-LaRoche,
Inc., 340 Kingsland Street, Nutley, NJ 07110-1199
Buprenex (buprenorphine hydrochloride), Reckitt & Colman
Pharmaceuticals Inc., Richmond, VA 23235
Darvocet N-100 (propoxyphene napsylate and acetaminophen),
Lilly Corporation, Lilly Corporate Center, Indianapolis, IN 46285
Demerol and Talwin (meperidine and pentazocine
hydrochloride), Sanofi Winthrop Pharmaceuticals, 90 Park Avenue, NY, NY 10016
Dilaudid (hydromorphone), Knoll Laboratories, a division
of Knoll Pharmaceutical Company, 3000 Continental Drive North, Mt. Olive, NJ
07828
Duragesic (fentanyl citrate transdermal), Janssen Pharmaceutical
Inc., 1125 Trenton-Harbourton Road, P.O. Box 200, Titusville, NJ 08560-0200
Indocin (indomethacin), Merck & Company, P.O. Box 4,
West Point, PA 19486-0004
Lortab (hydrocodone/acetaminophen), UBC Pharmaceutical
Inc., 1950 Lake Park Drive, Atlanta, GA 31139
Motrin (ibuprofen), The Upjohn Company, 7000 Portage
Road, Kalamazoo, MI 49001
MS Contin and
Oxycontin
(controlled-release
morphine sulfate and controlled-release oxycodone hydrochloride), Purdue Pharma
L.P., 100 Connecticut Avenue, Norwalk, CT 06850-3590
Orudis (ketoprofen), Wyeth-Ayerst Laboratories, Division
of American Home Products Corporation, P.O. Box 8299, Philadelphia, PA 19101
Stadol (butorphanol tartrate), Bristol-Myers Squibb,
P.O. Box 4500, Princeton, NJ 08543-4500
Tylox and Tylenol (oxycodone hydrochloride and
acetaminophen), McNeil Consumer Products Division, Division of McNeil-PPC Inc.,
Camp Hill Road, Ft. Washington, PA 19034
Vicodin (hydrocodone and acetominophen), Knoll Laboratories,
a division of Knoll Pharmaceutical Company, 3000 Continental Drive North, Mt.
Olive, NJ 07828
REFERENCES
Amenta, M. O. (1985). Hospice in the United States: Multiple
and varied programs. In B. C. Martocchio & K. Dufault (Eds.), The nursing
clinics of North America: Symposia on hospice compassionate care and the dying
experience (pp. 269-280). Philadelphia: W.B. Saunders.
American Pain Society. (1996). Principles of analgesic use
in acute pain and chronic cancer pain (3rd ed.). Glenview, IL: Author.
Ashburn, M. A. & Lipman, A. (1993). Management of pain in the
cancer patient. Anesthesia & Analgesia, 76 (2), 402-416.
Campbell, W. B., & Halushka, P. V. (1996). Lipid-derived autocoids:
Eicosanoids and platelet-activating factor. In P. B. Molinoff, R. W. Ruddon,
A. G. Gilman (Eds.), Goodman and Gilman's: The pharmacological basis of therapeutics
(9th ed., pp. 601-616). New York: McGraw-Hill.
Cherny, N., & Portenoy, R. K. (1994). The pain management of
cancer pain. CA: A Cancer Journal for Clinicians, 44 (5), 262-303.
Curtiss, C. P. (1995). Barriers to adequate pain management.
Paper presented at the oncology nursing society workshop on cancer pain, New
Orleans, LA.
Donnelly, S., & Walsh, D. (1995). The symptoms of advanced
cancer. Seminars in Oncology, 22 (2, Supp 3), 67-72.
Foley, K. M. (1985). The treatment of pain in the patient with
cancer. New England Journal or Medicine, 313, 84-95.
Fulton, J. S., & Johnson, G. B. (1993). Using high dose morphine
to relieve cancer pain. Nursing, 23 (2), 34-40.
Hileman, J. W., & Lackey, N. R. (1990). Self-identified needs
of patients with cancer at home and their home caregivers: A descriptive study.
Oncology Nursing Forum, 17 (6), 907-913.
Jacox, A., Carr, D. B., Payne R., et al. (1994). Management
of cancer pain: Clinical Practice Guideline No. 9 (AHCPR Pub. No. 94-0592).
Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of
Health and Human Services, Public Health Service.
Lewis, S. L. (1996). Nursing role management: Cell injury and
inflammation. In S. Lewis, I. Collier, & M. Heitkemper (Eds.), Medical surgical
nursing: Assessment and management of clinical problems (4th ed., pp. 181-206).
St. Louis: Mosby-Year Book.
Lipman, A. (1989). Opioid analgesics in the management of cancer
pain. American Journal of Hospice Care, 10 (6), 13-22.
McCaffery, M., & Beebe, A. (1989). Pain: Clinical manual
for nursing practice. St. Louis: Mosby.
Miakowski, C. (1993). Current concepts in the assessment and
management of cancer-related pain. MEDSURG Nursing, 2 (2), 113-118.
Watt-Watson, J. H., & Donovan, M. I. (1992). Pain management:
Nursing perspective. St. Louis: Mosby-Year Book.
Williams, C. L. (1991). Enhancing the quality of life in
the terminally ill: A manual on pain and symptom control. Hammond, LA: Author.
Louise
Plaisance, RN, C, DNS, is Associate Professor, Our Lady of the Lake College,
Baton Rouge, Louisiana, and Theresa F. Price, RN, MSN, OCN is Instructor, College
of Nursing, University of Southwestern Louisiana, Lafayette, Louisiana.
Duragesic Dose Prescription Based Upon
Daily Morphine Equivalence Dosage
Oral 24-Hour
Morphine
(mg/day)
IM 24-Hour
Morphine
(mg/day)
Duragesic
Dosage
(mg/h)
45�134
8�22
25
135�224
23�37
50
225�314
38�52
75
135�404
53�67
100
405�494
68�82
125
495�584
83�97
150
585�674
98�112
175
675�764
113�127
200
765�854
128�142
225
855�944
143�157
250
945�1034
158�172
275
1035�1124
173�187
300
Table
6
General Guidelines for Cancer Pain
Management in the Home Setting
Adapted from Amenta,
1985; the American Pain Society, 1996; Miakowski, 1993; Williams, 1991.