Managing an Acute Pain Crisis in a Patient With Advanced Cancer Natalie Moryl, MD Memorial Sloan-Kettering Cancer Center

1. Managing an Acute Pain Crisis in a Patient With Advanced Cancer Natalie Moryl, MD Memorial Sloan-Kettering Cancer Center Steven Z. Pantilat, MD Education Guides Editor

2. Acute Pain Crisis “This is as much of a crisis as a code”

3. Mr X’s Story • 33-year-old man with a 4-year history of metastatic mucinous adenocarcinoma of the appendix • Completed several cycles of chemotherapy • Many episodes of small bowel obstruction due to peritoneal carcinomatosis with several percutaneous draining ostomies • Multiple admissions for nausea, vomiting, and abdominal pain

4. Definition of a Pain Crisis • A pain crisis • Is an event in which the patient reports severe, uncontrolled pain that is causing the patient, the family, or both severe distress • May be acute in onset or worsening gradually to an intolerable level • Requires immediate intervention

5. Pain Assessment During a Pain Crisis • Dr S (palliative care consultant): The first thing was to understand what happened. Why was he saying that his pain was worse than it had ever been before?...I explained to them [patient and family] that something potentially catastrophic had happened since the celiac plexus block, and it might be a perforation. He very well might be dying of that, and then there was the severe pain we had to deal with.

6. Memorial Pain Assessment Card

7. Opioid Dose Ratios • There is variability in dose ratios when switching oral morphine, oral hydromorphone, and transdermal fentanyl to oral methadone, depending on the prior opioid dosea

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