A 69-year-old man is evaluated for low back discomfort. He has a history of metastatic prostate cancer to the spine without evidence of spinal cord compression. He is ambulatory and functional in all activities of daily living. He recently received palliative radiation therapy to treat metastatic disease in L1 and L3. The patient takes at least two naproxen 250-mg tablets daily. The pain medication reduces, but does not eliminate, his back discomfort.
On physical examination, vital signs are normal as are results of neurologic and mental status examinations. There is no point tenderness over the lumbar vertebrae.
The most appropriate next therapeutic step is to add a short-acting opioid. The pain in patients with advanced malignancy often outpaces the ability of non-narcotic analgesics to control the pain. In patients with cancer who have mild to moderate pain such as this one, an effective strategy is moving to step 2 on the World Health Organization three-step pain relief ladder by prescribing an intermittent low-dose narcotic in addition to adjuvant, non-narcotic pain medicine. Appropriate choices include immediate-release formulations of oxycodone, morphine, or oxymorphone.
Initiating a long-acting narcotic such as a fentanyl transdermal patch or extended-release oxycodone would not be indicated until the patient's pain is adequately controlled with short-acting narcotics, which can be rapidly titrated to achieve adequate pain control. Once pain control is established, the cumulative dose of the short-acting opioid can be used to calculate an effective dose of a long-acting opioid, with the dose reduced by 30% to 50% and access to a short-acting opioid maintained for break-through pain. If the short-acting opioid is needed more than three times daily, the amount of long-acting opioid is increased.
Changing to a different NSAID is much less likely to control this patient's pain than is adding a short-acting opioid analgesic.
- For mild to moderate cancer-associated pain, a short-acting opioid is indicated when non-opioid drugs fail to adequately control pain.