What is the best course of action for managing severe cancer pain with breakthrough pain at night despite taking Tylenol (acetaminophen), considering prescription of OxyContin (oxycodone)?

Management of Severe Cancer Pain with Breakthrough Pain at Night

For severe cancer pain with breakthrough pain at night despite acetaminophen (Tylenol) use, a strong opioid such as immediate-release oxycodone should be prescribed for breakthrough pain episodes, while also implementing a scheduled long-acting opioid regimen for background pain control. 1

Assessment and Initial Management

• Breakthrough pain in cancer patients is defined as transient exacerbation of pain occurring despite otherwise stable, persistent background pain
• Acetaminophen alone is insufficient for severe cancer pain management
• Strong opioids are recommended for severe chronic cancer pain 1

Recommended Treatment Plan

Background Pain Control

1. Initiate regular scheduled opioid therapy:
   • Start with oral oxycodone 5-15 mg every 4-6 hours as needed, then convert to around-the-clock dosing 2
   • For severe chronic cancer pain, administer on a regularly scheduled basis to prevent pain recurrence 1
   • Titrate dose based on individual response to achieve adequate analgesia while minimizing side effects

Breakthrough Pain Management

1. Add immediate-release oxycodone for breakthrough pain:
   • Typically dosed at approximately 1/6 of the total daily opioid requirement 1
   • Can be administered up to hourly if needed for breakthrough episodes
   • Monitor effectiveness and adjust dosage as needed

Specific Prescription Information

For Walgreens at 108 Cottage Grove Road, Madison:

• Immediate-release oxycodone 5-15 mg tablets
• Instructions: Take 1 tablet by mouth every 4-6 hours as needed for breakthrough pain
• Quantity: 30-60 tablets (adjust based on expected frequency of breakthrough episodes)
• Include appropriate DEA information and patient identification

Important Considerations

Renal Function

• If patient has renal impairment (eGFR <30 ml/min), consider fentanyl or buprenorphine instead of oxycodone 3
• In patients with normal renal function, oxycodone is an appropriate choice 1

Side Effect Management

• Constipation: Prescribe a prophylactic bowel regimen with stimulant laxatives 1
• Nausea/vomiting: Consider metoclopramide or antiemetics as needed 1
• Sedation: Monitor closely, especially during the first 24-72 hours of therapy 2

Titration Process

1. Use immediate-release formulation to determine effective daily dose
2. Calculate total 24-hour opioid requirement after pain control is achieved
3. Consider conversion to extended-release formulation for background pain once stabilized
4. Continue immediate-release formulation for breakthrough episodes

Follow-up Plan

• Reassess pain control within 1 week
• Evaluate for side effects and adjust medication regimen as needed
• Consider adding adjuvant medications (antidepressants, anticonvulsants) if pain has neuropathic features 1

Caution

• Do not abruptly discontinue opioid therapy once started
• Educate patient about safe storage and proper use
• Monitor for signs of respiratory depression, especially during initial titration

Remember that breakthrough pain in cancer patients significantly impacts quality of life and requires prompt, effective management with appropriate opioid therapy.