What is the treatment for non-radiating back pain (due to malignancy) with a severity of moderate (7/10)?

From the Guidelines

Treatment of moderate non-radiating back pain (7/10) due to malignancy typically requires a multimodal approach, starting with around-the-clock scheduled opioid medications and adding non-opioid analgesics and adjuvant medications as needed. According to the NCCN clinical practice guidelines in oncology 1, the management of cancer pain is complex and often requires a combination of pharmacologic and nonpharmacologic therapies.

Pharmacologic Interventions

• Nonopioid analgesics such as acetaminophen 1000mg every 6 hours (maximum 4000mg daily) or NSAIDs like ibuprofen 400-600mg every 6 hours can be used as first-line treatment for mild to moderate pain 1.
• Opioid analgesics such as morphine 15-30mg every 4 hours or oxycodone 10-20mg every 4-6 hours can be added for moderate to severe pain, with breakthrough dosing available as needed 1.
• Adjuvant medications like gabapentinoids (gabapentin starting at 300mg daily and titrating up to 300mg three times daily) for neuropathic components, and steroids like dexamethasone 4-8mg daily for inflammation and to improve appetite can be added to the treatment regimen 1.

Nonpharmacologic Interventions

• Behavioral interventions, physical/occupational therapy, and complementary approaches like radiation therapy can be valuable additions to pharmacologic interventions 1.
• Interventional procedures such as nerve blocks or intrathecal pain pumps may be appropriate for refractory pain 1.
• Regular reassessment of pain control and side effects is essential, with dose adjustments as needed to balance pain relief with minimizing adverse effects 1.

Treatment Approach

A comprehensive approach targeting different pain mechanisms simultaneously is essential, as cancer pain often involves inflammatory, neuropathic, and nociceptive components. The treatment plan should be individualized based on the patient's specific needs and circumstances, with frequent reassessment and adjustments as needed to ensure optimal pain control and minimize adverse effects 1.

From the FDA Drug Label

The majority of patients are adequately maintained with fentanyl transdermal system administered every 72 hours Fentanyl transdermal system is indicated for management of persistent, moderate to severe chronic pain that: requires continuous, around-the-clock opioid administration for an extended period of time Patients who are considered opioid-tolerant are those who have been taking, for a week or longer, at least 60 mg of morphine daily, or at least 30 mg of oral oxycodone daily, or at least 8 mg oral hydromorphone daily, or an equianalgesic dose of another opioid TABLE E* RECOMMENDED INITIAL FENTANYL TRANSDERMAL SYSTEM DOSE BASED UPON DAILY ORAL MORPHINE DOSE Oral 24-hour Morphine (mg/day) Fentanyl Transdermal System Dose (mcg/hr) 60-134 25 135-224 50 225-314 75 315-404 100

For non-radiating back pain due to malignancy with a severity of moderate (7/10), the treatment with fentanyl transdermal system should be considered for patients who are opioid-tolerant.

• The initial dose of fentanyl transdermal system can be determined based on the patient's daily oral morphine dose using Table E.
• For example, if the patient is taking 60-134 mg/day of oral morphine, the recommended initial fentanyl transdermal system dose is 25 mcg/hr.
• The dose can be titrated every 3 days based on the patient's response to the medication.
• It is essential to monitor the patient closely for respiratory depression and other adverse effects.
• Short-acting analgesics may be used as needed for breakthrough pain until the patient is stabilized on the fentanyl transdermal system 2.

From the Research

Treatment for Non-Radiating Back Pain due to Malignancy

The treatment for non-radiating back pain due to malignancy with a severity of moderate (7/10) involves a combination of drug and non-drug measures 3.

• Drug Therapy: Strong opioids, such as oxycodone and morphine, are commonly used for cancer pain management 3, 4, 5, 6.
• Non-Drug Measures: Non-drug measures, such as invasive procedures, physical therapy, acupuncture, and psychotherapy, can also be effective in managing cancer pain 3.
• Pain Management: Cancer pain is divided into visceral, bone, or neuropathic pain and has characteristics of continuous or intermittent pain 3.
• Opioid Comparison: Studies have compared the effectiveness of different opioids, such as oxycodone and morphine, and found that they have similar levels of pain relief and adverse events 4, 5, 6.
• Individual Response: Individual responses to opioids can vary, and some patients may require changes in their treatment schedules over time 6.
• Adjuvant Analgesics: Adjuvant analgesics may be required in addition to opioids to manage cancer pain effectively 6.

It is essential to monitor the side effects of opioids and adjust the treatment plan accordingly 3. The management of cancer pain has improved due to rapid diagnosis and treatment, understanding of analgesics, and cooperation between patients, their families, and healthcare providers 3.