Indian Journal of Pain

CASE REPORT
Year
: 2017  |  Volume : 31  |  Issue : 1  |  Page : 65--67

Safe perioperative opioid taper in cancer patients needs meticulous multimodal management


Anjum Khan Joad, Manisha Hemrajani, Pratima Agarwal, Shikha Jain, Vinita Jain 
 Department of Anaesthesiology and Palliative Care, Bhagwan Mahaveer Cancer Hospital, Jaipur, Rajasthan, India

Correspondence Address:
Manisha Hemrajani
Department of Anaesthesia and Palliative Care, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan
India

Abstract

Opioid therapy plays a vital role in chronic pain management of advanced cancer patients. Some patients require discontinuation of opioids when an intervention appropriately controls the pain. Safe discontinuation of opioids poses a challenge among lack of evidence-based standardized taper protocol. We report a patient with a soft tissue sarcoma in whom opioid was tapered in the background of acute postoperative pain.



How to cite this article:
Joad AK, Hemrajani M, Agarwal P, Jain S, Jain V. Safe perioperative opioid taper in cancer patients needs meticulous multimodal management.Indian J Pain 2017;31:65-67


How to cite this URL:
Joad AK, Hemrajani M, Agarwal P, Jain S, Jain V. Safe perioperative opioid taper in cancer patients needs meticulous multimodal management. Indian J Pain [serial online] 2017 [cited 2019 Nov 18 ];31:65-67
Available from: http://www.indianjpain.org/text.asp?2017/31/1/65/205714


Full Text



 Introduction



It is a common practice to prescribe high doses of opioids in advanced cancer patients to achieve adequate pain relief. Occasionally, neurolysis or aggressive surgical intervention with palliative intent can abruptly eliminate the need for high-dose opioid therapy. Safe discontinuation of opioids in such cases needs meticulous planning. The aim is to control pain while avoiding overdose and withdrawal symptoms.

There is a considerable variation in the opioid tapering protocols followed worldwide, and no single regimen has been proven to be superior to the others. However, the universal goal is well defined: Individual titration of the rate of weaning according to the patient's response. Previous reporting of cases in literature have been on opioid taper in chronic noncancer pain related to drug abuse or intolerable side effects. Here, we discuss successful and safe opioid tapering in a patient with advanced malignancy after surgery complicated by the presence of acute postoperative pain as well as phantom pain.

 Case Report



A 37-year-old male patient presented to our hospital with a recurrent soft tissue sarcoma of the right axilla. The patient was advised the right forequarter amputation. However, he declined surgery despite repeated counseling sessions. As a result, morphine was started at an initial dose of 10 mg every 4 h by the palliative care physician. Gabapentin (300 mg/day), carbamazepine (300 mg/day) and amitriptyline (10 mg HS) were also added to address the neuropathic component of pain. Over the next 11 months, the patient was comfortable on the combination of morphine, paracetamol, gabapentin, amitriptyline, and ibuprofen. The analgesic requirement gradually increased with progressing disease necessitating escalation of morphine dose to 60 mg every 4 h, paracetamol 2 gm/day, gabapentin 900 mg/day, ibuprofen 1200 mg/day and amitriptyline 75 mg. The disease gradually led to paralysis of the right upper limb and finally, the patient consented to and underwent a right forequarter amputation.

The source of severe chronic pain was removed abruptly but with the expected acute postoperative pain, the postoperative morphine dose requirement was unpredictable. Intraoperatively, the patient received an intravenous infusion of lignocaine at 1.5 mg/h and injection diclofenac 75 mg. Postoperatively, wound was infiltrated with bupivacaine 0.5% solution, and a basal intravenous infusion of morphine was initiated at the rate of 3 mg/h using patient-controlled analgesia pump, set for intravenous boluses of 1.5 mg and a lockout period of 10 min. The intravenous dose was calculated as one-third of total oral dose, i.e., 120 mg/day or 5 mg/h. A further reduction to 3 mg/h was done based on the literature reporting that 50% of the total dose can prevent withdrawal symptoms. It was continued till 48 h after the procedure. An infusion of dexmedetomidine was also administered at 0.4 mg/h for the 1st day. Overall, he had consumed 72 mg morphine in 24 h (no rescue doses), i.e., an oral equivalent of 216 mg. An initial rapid taper had already been achieved safely and was continued thereafter by decreasing the oral dose to 50% of the preoperative dose i.e., 30 mg every 4 h (180 mg in a day) with free access to oral morphine as a rescue. Oral clonidine was started at a dose of 100 μg thrice daily to cover insomnia and anxiety. Gabapentin and amitriptyline were continued in same doses. The patient was closely monitored for signs of withdrawal for another 2 days in the ward.

This initial rapid taper was followed by a gradual taper by reducing the dose by 30 mg/week initially and later by 5 mg/week and increasing the dosing interval.

Psychological support was provided to alleviate the element of anxiety associated with opioid tapering and the loss of his right arm.

Two weeks after the surgery, the patient developed phantom limb pain which was managed by titrating gabapentin and amitriptyline. Over 10 weeks, morphine was gradually discontinued.

 Discussion



Clinicians prescribing high doses of opioids for cancer and noncancer pain often face the challenge of safe discontinuation under the circumstances such as inadequate analgesia, intolerable side effects, or opioid misuse.[1]

Clinically relevant physical dependence and tolerance develop as early as 2–3 weeks in patients taking opioids on a daily basis.[2] Abrupt discontinuation of opioids in such cases can precipitate withdrawal symptoms such as anxiety, insomnia, diarrhea, abdominal cramps, rhinorrhea, lacrimation, and signs of sympathetic hyperactivity such as diaphoresis, tachycardia. At the same time, continuing high doses of opioids after the removal of the cause of pain may not be safe.

Guidelines have been formulated for the safe tapering of opioids with the main objective being patient safety and comfort with minimal incidence of withdrawal symptoms. The American Academy of Pain Medicine discusses a range of reduction of daily dose from 10% each day or 20% every 3–5 days to 25% each week.[3]

A similar varying rate of taper has been suggested by Canadian guidelines [4] ranging from 10% of the total daily dose every day to 10% of total daily dose every 1–2 weeks Other guidelines developed by the Department of Veterans Affairs and the Department of Defense [5] recommended a taper rate of 20%–50% per week of the original dose, whereas, Centers for Disease Control guidelines consider a slow taper rate of 10% per week to be more appropriate. Irrespective of the initial rate of taper, the last stage of taper, when one-third of the dose is reached, should be very slow.[6]

In addition, it is preferable to switch the patient to long-acting opioids as it allows easy titration and smooth weaning.

Each case needs to be individualized, taking into consideration patient specific factors such as anxiety level, risk of withdrawal, duration of opioid therapy, and comorbidities.[1]

In our patient, morphine had to be tapered due to the surgical removal of the tumor, i.e., the source of pain. The intravenous equivalent of the morphine oral dose is its one-third, i.e., 120 mg or 5 mg/h (total oral dose 360 mg). Literature suggests that even a dose [7] We, therefore, started an infusion of 3 mg/h with a PCA pump and multimodal management for postoperative pain including diclofenac and dexmedetomidine that have an opioid-sparing effect.[7] The initial rapid taper of 50% (30 mg every 4 h, i.e. 180 mg in a day) was achieved in the in-patient setting with intensive monitoring for signs and symptoms of inadequate (inadequate analgesia, withdrawal phenomena) or excessive (sedation, respiratory depression) opioid administration.

This was followed by slow taper rate of 30 mg/week (approximately 10%). The tapering was slowest during the last 4 weeks, (10–5 mg/week.)

A detailed inquiry about withdrawal symptoms along with patient and family education and psychosocial counseling were carried out during follow-up visits, completing the taper over 10 weeks.

This case was reported to highlight the challenges faced by palliative care physicians while tapering opioids in advanced cancer patients and simultaneously controlling acute postoperative pain as well as phantom pain.

 Conclusion



Successful tapering of opioids in the perioperative period is a complex process but can be achieved by individualizing each case. The team needs to plan multidisciplinary care addressing the patient specific considerations, multimodal pain management, psychosocial intervention, and appropriate patient education.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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