Management of predictable pain using fentanyl pectin nasal spray in patients undergoing radiotherapy
A 61-year-old man with a 2.5 cm invasive, nonkeratinizing, squamous cell carcinoma (T2N2BM0) in the left tonsil region was referred for concurrent chemotherapy and radiation therapy (6,800 cGy in 34 fractions with daily sensitizing chemotherapy continued for 7 weeks). Prophylactic supersaturated calcium phosphate oral rinse was used from day 1, but the patient developed mucositis in week 2 that progressed to grade III by the end of treatment.\nAt the beginning of treatment, the patient had little pain, but quickly started to experience significant pain especially when swallowing. Long-acting analgesia (hydrocodone/acetaminophen; 5/500 mg increasing to 7.5/500 mg every 6–8 hours) was initiated in week 2, and expanded in week 3 by the addition of fentanyl transdermal patches every 72 hours (initially 25 μg, later increased to 50 μg and then 75 μg). Despite that regimen plus hydrocodone/acetaminophen 30 minutes before meals, he experienced 6/10 pain with swallowing and awoke 2–3 times a night with pain that he rated as 7/10. While the long-acting analgesia reduced overall pain, it did not affect the severity of the acute episodes of pain associated with swallowing or the discomfort associated with the need to wear an immobilizing mask during radiotherapy.\nFPNS was started in week 5 (100 μg); in particular, the patient was instructed to use FPNS in an anticipatory manner 20 minutes before lunch and dinner, and 20 minutes before radiotherapy sessions. In addition, he used FPNS to treat pain that woke him at night. As an anticipatory treatment, FPNS reduced pain from 8/10 to 3/10. At night, FPNS reduced pain from 6/10 to 2/10, which allowed the patient to return to sleep until the morning. After completion of 34 radiotherapy sessions without interruption, the patient was continued on fentanyl patches (75 μg every 72 hours) plus FPNS (100 μg 20 minutes before meals). By 4 weeks after therapy, the mucositis had resolved sufficiently to allow the oral rinse to be discontinued and the dose of the fentanyl patches to be reduced (25 μg every 72 hours). By 5 weeks after therapy, the fentanyl patches and FPNS were discontinued.