Summary of recommendations
Cancer pain management in adults: Evidence-based clinical practice guidelines adapted for use in Australia
|PCC1. Routinely establish a multidisciplinary team approach to pain management that involves allied care health professionals and primary care health professionals according to the person’s pain management needs and preferences. (SIGN)|
| PCC2. Adopt a person-centred approach to pain management (NICE), which involves:
|S1. For all patients who are able to communicate their level of pain: At each clinical encounter, assess worst and average pain intensity during the previous 24 hours using a self-reported numerical rating scale from zero to 10, where zero represents ‘no pain’ and 10 represents ‘worst pain you can imagine’. (NCCN)|
| S2. For people who cannot self-report due to cognitive impairment: At each clinical encounter, use the Abbey Pain Scale.
Recommended by the Australian Pain Society: Australian Pain Society. Residential Aged Care Facilities - Management Strategies. Sydney: Australian Pain Society; 2005. Available from: http://www.apsoc.org.au/owner/files/9e2c2n.pdf APS 2005.
| A1. Complete a comprehensive assessment if either of the following apply:
• a new patient reports a pain score of 2 or more on self-reported numerical rating scale of zero to 10 or pain score is 3 or more on the Abbey Pain Scale (see Screening)
Assess all the following to determine the individual’s pain management needs:
The Working Group considered this information to provide necessary context for other assessments
• Pain severity (using a validated tool) (NCCN, SIGN)
• Pain experience (location, interference, timing, description, aggravating and relieving factors) (ESMO, NCCN, NHS, SIGN)
• Current and previous management of pain (ESMO, NCCN, NHS, SIGN) and other symptoms
The Working Group considered this information to provide necessary context for other assessments
• Physical examination and, where needed, further investigations (NCCN, NHS, SIGN)
• Functional status (ESMO)
• Risk factors for poorly controlled pain (NCCN)
• Patient and family preferences (goals and expectations for comfort, advance directives) (NCCN)
• Factors suggesting an oncological emergency. (NCCN)
Reassess whenever there is a change in pain or a new pain is reported.
|SM1. For all patients with pain, provide education about cancer-related pain and its management. (NCCN, SIGN)|
| SM2. Patients with pain should be provided with verbal and written information on pain and its management, including the following:
• pain causes
• common experiences of cancer pain (e.g. onset, timing)
• effective treatments (including medicines and non-pharmacological management strategies)
• effect of medicines including breakthrough analgesia (e.g. onset and duration of effect; when to take them)
• side-effects of medicines and how to prevent or manage them
• any safety concerns (e.g. mixing with alcohol, driving)
• ways to ensure patients have adequate access and supply to prescribed opioids
• how to work with health professionals to achieve the best pain control possible (e.g. the importance of reporting rather than concealing pain, side-effects and other concerns about medication)
• common attitudes and beliefs that may prevent people with cancer receiving effective pain control (e.g. fears that opioids are addictive and used only at the end of life, and that patients will develop tolerance over time requiring dose escalation)• when to seek help (e.g. if vomiting and unable to keep down fluids for one day, bowels not open 3 days, new pain, change in pain or pain not relieved by medication, difficulty arousing the patient from sleep easily during the daytime, confusion, difficulty accessing the medications).
Systematic review by Koller et al (2012): Koller A, Miaskowski C, De Geest S, Opitz O, Spichiger E. A systematic evaluation of content, structure, and efficacy of interventions to improve patients' self-management of cancer pain. J Pain Symptom Manage. 2012 Aug;44(2):264-84.
| SM3. Include the person’s family, carers and significant others in education about pain and its management, if appropriate.
Carers are frequently involved in decision-making (e.g. to start and adhere to opioids) and management
|P1. For patients with continuing pain, begin regular analgesia with paracetamol and/or a nonsteroidal anti-inflammatory drug (NSAID) if the patient has no contraindications. (ESMO, NCCN, SIGN)|
|P2. If pain is moderate or severe or continues despite treatment with paracetamol or NSAIDs, consider a regular oral opioid. (ESMO, NCCN, SIGN)|
|P3.If pain continues or recurs despite regular oral opioid analgesia and the patient feels that analgesia is inadequate, consider either of the following options:
• Add a NSAID (if the person is not already taking and NSAID and has no contraindications). (EAPC)
• Increase regular dose of opioid to incorporate the rescue doses taken in previous 24 hours (SIGN), then reassess pain severity and adverse effects within 48 hours. (Consensus)
|P4. Methadone should be initiated and titrated only by specialists familiar with its use. (EAPC, ESMO, NCCN)|
|P5. The transdermal route of administration can be considered as an alternative to oral administration if required for patients unable to take oral medications, reduced risk of constipation or patient convenience. (EAPC) Due to the sloe onset of effect and long duration of action, the transdermal route should only be considered when pain is stable. (ESMO, NCCN, SIGN)
Use one of the following options, referring to the eviQ Opioid Conversion Calculator:
• Switch to transdermal buprenorphine (suitable for patients with stable mild pain only). (NICE) Note: A 20 mcg/hour buprenorphine transdermal patch is equivalent to 30 mg morphine daily orally.
• Switch to transdermal fentanyl. (NICE) Note: The lowest dose available (12 mcg/hourr) for fentanyl transdermal patch is equivalent to 45 mg morphine daily orally.
Due to long duration of action, the transdermal route should be considered only when pain is stable. (ESMO, NCCN, SIGN)
|P6. For patients with renal impairment, carefully monitor for treatment-related adverse effects. If opioid-related adverse effects occur, consider the following options:
• Reduce the total 24-hour dose of regular opioid (either by reducing dose and maintaining dose interval, or increasing dose interval and maintaining dose). (ESMO, SIGN)
• Switch from sustained release to immediate release opioid at an appropriate regular dosing interval. (SIGN)
• Switch to a different opioid (e.g. consider buprenorphine or fentanyl instead of morphine, codeine or hydromorphone) or methadone under specialist supervision. (EAPC, ESMO, NCCN, SIGN)
|P7. Morphine should be used with caution in patients with severe kidney disease (calculated creatinine clearance of less than 30 mL/min) in whom it may require reductions in dose and frequency. (EAPC, SIGN)|
|P8. In addition to regular opioids, routinely prescribe short-acting analgesia at a dose equivalent to one-sixth of total 24-hour dose, to be administered if breakthrough pain occurs. (NHS, SIGN) Rescue doses should be prescribed at 1-hourly intervals when required (NCCN) with advice given for the patient to seek health care professional advice if 3 consecutive doses have not relieved pain. (Consensus)|
|P9. If breakthrough pain occurs, monitor the number of breakthrough doses. If rescue analgesic doses have been effective with no adverse effects, re-titrate the regular opioid 24-hour dose by calculating the previous 24 hour opioid requirement including breakthrough doses. (SIGN) Note - if breakthrough analgesia is taken preemptively for incident pain, then the regular dose may not need to be increased.|
|P10. If the person experiences incident pain on a background of stable pain control while taking regular opioids, give additional oral short-acting opioids at a dose equivalent to one-sixth of total 24-hour dose. Transmucosal fentanyl preparations may be of use and require individual titration.(NHS, SIGN, EAPC)|
|P11. If the person experiences incident pain (e.g. movement-related pain or pain with dressing changes), advise him/her to take preemptive analgesia 30 minutes before activity that is likely to cause pain. (EAPC, NCCN, NHS, SIGN)|
|P12. For patients with neuropathic pain that persists despite non-opioid and opioid analgesia consider the following options (EAPC, ESMO, NCCN, SIGN):
• Anticonvulsant agents (gabapentin or pregabalin)
• Antidepressants (amitriptyline, nortriptyline or venlafaxine).
|P13.For patients with bone metastases, consider bisphosphonates for prevention of bone pain. (ESMO, NCCN, NHS, SIGN)|
|P14. For patients with painful bone metastases, consider single-fraction radiotherapy or radioisotopes. (ESMO, NCCN, NHS, SIGN)|
|P15. Consider denosumab for preventing skeletal events and bone pain from metastatic breast or prostate cancer. (NCCN, NHS, SIGN)|
|P16. For patients with refractory pain despite carefully titrated doses of conventional medical therapies, consider whether a spinal route of administration may be indicated. (NCCN, NHS, SIGN)|
|P17. Consider nerve blocks for selected pain syndromes (e.g. coeliac plexus block for pain in pancreas or upper abdomen). (NCCN)|
|P18. Consider intrathecal infusion of analgesic for patients with any of the following:
• difficult-to-control pain (EAPC)
• diffuse pain (NCCN)
• unacceptable opioid-related toxicity despite optimal use of adjuvants and a trial of switching opioids. (SIGN)
Refer to a specialist pain medicine physician or palliative medicine physician.
|P19. Reduce the risk of constipation in non-terminal patients by using all of the following strategies:
• Maintain adequate hydration. (NCCN)
• Encourage physical activity (ambulant patients). (NCCN)
• Provide education on bowel hygiene routine (e.g. dietary fibre). (Consensus)
• Use a combination of stimulant and softening laxatives. (EAPC, NCCN, NICE, SIGN)
• Avoid other medicines that can aggravate constipation (e.g. 5HT3 antagonists) if possible. (Consensus)
|P20. For an ambulant non-terminal patient with critical constipation caused by opioids that is not responding to oral stimulant and softening laxatives or polyethylene glycol (NCCN), consider one of the following options:
• Switch to less constipating opioid (e.g. fentanyl). (NICE)
• Switch to a combination of oxycodone hydrochloride with naloxone hydrochloride if the person's regular 24-hour opioid dose conversion is below maximum dose.
The combination of oxycodone hydrochloride and naloxone hydrochloride has not been compared with laxatives in this patient population. (NPS Radar. Oxycodone-with-naloxone controlled-release tablets (Targin®). 2011(December) [cited 2012 20th October]; Available from: http://www.nps.org.au/__data/assets/pdf_file/0005/135869/oxycodone_with_naloxone.pdf)
• For patients receiving palliative care and for whom other laxative therapies are not indicated or effective, consider short-term use of methylnaltrexone. (NCCN, EAPC)
|P21. When commencing an opioid and at each opioid dose increment, routinely prescribe ‘as required’ prophylactic antiemetic (e.g. prochlorperazine maleate, metoclopramide or haloperidol). (EAPC, NCCN, NICE)|
|P22. If nausea persists after symptom review, consider prescribing an antiemetic to be taken regularly. (ESMO, NCCN, NHS, NICE)|
|P23. If nausea is persistent or severe, investigate further to determine causes (e.g. constipation, central nervous system pathology, chemotherapy, radiation therapy). (NCCN)|
|P24. If opioid toxicity is suspected (Consensus):
• Review all medicines and consider whether medicines may be contributing to the signs and symptoms.
• Take a detailed history and consider whether the person’s underlying disease (e.g. brain metastases, hepatic impairment) or other factors may be contributing to the signs and symptoms.
• Complete a thorough physical examination.
• Consider further investigations.
|P25. When opioid-related toxicity of the central nervous system is suspected, consider the differential diagnosis of causes. Consider undertaking the following investigations as indicated by the clinical situation (Consensus):
• Ask about relevant history.
• Check electrolytes (sodium, potassium, chloride, serum calcium), urea, creatinine, calcium, glucose, oxygen saturations.
• Perform urine dipstick test.
• Order chest X-ray, CT of brain if indicated.
|P26. If opioid-related toxicity of the central nervous system is a probable cause of confusion or other central nervous system symptoms (NHS):
• Consider supplemental hydration if the patient is dehydrated.
• Consider switching to a different opioid or reducing dose and retitrate according to response.
|P27. For opioid-related confusion or delirium, treat the underlying aetiology and manage according to life expectancy (Consensus):
• If NOT last days of life, trial non-pharmacological management first to manage delirium symptoms (e.g. well lit, quiet environment). If the symptoms are not adequately improved consider reducing dose of opioid or switching to a different opioid.
|P28. Manage opioid-related myoclonus according to life expectancy (Consensus):
• Manage reversible causes such as renal impairment, dehydration, very high doses of opioids.
• If NOT last days of life, consider reducing dose of opioid or switching to a different opioid.
• If last days of life, consider reducing dose of opioid if appropriate and/or a benzodiazepine in addition to reducing opioid dose or swtiching opioid.
|P29. Respiratory depression is an uncommon adverse effect of opioid therapy for cancer pain.
If opioid-related respiratory depression is suspected (Consensus):
• Eliminate other causes such as effect of sedatives, hypercapnia and/or excessive oxygen flow.
• Check hydration status and renal function.
• For patients receiving methadone, consult a specialist pain medicine physician, palliative medicine physician, clinical pharmacist or clinical pharmacologist familiar with its use.
|P30. Manage opioid-related respiratory depression with all of the following (Consensus):
• Withhold opioid dose and recommence either at lower dosing frequency or reduced dose.
• Ensure the person is positioned properly.
• Rehydrate if dehydrated.
|P31. Manage opioid-related respiratory depression according to severity of symptom:
• Withhold next opioid dose and recommence either at a reduced dose or less frequent dosing interval.
• Ensure the person is positioned to maintain airway and provide oxygen if appropriate.
• If respiratory rate ≤ 8/minute and patient unrousable, use appropriate dose of naloxone in frequent small doses that aim to improve consciousness without worsening pain (diluting ampoule to 10ml). (ESMO, NCCN)
• If patient rousable (despite low respiratory rate), monitor patient closely for decrease in rousability until respiratory rate improves. Encourage deep breathing.
• For patients receiving fentanyl transdermal patches or methadone, consult a specialist pain medicine physician, palliative medicine physician, clinical pharmacist or clinical pharmacologist familiar with use of the agent.
|P32. If opioid-related pruritis is suspected, exclude renal impairment and hepatic impairment as cause. (Consensus)|
|P33. Manage opioid-related pruritis with either or both the following:
• Consider switching to a different opioid. (NCCN, NHS) If pruritis persists despite opioid switching after trialling more than one opioid, refer to a relevant specialist team (e.g. palliative care and/or pain medicine). (Consensus)
• Consider symptomatic management with an H1 antihistamine (choose one of the newer, less sedating agents). (Consensus)
|P34. Consider urinary retention in patients with urinary symptoms. (Consensus)|
|P35. If opioid-induced hyperalgesia is suspected (e.g. pain is escalating despite pain management according to these guidelines), refer to palliative care team or palliative medicine specialist for urgent advice. (Consensus)|
|P36. Consider switching to a different opioid in either of the following situations:
• Optimal pain relief cannot be achieved despite appropriate dose. (ESMO, NCCN, NHS, NICE)
• The patient is experiencing unacceptable opioid-related adverse effects. (EAPC)
|P37. If switching to a different formulation or route of administration with the same agent, look up conversion for total 24-hour opioid dose via the eviQ Opioid Conversion Calculator. (EAPC, ESMO, NCCN, NHS, NICE)|
|P38. If switching to a different agent because the previous route of administration is no longer possible, a starting dose lower than the equivalent total 24-hour opioid dose of the previous agent should be used. (EAPC)|
|P39. If switching to a different opioid agent due to unacceptable treatment-related adverse effects, despite optimal pain relief, start with a lower dose, then adjust dose carefully while monitoring for pain control and adverse effects. (EAPC, ESMO)|
|P40. If there is reason to suspect that a patient’s prescribed opioids are being misused or diverted:
• Explain to the person that goal is pain relief without misuse. (Consensus)
• Assess for opioid dependency disorder. (Consensus)
• Establish a treatment agreement with the person, including an agreement to limit the supply of opioids to a single prescriber and pharmacy. (NCCN)
|P41. Advise all patients and carers to ensure medicines are kept out of children’s reach, out of sight and in a secure cupboard. (Consensus)|
|P42. For patients taking opioids, assess capacity to drive using current national guidelines and warn of impairment at higher doses.
Austroads Limited. Assessing fitness to drive. Medical standards for licensing and clinical management guidelines. Sydney: Austroads Ltd; 2012. Available from: http://www.austroads.com.au
|P43. If pain is not adequately controlled despite recommended pain management strategies, including analgesic medication, consult a specialist pain medicine physician or palliative medicine physician.(NICE, NHS)|
|N1. Consider referral to a physiotherapist for assessment of functional ability and potential suitability of non-pharmacological pain management strategies. (NCCN, NHS, SIGN)|
|N2. Provide support for any psychosocial and spiritual concerns identified during comprehensive assessment.|
|N3. Consider referral to an occupational therapist for assessment and management. (NCCN, NHS)|
| N4. Consider referral to a clinical psychologist for psychological therapies and support:
• Cognitive–behavioural therapy (NCCN, SIGN)
• Relaxation techniques (NCCN)
• Distraction techniques (NCCN)
• Guided imagery therapy. (NCCN)
| N5. Consider music either prerecorded or with a music therapist |
Systematic review by Bradt et al (2011): Bradt J, Dileo C, Grocke D, Magill L. Music interventions for improving psychological and physical outcomes in cancer patients.Cochrane Database Syst Rev. 2011 Aug 10;(8):CD006911. doi: 10.1002/14651858.CD006911.pub2.
| N6. Offer to discuss any complementary therapies the person may wish to consider, and provide reliable information about the evidence for their effectiveness.
Principles of holistic management; Potential for drug–drug interactions