FEATURE Cancer pain management
Managing adult cancer pain:
The latest NCCN guidelines
Pain management is important for cancer patients during therapy and some-
times after treatment is completed—not just at the end of life.
BY CARL SHERMAN
Pain is common in cancer — one-third
of patients undergoing treatment and three-fourths of those with advanced
disease experience it — and pain is among the symptoms patients fear the most. "It is impera-tive that physicians and nurses caring for these patients be adept at the assessment and treat-ment of cancer pain," say the authors of Adult Cancer Pain , a practice guideline published by the National Comprehensive Cancer Network (NCCN).
Oncology nurses have an important role here,
says Judith Paice, PhD, RN, director of the cancer pain program at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, and a member of the panel that issued the guideline. "Nurses see patients more often, and patients are often reluc-tant to report pain to their physicians because they don't want to distract them from cancer care. Patients are more inclined to discuss pain with nurses."
In recent years, "awareness that pain manage-
ment is not only for end-of-life care has been
increasing," says Dr Paice. "There is a new
population of patients who have essentially been
cured or who can expect long-term survival
but have been left with serious pain issues as
a result of treatment. They may be using pain
medication for life." Aggressive pain manage-
ment is starting earlier in care, she adds, with
the realization that such management can make
possible effective chemotherapy or radiotherapy
www.OncologyNurseAdvisor.com • JUNE 2010 • ONCOLOGY NURSE ADVISOR 27
FEATURE Cancer pain management
that might otherwise be cut short because of painful side
When the patient rates pain as
effects like neuropathy.
severe, a short-acting opioid,
titrated rapidly, is considered to
The fi rst step in pain management is one that most nurses
be the treatment of choice.
(and doctors) neglect, notes Dr Paice. "Instead of making a full assessment, as soon as they hear the patient has pain, they jump to a medication they feel comfortable with."
opiates and other pain management strategies. Medical and
At the initial screening, ask the patient to rate the intensity
especially oncologic history (including current and prior
of his or her pain using a numerical, categorical, or pictorial
chemotherapy, radiation, and surgery), along with medica-
scale, and to characterize its quality (Figure 1). Determining
tion history, provide an important context for treatment.
whether pain is throbbing, aching, tingling, or sharp may
Physical examination and laboratory fi ndings may identify
provide useful information about its etiology and helps to
causes of pain (such as spinal cord compression) requiring
specifi c remedies.
The goal of the full assessment is a "pain diagnosis" to guide
Psychosocial issues—family support and distress associated
an individualized treatment plan. It should include the onset
with pain and disease—should also be evaluated, the guideline
and course of the pain, exacerbating and ameliorating factors,
suggests. Concern about risk of addiction has come to the fore
relief measures that have already been tried, and historical
in recent years: "Ask about the use of recreational drugs and any
information relating to the patient's overall experience with
history of addiction or abuse—including family history," Dr Paice emphasizes. Trouble in the past "doesn't mean we with-hold medication, but perhaps we provide a different structure
and are more attentive to our prescribing patterns."
CHOOSING AN ANALGESIC
Pain intensity is the key variable in analgesic choice for
patients who are not already taking opioids.
• When the patient rates pain as severe (for example, 7 on
a 10-point scale), a short-acting opioid, titrated rapidly, is the treatment of choice, augmented with other drugs if
the patient has neuropathic pain.
• The protocol is similar for patients with more moderate
pain (4-6 on a 10-point scale), except that titration of the opioid can be slower.
• For pain of mild intensity (1-3), NSAIDs and acetamino-
phen are alternatives to opioid therapy.
Whatever the pain intensity or primary analgesic, the
addition of a co-analgesic should be considered when there are indications of a cancer pain syndrome: neuropathic pain, bone pain, or pain associated with infl ammation. If the
pain is related to an oncologic emergency, appropriate steps
(such as surgery, corticosteroids, radiotherapy, or antibiotics)
must also be taken. Pain in a patient who is already taking
opioids requires an adjustment of dosage, reevaluation for possible underlying causes, and perhaps the addition of
The most commonly used short-acting opioids are morphine,
FIGURE 1. An example of a pain scale
hydromorphone, fentanyl, and oxycodone. The guidelines
28 ONCOLOGY NURSE ADVISOR • JUNE 2010 • www.OncologyNurseAdvisor.com
advise against meperidine and propoxyphene, particularly for long-term or high-dose use, because of toxicity; they caution that partial agonists and mixed agonist-antagonist preparations are of limited utility in cancer pain and can pre-cipitate withdrawal in opioid-dependent patients. Tramadol is weaker than other opioids but may have some value for mild to moderate pain.
Oral administration is best, as it is usually the easiest form
of delivery. For patients not already taking opioids, the drug should be initiated at the equivalent of 5 mg to 15 mg of morphine sulfate orally, or 2 mg to 5 mg intravenously, and titrated to a level suffi cient to relieve pain throughout the dosing interval without causing intolerable adverse effects. For breakthrough pain during opioid therapy, administer 10% to 20% of the 24-hour dose orally, or 10%
The NCCN Web site
Effi cacy and side effects should be reassessed every 60 minutes
depression and acute changes in mental status, although
(15 minutes after intravenous administration). If moderate rare, can be addressed immediately with a reversing agent to severe pain remains unchanged or has increased, raise the
such as naloxone.
dosage by 50% to 100%; if severe pain has become moderate,
The effi cacy/side-effect ratio for the individual patient
repeat the same dose and reassess an hour later. When pain has
may differ among drugs, so opioid rotation—switching to
been relieved or reduced to mild levels, consider converting to
an equivalently dosed different agent—is an option when
an extended-release agent or a non-opioid analgesic, providing
side effects are diffi cult to control at therapeutically neces-
short-acting "rescue medication" as needed.
Managing side eff ects is a key component of opioid therapy.
Constipation is a problem best prevented by a bowel regi-
NSAIDs AND ACETAMINOPHEN
men, initiated along with the drug, that includes a stimulant
Acetaminophen or an NSAID may be used instead of an
laxative and stool softener. If constipation develops, increase
opioid for mild pain or as a co-analgesic to reduce opioid dosage. NSAIDs can also be added to the opioid for pain associated with infl ammation.
Managing common side eff ects such
NSAIDs should be given with caution to patients who are
at increased renal, gastrointestinal (GI), or cardiac risk or
as nausea, constipation, and motor
who have bleeding disorders. If NSAIDs are prescribed over
and cognitive impairment is a
the long term, monitor blood pressure, blood urea nitrogen, creatinine, complete blood count, and fecal occult blood
key component of opioid therapy.
every 3 months. Concurrent proton pump inhibitor therapy may forestall GI problems. Switching to a different agent
the stool softener-laxative (after ruling out bowel obstruc-
or a COX-2 inhibitor may make continuation of effective
tion), or consider reducing the opioid dosage and adding a
NSAID therapy possible when GI toxicity is troublesome
but not serious.
Nausea may respond to prochlorperazine, haloperidol, or
Chronic acetaminophen therapy is not without risks.
metoclopramide. Consider an antiemetic prophylactically
The safety of the 4-g maximum daily dose has not been
for a patient who has a history of opioid-induced nausea. defi nitively established over the long term, Dr Paice notes. Pruritus is best treated with an antihistamine.
Problems may arise with cachectic patients, she points out:
Motor and cognitive impairment usually resolve spon-
"the metabolic breakdown of acetaminophen depends
taneously within 2 weeks of stable opioid administration.
on enzymes that may not be released without eating.
Sedation may require a dose reduction, more frequent These people are at greater risk from toxic by-products of administration to reduce peak concentration, or the addition
of caffeine, a psychostimulant, or modafi nil. Respiratory
Continued on page 30
www.OncologyNurseAdvisor.com • JUNE 2010 • ONCOLOGY NURSE ADVISOR 29
FEATURE Cancer pain management
With NSAIDs and particularly acetaminophen, the risk of
to merit preemptive analgesic treatment. The guidelines
overdose is raised by the cumulative impact of hidden sources.
advocate a multimodal approach with an emphasis on local
"It's embedded in so many over-the-counter preparations—
anesthetics such as lidocaine, prilocaine, or tetracaine,
sinus medicines, sleep medicines. Most people don't read the
delivered via creams, iontophoretic devices, or subcutane-
label that carefully," she says.
ous injection (allow suffi cient time for anesthetic onset).
Sedation, systemic analgesia, even general anesthesia may be
CANCER PAIN SYNDROMES
indicated. Nonpharmacologic approaches (such as massage,
Co-analgesics may be required for cancer pain of certain heat or ice, ultrasound, or relaxation training) frequently etiologies, alone or in combination with opioids.
have a role as well.
For neuropathic pain , antidepressants and anticonvulsants
"Patients usually tolerate procedures better when they know
are fi rst-line drugs of choice. Tricyclics (imipramine, what to expect," the authors say. Providing full explanations desipramine) are the best validated and most common-
with ample time for patients to assimilate information and
ly prescribed among the antidepressants. A low initial have questions answered can reduce anticipatory anxiety.
dose with gradual titration will optimize tolerability.
Anticholinergic adverse effects (dry mouth, sedation, PSYCHOSOCIAL SUPPORT AND EDUCATION
urinary hesitancy) are common, however, particularly Patients and families need to be reassured that steps can and
with the more effective tertiary amines imipramine and
will be taken to manage pain and its accompanying distress
amitriptyline. Other antidepressants, including duloxetine,
and will most likely involve oral medication only. They will
venlafaxine, and bupropion, may be better tolerated by benefi t emotionally from the simple acknowledgment that some patients, but less evidence supports their effi cacy for
pain is a problem and that the clinician will work together
with them and remain available until they gain relief.
Among anticonvulsants, gabapentin and pregabalin are
Talking through the issues surrounding pain — its mean-
most often used. Of the two, pregabalin is more effi ciently
ing to the patient and the fears that surround it — can be
absorbed and can be titrated more quickly. Topical agents,
enormously helpful. In progressive disease, "it's a wonderful opportunity to address advance care planning," Dr Paice emphasizes.
"Most patients require
Psychosocial support may include teaching coping skills
education about how to
that reduce the impact of pain and give the patient some measure of control. These include relaxation and distrac-
use rescue medication
tion techniques, guided imagery, and cognitive strategies
for breakthrough pain."
to maximize comfort and limit stress. CDs and other resources are widely available and can be quite helpful,
—Judith Paice, PhD, RN
says Dr Paice.
Relaxation and guided imagery may be particularly valu-
able for breakthrough pain, during the interval before rescue
such as the lidocaine patch or diclofenac gel, can augment
medication begins to work, she says. "It can keep muscle
tension down and keep pain from escalating while waiting
Glucocorticoids are effective for acute pain related to for the immediate-release medication to work."
infl ammation or nerve compression and for bone pain ,
Depression is closely linked to pain and may become more
but their extended use carries the risk of signifi cant adverse
evident as physical symptoms are brought under control. Refer
effects. Bone pain may also benefi t from an NSAID; a trial
patients to a mental health professional when indicated.
of bisphosphonates, hormone therapy, or chemotherapy; or
Patient and family education should include full explana-
from physical therapy.
tion of why medications are prescribed, what they can be
expected to do, and how best to use them. "Most patients
require education about how to use rescue medication for
Diagnostic and therapeutic maneuvers common in cancer
breakthrough pain," adds Dr Paice. Cautions surrounding
care (arterial or central lines, injections, bone marrow controlled substances (safeguarding them in the home, for aspiration, lumbar puncture, skin biopsy) are suffi ciently
example) and the impact of sedating medication on driving
uncomfortable and anxiety-producing for many patients and other activities are important to discuss.
30 ONCOLOGY NURSE ADVISOR • JUNE 2010 • www.OncologyNurseAdvisor.com
Neurostimulation may be indicated
Physical modalities are often valuable adjuncts to pharma-
for neuropathy, and radiofrequency
cotherapy. Physical therapy might be indicated, for example, for disuse syndromes that accompany and compound chronic
ablation can be helpful for patients
pain; a therapist's guidance in gait, posture, and movement
with painful bone lesions.
can help minimize pain after surgery. Application of heat, cold, ultrasound, and electrical stimulation often substan-tially reduce muscle pain. Massage can be extremely useful
for well-localized pain syndromes. For example, celiac
when there is signifi cant muscle involvement and for general
plexus block can relieve the pain of pancreatic cancer,
and superior hypogastric plexus block can be used for
Alternative and complementary modalities , such as acu-
midline pelvic pain. Neurostimulation may be indicated
puncture and acupressure, are highly acceptable to some for neuropathy and radiofrequency ablation for painful patients.
Medical interventions such as nerve block are worth con-
sidering for certain types of cancer pain, after surgery, or THE NCCN CANCER PAIN GUIDELINES
when adequate analgesia is not otherwise possible without
The full text of the National Comprehensive Cancer
intolerable side effects. These generally require consultation
Network's Clinical Practice Guidelines in Oncology: Adult Cancer
with a pain specialist or referral to a specialty clinic.
Pain , is available online at: www.nccn.org/professionals/
Among commonly used procedures are epidural, intrathe-
physician_gls/PDF/pain.pdf . Registration (which is free)
cal, and regional plexus infusions of opioids, local anesthet-
is required for access. ■
ics, or other medications using an external or implanted pump. Neurodestructive procedures can be very useful
Carl Sherman is a medical writer in New York City.
www.OncologyNurseAdvisor.com • JUNE 2010 • ONCOLOGY NURSE ADVISOR 31
Pain Management Clinic Certification Withdrawal / Cancellation form Physician Name Please print the same name as used on your application. Pain Management Clinic Name Please print the same name as used on your application. The Texas Medical Board cannot give legal advice. Please consult an attorney if you have questions regarding whether or not your clinic meets one of the exemptions listed in Texas Medical Board rule Chapter 195. However, please note that the Board does have inspection authority, and owners of clinics that are not properly registered can be investigated.
PPG-TAB A: AMPLIFICATION OF THE MINIMAL STANDARDS OF FITNESS FOR DEPLOYMENT TO THE CENTCOM AOR; TO ACCOMPANY MOD ELEVEN TO USCENTCOM INDIVIDUAL PROTECTION AND INDIVIDUAL/UNIT DEPLOYMENT POLICY 1. General. This PPG-TAB A accompanies MOD ELEVEN, Section 15.C. and provides amplification of the minimal standards of fitness for deployment to the CENTCOM AOR, including a list of medical conditions that may be sufficient to deny medical clearance for or to disapprove deployment of a service member, civilian employee, volunteer, or contractor's employee. The list of deployment-limiting conditions is not comprehensive; there are many other conditions that may result in denial of medical clearance for deployment. Possession of one or more of the conditions listed in this tab does not automatically imply that the individual may not deploy. Rather, it imposes the requirement to obtain a knowledgeable physician's opinion as to the deployability status of the individual. "Medical conditions" as used here also include those health conditions usually referred to as dental, oral, psychological and/or emotional.