Key messages
- The majority of pain in palliative care patients can be effectively treated with available drugs and best practice management strategies, which includes regular assessment of pain with validated assessment tools. [1]
- Strong evidence supports treating cancer pain with non-steroidals, opioids, radionuclides and radiotherapy. [2] Bisphosphonates are effective in the treatment of malignant bone pain. [3]
- Whilst many opioid formulations are available and are effective, the recommended first line treatment for cancer pain continues to be oral morphine. [4]
- Recent evidence-based guidelines for neuropathic pain [5,6] suggest that two groups of medications may be used as first line adjuvant treatment – of the antidepressants, either tricyclics or venlafaxine, and of the anticonvulsants, either gabapentin or pregabalin. Opioids and tramadol are also effective in neuropathic pain, and are suggested to be co-administered first line in neuropathic cancer pain. [6]
Background
Pain is a frequent complication of cancer, and is common in many other life-limiting illnesses. Pain that is not well controlled causes significant distress and disability. The effective management of pain is therefore a core element of palliative care practice. Most pain can be effectively treated using standard care according to the WHO analgesic ladder. [1]
Topics covered here are:
In the palliative care setting, some of the important contributers to pain to consider and treat specifically are:
- Pathological fractures
- Malignant wounds
- Infection
- Radiotherapy / chemotherapy effects (usually short term)
- Lymphoedema
- Depression / anxiety / fear
- Frailty, decreasing mobility or becoming bed-bound
- Constipation and urinary retention.
Active research areas / controversies
Much of the evidence about pain management comes from studies in populations quite different from palliative care patients.[8] Studies of acute pain, single dose studies of particular analgesics, and studies in non-malignant pain syndromes like post herpetic neuralgia and diabetic neuropathy all contribute to the evidence, but must be treated with care when extrapolated to palliative care.
Further research is needed to identify the most effective pain assessment tools for use in palliative care [7] and to improve processes of routine care so that pain is managed most effectively. [8]
Head to head trials of adjuvants in neuropathic pain are needed to strengthen the evidence base. [5]
Randomised controlled trials are currently under way in Australia to assess the effectiveness of ketamine as an adjuvant in poorly controlled pain, and to identify safe and effective breakthrough doses of opioids .
References
- Azevedo Sao Leao Ferreira K., Kimura M, Jacobsen Texeira M. The WHO analgesic ladder for cancer pain control, twenty years of use. How much pain relief does one get from using it? Supportive Care in Cancer. 2006 Nov;4(11):1086-93.
- Lorenz K, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA, et al. Evidence for improving palliative care at the end of life: a systematic review. Annals of Internal Medicine. 2008 Jan 15;148(2):147-159.
- Qaseem A, Snow V, Shekelle P, Casey DR Jr, Cross JT Jr, Owens DK, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2008 Jan 15;148(2):141-146.
- Hanks GW, Conno F, Cherny N, Hanna M, Kalso E, McQuay HJ, et al., Morphine and alternative opioids in cancer pain: the EAPC recommendations. British Journal of Cancer. 2001 Mar 2;84(5):587-93.
- Finnerup NB, Otto M, McQuay HJ, Jensen TS, Sindrup SH. Algorithm for neuropathic pain treatment: An evidence based proposal. Pain. 2005 Dec 5;118(3):289-305.
- Dworkin RH, O’Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, et al. Pharmacological management of neuropathic pain: Evidence-based recommendations. Pain. 2007 Dec 5;132(3):237-251.
- Holen JC, Hjermstad MJ, Loge JH, Fayers PM, Caraceni A, De Conno F, et al. Pain assessment tools: is the content appropriate for use in palliative care? Journal of Pain & Symptom Management. 2006 Dec;32(6):567-80.
- Carr , D., et al., Evidence report on the treatment of pain in cancer patients. J Natl Cancer Inst Monogr., 2004. 32: p. 23-31. [ Reference added in update, October 2009]
This page was created on 23 May 2008 and is due for review in May 2010
Last updated 16 November 2009
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