Adult Cancer Pain

Authors: Robert Swarm MD, Amy Pickar Abernethy MD, Doralina L. Anghelescu MD, Costantino Benedetti MD, Craig D. Blinderman MD, MA, Barry Boston MD, Charles Cleeland PhD, Nessa Coyle PhD, NP, Oscar A. deLeon-Casasola MD, June G. Eilers PhD, APRN, Betty Ferrell RN, PhD, Nora A. Janjan MD, MPSA, MBA, Sloan Beth Karver MD, Michael H. Levy MD, PhD, Maureen Lynch MS, APRN, Natalie Moryl MD, Barbara A. Murphy MD, Suzanne A. Nesbit PharmD, BCPS, Linda Oakes RN, MSN, Eugenie A. Obbens MD, PhD, Judith A. Paice PhD, RN, Michael W. Rabow MD, Karen L. Syrjala PhD, Susan Urba MD and Sharon M. Weinstein MD
View More View Less
Volume/Issue:
Volume 8: Issue 9
Online Publication Date:
Sep 2010
DOI:
https://doi.org/10.6004/jnccn.2010.0076
Restricted access

All currencies in US Dollar

PayPal Logo
OverviewPain, defined as “a sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage,”1 is one of the most common symptoms associated with cancer. Cancer pain or cancer-related pain is distinct from pain experienced by patients without malignancies. Pain occurs in approximately one quarter of patients with newly diagnosed malignancies, one third of patients undergoing treatment, and three quarters of patients with advanced disease,2–4 and is one of the symptoms patients fear most. Unrelieved pain denies patients comfort and greatly affects their activities, motivation, interactions with family and friends, and overall quality of life.The importance of relieving pain and availability of effective therapies make it imperative that physicians and nurses caring for these patients be adept at the assessment and treatment of cancer pain.5–7 This requires familiarity with the pathogenesis of cancer pain; pain assessment techniques; common barriers to the delivery of appropriate analgesia; and pertinent pharmacologic, anesthetic, neurosurgical, and behavioral approaches to the treatment of cancer pain.The most widely accepted algorithm for the treatment of cancer pain was developed by the WHO.8,9 It suggests that patients with pain be started on acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). If this is not sufficient, patients should be escalated to a weak opioid, such as codeine, and then to a strong opioid, such as morphine. Although this algorithm has served as an excellent teaching tool, the management of cancer pain is considerably more complex than this 3-tiered “cancer pain ladder”...
  • 1.

    Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl 1986;3(Supp 1):226.

    • Search Google Scholar
    • Export Citation
  • 2.

    Cohen MZ, Easley MK, Ellis C. Cancer pain management and the JCAHO's pain standards: an institutional challenge. J Pain Symptom Manage 2003;25:519–527.

    • Search Google Scholar
    • Export Citation
  • 3.

    Goudas LC, Bloch R, Gialeli-Goudas M. The epidemiology of cancer pain. Cancer Invest 2005;23:182–190.

  • 4.

    Svendsen KB, Andersen S, Arnason S. Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms. Eur J Pain 2005;9:195–206.

    • Search Google Scholar
    • Export Citation
  • 5.

    Cleeland CS, Gonin R, Hatfield AK. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994;330:592–596.

  • 6.

    Martin LA, Hagen NA. Neuropathic pain in cancer patients: mechanisms, syndromes, and clinical controversies. J Pain Symptom Manage 1997;14:99–117.

    • Search Google Scholar
    • Export Citation
  • 7.

    Mercadante S. Malignant bone pain: pathophysiology and treatment. Pain 1997;69:1–18.

  • 8.

    Stjernsward J. WHO cancer pain relief programme. Cancer Surv 1988;7:195–208.

  • 9.

    Stjernsward J, Colleau SM, Ventafridda V. The World Health Organization Cancer Pain and Palliative Care Program. Past, present, and future. J Pain Symptom Manage 1996;12:65–72.

    • Search Google Scholar
    • Export Citation
  • 10.

    Caraceni A, Weinstein SM. Classification of cancer pain syndromes. Oncology (Williston Park) 2001;15:1627–1640.

  • 11.

    Hewitt DJ. The management of pain in the oncology patient. Obstet Gynecol Clin North Am 2001;28:819–846.

  • 12.

    Portenoy RK. Cancer pain. Epidemiology and syndromes. Cancer 1989;63:2298–2307.

  • 13.

    Hicks CL, von Baeyer CL, Spafford PA. The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain 2001;93:173–183.

    • Search Google Scholar
    • Export Citation
  • 14.

    Serlin RC, Mendoza TR, Nakamura Y. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain 1995;61:277–284.

    • Search Google Scholar
    • Export Citation
  • 15.

    Soetenga D, Frank J, Pellino TA. Assessment of the validity and reliability of the University of Wisconsin Children's Hospital Pain scale for Preverbal and Nonverbal Children. Pediatr Nurs 1999;25:670–676.

    • Search Google Scholar
    • Export Citation
  • 16.

    Al-Atiyyat HN. Cultural diversity and cancer pain. J Hosp Palliat Nurs 2009;11:154–164.

  • 17.

    Ezenwa MO, Ameringer S, Ward SE, Serlin RC. Racial and ethnic disparities in pain management in the United States. J Nurs Scholarsh 2006;38:225–233.

    • Search Google Scholar
    • Export Citation
  • 18.

    American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 5th ed. Glenview, IL: American Pain Society; 2003.

    • Search Google Scholar
    • Export Citation
  • 19.

    Mercadante SL, Berchovich M, Casuccio A. A prospective randomized study of corticosteroids as adjuvant drugs to opioids in advanced cancer patients. Am J Hosp Palliat Care 2007;24:13–19.

    • Search Google Scholar
    • Export Citation
  • 20.

    Klepstad P, Kaasa S, Borchgrevink PC. Start of oral morphine to cancer patients: effective serum morphine concentrations and contribution from morphine-6-glucuronide to the analgesia produced by morphine. Eur J Clin Pharmacol 2000;55:713–719.

    • Search Google Scholar
    • Export Citation
  • 21.

    Klepstad P, Kaasa S, Skauge M, Borchgrevink PC. Pain intensity and side effects during titration of morphine to cancer patients using a fixed schedule dose escalation. Acta Anaesthesiol Scand 2000;44:656–664.

    • Search Google Scholar
    • Export Citation
  • 22.

    Cherny NI. The pharmacologic management of cancer pain. Oncology (Williston Park) 2004;18:1499–1515.

  • 23.

    Hanks GW, Conno F, Cherny N. Morphine and alternative opioids in cancer pain: the EAPC recommendations. Br J Cancer 2001;84:587–593.

  • 24.

    Kornick CA, Santiago-Palma J, Khojainova NL. A safe and effective method for converting cancer patients from intravenous to transdermal fentanyl. Cancer 2001;92:3056–3061.

    • Search Google Scholar
    • Export Citation
  • 25.

    Tiseo PJ, Thaler HT, Lapin J. Morphine-6-glucuronide concentrations and opioid-related side effects: a survey in cancer patients. Pain 1995;61:47–54.

    • Search Google Scholar
    • Export Citation
  • 26.

    Portenoy RK, Foley KM, Stulman J. Plasma morphine and morphine-6-glucuronide during chronic morphine therapy for cancer pain: plasma profiles, steady-state concentrations and the consequences of renal failure. Pain 1991;47:13–19.

    • Search Google Scholar
    • Export Citation
  • 27.

    Davis MP, Homsi J. The importance of cytochrome P450 monooxygenase CYP2D6 in palliative medicine. Support Care Cancer 2001;9:442–451.

  • 28.

    Bruera E, Kim HN. Cancer pain. JAMA 2003;290:2476–2479.

  • 29.

    Barkin RL, Barkin SJ, Barkin DS. Propoxyphene (dextropropoxyphene): a critical review of a weak opioid analgesic that should remain in antiquity. Am J Ther 2006;13:534–542.

    • Search Google Scholar
    • Export Citation
  • 30.

    Goldstein DJ, Turk DC. Dextropropoxyphene: safety and efficacy in older patients. Drugs Aging 2005;22:419–432.

  • 31.

    Aubert R, Stanek EJ, Yao J. Risk of breast cancer recurrence in women initiating tamoxifen with CYP2D6 inhibitors [abstract]. J Clin Oncol 2009;27(Suppl 1):Abstract CRA508.

    • Search Google Scholar
    • Export Citation
  • 32.

    Dezentje V, Van Blijderveen NJ, Gelderblom H. Concomitant CYP2D6 inhibitor use and tamoxifen adherence in early-stage breast cancer: a pharmacoepidemiologic study [abstract]. J Clin Oncol 2009;27(Suppl 1):Abstract CRA509.

    • Search Google Scholar
    • Export Citation
  • 33.

    Portenoy RK, Lesage P. Management of cancer pain. Lancet 1999;353:1695–1700.

  • 34.

    Stevens RA, Ghazi SM. Routes of opioid analgesic therapy in the management of cancer pain. Cancer Control 2000;7:132–141.

  • 35.

    Harris JT, Suresh Kumar K, Rajagopal MR. Intravenous morphine for rapid control of severe cancer pain. Palliat Med 2003;17:248–256.

  • 36.

    McNicol E, Horowicz-Mehler N, Fisk RA. Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review. J Pain 2003;4:231–256.

    • Search Google Scholar
    • Export Citation
  • 37.

    Mercadante SComments on Wang ., PAIN, 67 (1996) 407-416. Pain 1998;74:106–107.

  • 38.

    Mercadante S. Pathophysiology and treatment of opioid-related myoclonus in cancer patients. Pain 1998;74:5–9.

  • 39.

    Wilson RK, Weissman DE. Neuroexcitatory effects of opioids: patient assessment #57. J Palliat Med 2004;7:579.

  • 40.

    Moryl N, Carver A, Foley KM. Pain and palliation. In: Holland JF, Frei E, eds. Cancer Medicine. Vol. I7. Hamilton, ON: BC Decker Inc; 2006:1113–1124.

    • Search Google Scholar
    • Export Citation
  • 41.

    Moryl N, Obbens EA, Ozigbo OH, Kris MG. Analgesic effect of gefitinib in the treatment of non-small cell lung cancer. J Support Oncol 2006;4:111.

  • 42.

    Boettger S, Breitbart W. Atypical antipsychotics in the management of delirium: a review of the empirical literature. Palliat Support Care 2005;3:227–237.

    • Search Google Scholar
    • Export Citation
  • 43.

    Breitbart W, Marotta R, Platt MM. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 1996;153:231–237.

    • Search Google Scholar
    • Export Citation
  • 44.

    Bruera E, Belzile M, Neumann C. A double-blind, crossover study of controlled-release metoclopramide and placebo for the chronic nausea and dyspepsia of advanced cancer. J Pain Symptom Manage 2000;19:427–435.

    • Search Google Scholar
    • Export Citation
  • 45.

    Challoner KR, McCarron MM, Newton EJ. Pentazocine (Talwin) intoxication: report of 57 cases. J Emerg Med 1990;8:67–74.

  • 46.

    Katcher J, Walsh D. Opioid-induced itching: morphine sulfate and hydromorphone hydrochloride. J Pain Symptom Manage 1999;17:70–72.

  • 47.

    Marinella MA. Acute colonic pseudo-obstruction complicated by cecal perforation in a patient with Parkinson's disease. South Med J 1997;90:1023–1026.

    • Search Google Scholar
    • Export Citation
  • 48.

    Reissig JE, Rybarczyk AM. Pharmacologic treatment of opioid-induced sedation in chronic pain. Ann Pharmacother 2005;39:727–731.

  • 49.

    Tarcatu D, Tamasdan C, Moryl N, Obbens E. Are we still scratching the surface? A case of intractable pruritus following systemic opioid analgesia. J Opioid Manag 2007;3:167–170.

    • Search Google Scholar
    • Export Citation
  • 50.

    Prommer E. Modafinil: is it ready for prime time? J Opioid Manag 2006;2:130–136.

  • 51.

    Hawley PH, Byeon JJ. A comparison of sennosides-based bowel protocols with and without docusate in hospitalized patients with cancer. J Palliat Med 2008;11:575–581.

    • Search Google Scholar
    • Export Citation
  • 52.

    Slatkin NE. Opioid switching and rotation in primary care: implementation and clinical utility. Curr Med Res Opin 2009;25:2133–2150.

  • 53.

    Mercadante S, Arcuri E, Ferrera P. Alternative treatments of breakthrough pain in patients receiving spinal analgesics for cancer pain. J Pain Symptom Manage 2005;30:485–491.

    • Search Google Scholar
    • Export Citation
  • 54.

    Greenberg HS, Taren J, Ensminger WD, Doan K. Benefit from and tolerance to continuous intrathecal infusion of morphine for intractable cancer pain. J Neurosurg 1982;57:360–364.

    • Search Google Scholar
    • Export Citation
  • 55.

    Chen H, Lamer TJ, Rho RH. Contemporary management of neuropathic pain for the primary care physician. Mayo Clin Proc 2004;79:1533–1545.

  • 56.

    Lussier D, Huskey AG, Portenoy RK. Adjuvant analgesics in cancer pain management. Oncologist 2004;9:571–591.

  • 57.

    Jin Y, Desta Z, Stearns V. CYP2D6 genotype, antidepressant use, and tamoxifen metabolism during adjuvant breast cancer treatment. J Natl Cancer Inst 2005;97:30–39.

    • Search Google Scholar
    • Export Citation
  • 58.

    Manfredi PL, Gonzales GR, Sady R. Neuropathic pain in patients with cancer. J Palliat Care 2003;19:115–118.

  • 59.

    Stockler M, Vardy J, Pillai A, Warr D. Acetaminophen (paracetamol) improves pain and well-being in people with advanced cancer already receiving a strong opioid regimen: a randomized, double-blind, placebo-controlled cross-over trial. J Clin Oncol 2004;22:3389–3394.

    • Search Google Scholar
    • Export Citation

  • Levy MH, Chwistek M, Mehta RS. Management of chronic pain in cancer survivors. Cancer J 2008;14:401–409.

  • Levy MH, Samuel TA. Management of cancer pain. Semin Oncol 2005;32:179–193.

  • Kochhar R, Legrand SB, Walsh D. Opioids in cancer pain: common dosing errors. Oncology (Williston Park) 2003;17:571–575; discussion 575–576, 579.

    • Search Google Scholar
    • Export Citation

  • Ripamonti C, Zecca E, Bruera E. An update on the clinical use of methadone for cancer pain. Pain 1997;70:109–115.

Copyright:
Copyright © 2010 by the National Comprehensive Cancer Network
Page Numbers:
1046–1086
Article Category:
Review Article
Print Publication Date:
01 Sep 2010
Online Publication Date:
Sep 2010
Keywords:
NCCN Clinical Practice Guidelines; NCCN Guidelines; cancer; pain; malignancy; pain assessment; pain intensity rating
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 2089 635 52
PDF Downloads 469 115 18
EPUB Downloads 0 0 0