The management of cancer pain in adults has and continues to be an issue both in primary and secondary care, with patients often fearing this symptom more than death itself. The incidence of cancer pain increases from one-third of patients in early stage disease to three-quarters in the advanced stages of cancer.1 Uncontrolled pain reduces a person’s quality of life, affects their response to illness, and limits their ability to self care.2 It is therefore extremely important that healthcare professionals manage cancer pain effectively regardless of disease stage or care setting. However, as more people prefer to be cared for at home by their primary care team, it has become increasingly important to be able to manage the symptoms of cancer pain effectively in this setting, thereby preventing unwanted hospital admissions.1
It has now been 3 years since the publication of SIGN 106 on Control of pain in adults with cancer3 and this article revisits this guideline, building on the summary that Dr Cormie wrote,4 and:
- highlights the key recommendations
- discusses the successes and ongoing challenges it presents
- examines some of the new pharmacological developments in this clinical area.
The patient should always remain at the centre of any management plan. Good communication between all professionals involved in the patient’s care is paramount to ensuring that pain is assessed accurately, appropriate treatment is commenced, side-effects are minimised, and compliance with the treatment plan is improved.5 The SIGN guideline emphasises that, ‘Patients value professionals who adopt a holistic approach to care and are competent in dealing with (and are able to communicate about) the spiritual, psychological, and emotional impact of pain.’3
Despite there being far more training opportunities available nowadays to support healthcare professionals in improving and maintaining our pain management and communication skills, keeping up to date remains a challenge for healthcare professionals as available resources to access these opportunities are becoming limited.
As the experience of pain is a highly complex phenomenon, its multidimensional nature must be acknowledged during its assessment and management. It is recommended that routine screening for psychological distress should be carried out using a validated tool.3 There is now strong evidence that components of cognitive behavioural therapy (CBT) have led to improvements in depression, social outcomes, objective physical outcomes, and quality of life.6 SIGN has therefore recommended that CBT be considered as part of a comprehensive treatment programme for those with cancer-related pain that results in distress and disability.3 However, ensuring that all patients with cancer have access to a healthcare professional who has this specialist knowledge remains a challenge.
Assessment of pain
The patient should be the prime assessor of their own pain as healthcare professionals have been shown to underestimate the level of pain a patient experiences, while family members tend to overestimate.3,7 The healthcare professional should take a detailed history in partnership with the patient. This information is vital to a comprehensive pain assessment and should include the elements shown in Box 1 (below).3
There are a number of validated pain assessment tools available but none have been accepted universally. The SIGN guideline recommends however that pain assessment should be carried out regularly (daily if not adequately controlled) and treatment outcomes monitored using visual analogue scales (VAS), verbal, or numerical rating scales (NRS)3 as these can also be used in an elderly population and where cognitive impairment is evident.8 Ideally, there should be consistency in the assessment tools used in primary and secondary care as this will help with the transition of patient care between the two sectors.
Following assessment of pain, healthcare professionals are accountable for ensuring that actions are taken promptly to maximise patients’ control of pain. All individuals who have complex and/or poorly controlled pain should be referred to the local specialist palliative care service. Therefore, all members of the healthcare team must be aware of the referral pathway to access these services.
|Box 1: Clinical history and physical examination in adults with cancer pain3|
Principles of pain management
The SIGN guideline states that, ‘All medical professionals have a responsibility to initiate immediate and short-term pain relieving measures while considering other analgesic options such as surgery, chemotherapy, or radiotherapy.’3 This should be implemented in line with the principles of treatment outlined in the World Health Organization (WHO) cancer pain relief programme. The WHO three-step ladder approach outlines treatment according to the severity of the patients’ pain, with interventions starting at the most appropriate rung of the ladder (see Figure 1).3
Figure 1: Adaptation of the WHO analgesic ladder to show analgesic treatment options3
*Non-opioids and adjuvants can be used at any step.
Treatment with non-opioid drugs
Non-opioid drugs can be used at any step of the WHO analgesic ladder. When used in combination with opioids they often result in better pain control at lower doses of opioids, thereby potentially reducing the opioid side-effects. It is therefore recommended that paracetamol and/or a non-steroidal anti-inflammatory drug (NSAID) is prescribed unless contraindicated.3
Bisphosphonates should be considered for the treatment of pain in patients who have metastatic bone disease, but there is insufficient evidence to recommend them for first-line therapy. Use of this therapy should include monitoring of calcium levels because of the risk of hypocalcaemia.3
A tricyclic antidepressant (e.g. amitriptyline or imipramine) or an anticonvulsant (e.g. gabapentin, carbamazepine, or phenytoin) should be offered to patients who are experiencing neuropathic pain. However, careful monitoring of side-effects is essential.3
It should be noted that in palliative care, up to a quarter of all prescriptions written are for licensed drugs given for unlicensed indications, and/or an unlicensed route.3
Treatment with opioid drugs
Codeine and dihydrocodeine are the weak opioids of choice for patients who have mild to moderate pain (step 2 on the WHO analgesic ladder). This is pain that patients would score 3–6 out of 10 on a VAS or NRS. There is limited evidence to indicate that tramadol should be considered as a step 2 analgesic and no evidence was found to support the superiority of cocodamol 8/500 over paracetamol alone.3
Patients who have moderate to severe pain (step 3 on WHO analgesic ladder) and who score their pain to be 7–10 out of 10 on VAS or NRS should be prescribed a strong opioid. There are a number of strong opioids used in the control of cancer pain, but morphine remains the oral drug of choice, with diamorphine as the parenteral drug of choice (because of its better solubility compared with morphine). Diamorphine is given predominantly via the subcutaneous route as this is more accepted by the patient and easier for the healthcare professional to administer.
Titration of morphine
The starting dose of immediate-release (IR) oral morphine for cancer pain should be determined by the severity of pain, the age and frailty of the patient, and their renal function. This dose will usually be between 2.5 and 10 mg and the patient should be advised to take this every 4 hours. The same dosage should also be prescribed on a when necessary (prn) basis and the patient advised to take this as often as is required for breakthrough pain (defined as a ‘transient flare of pain of moderate or severe intensity arising on a background of controlled pain’).3,9 Breakthrough pain can either be spontaneous (sudden and unexpected) or incident (associated with an action [e.g. movement]). Medication for breakthrough pain should be taken in anticipation of events that are likely to precipitate incident pain.3
If breakthrough doses are needed, both the regular and prn dose should be recalculated accordingly by totalling all doses taken in the previous 24-hour period and dividing this by six (e.g. 10 mg morphine IR 4 hourly [60 mg daily] plus three breakthrough doses
[i.e. 10 mg x 3] = 90 mg daily). The new dose prescribed should therefore be 15 mg morphine IR 4 hourly and 15 mg prn.
This process should be repeated on a daily basis until the pain is controlled. The 4-hourly dose of IR morphine can then be converted to a 12-hourly modified-release (MR) dose by dividing the effective total 24 hour dose by two (e.g. 20 mg morphine IR four hourly = 60 mg morphine MR twice daily and 20 mg morphine IR prn for breakthrough pain).
The patient or family member should be advised to keep a written record of all doses taken and their effectiveness, which will help with daily assessment during the titration phase. Education regarding actual and potential side-effects should also be provided. Opioid-naïve patients should have access to a prophylactic anti-emetic, which can be taken as required. The majority of patients taking opioids will develop constipation; however uncertainty remains about the best laxative to use.10 Therefore, the best prophylactic treatment for constipation continues to be a combination of a stimulant and a softening laxative.3
The use of the WHO analgesic ladder has been shown to manage pain effectively in approximately 75% of patients with cancer. However, despite dose titration and appropriate management of predictable side-effects, a minority of patients will need an opioid switch to improve the balance between efficacy and side-effects.3
Before switching opioids, a comprehensive reassessment of the patient’s pain and side-effects should be carried out and advice sought from specialist palliative care services if required.3
Although complementary therapies have increased in popularity, the evidence to support their use in the treatment of cancer pain remains weak.3
Radiotherapy should be considered for patients who have bone metastases and whose pain is difficult to control by pharmacological methods.3
Vertebroplasty for patients with vertebral collapse and cementoplasty for patients with pelvic bone metastases should also be considered when control of pain proves difficult with conventional means.3 A referral to an appropriate specialist may be necessary, however, as there is limited availability of these procedures.
Anaesthetic interventions such as coeliac plexus block and neuraxial opioids should be considered to improve pain control and quality of life for patients who have cancer pain that is difficult to control.3
Developments since 2008
There have been a number of developments in the management of breakthrough pain in patients with cancer since the SIGN 106 guideline was published. These include new formulations, such as fentanyl in buccal, oromucosal, nasal spray, and sublingual tablet form.
The Scottish Medicines Consortium has made recommendations on some of these new products
The current SIGN guideline on cancer pain is due to be considered for review this year, but the process of review is so lengthy that I do not expect to see a revised guideline for some time yet so we should continue to work with what we have and try to keep up to date with the new products that are becoming available. This is another challenge in itself.
On the whole, I believe that cancer pain is being managed more effectively now that we have this guideline. The primary care team has a crucial role to play in the management of patients’ symptoms as more people wish to be cared for at home, particularly in the last days and weeks of their lives. However, continually having to keep ourselves up to date with the latest developments remains a challenge because of the ever-decreasing resources that are required to enable us to attend educational events.
We have to maintain our ability to communicate well with our patients and colleagues to ensure that pain is managed optimally, with minimal side-effects, to improve quality of life. After all, surely this is what we would want for ourselves.
- Portenoy R. Cancer pain. Epidemiology and symptoms. Cancer 1989; 63 (11 Suppl): 2298–2307.
- Tittle M, McMillan S, Hagan S et al. Validating the brief pain inventory for use with surgical patients with cancer. Oncol Nurs Forum 2003; 30 (2): 325–330.
- Scottish Intercollegiate Guidelines Network. Control of pain in adults with cancer. SIGN 106. SIGN: Edinburgh, 2008. Available at: www.sign.ac.uk/guidelines/fulltext/106/index.html
- Cormie P. GPs can manage the challenge of severe cancer pain in adults. Guidelines in Practice 2009; 12 (4): 35–39.
- McLoughlin P. Community specialist palliative care: experiences of patients and carers. Int J Palliative Nurs 2002; 8 (7): 344–353.
- Graves K. Social cognitive therapy and cancer patients’ quality of life: a meta-analysis of psychosocial intervention components. Health Psychol 2003; 22 (2): 210–219.
- Cleeland C, Gonin R, Hatfield A et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994; 330 (9): 592–596.
- Littman G, Walker B, Schneider B et al. Reassessment of verbal and visual analog ratings in analgesic studies. Clin Pharmacol Ther 1985; 38 (1): 16–23.
- Portenoy R, Hagen N. Breakthrough pain: definition, prevalence and characteristics. Pain 1990; 41 (3): 273–281.
- Candy B, Jones L, Goodman M et al. Laxatives or methylnaltrexone for the management of constipation in palliative care patients: a Cochrane review. Cochrane Database Syst Rev 2011; (1): CD003448G