The recommendations that follow are those from the guideline's executive summary; detailed recommendations can be found in the original guideline document. Each recommendation is rated based on the level of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, Good Practice Points) and level of the evidence (Level I-Level IV) are presented at the end of the Major Recommendations field.
General
A - Patients and their families should be reassured that most cancer pain can be relieved safely and effectively. (Grade A, Level Ib)
A - Involvement of a multidisciplinary team of specialists is associated with effective analgesia and better health outcomes. (Grade A, Level Ib)
GPP - Clinicians should assess patients for pain and provide optimal relief throughout the course of illness. (GPP)
Evaluation of Cancer Pain
A - Cancer pain should be comprehensively evaluated because this results in improved analgesia. (Grade A, Level Ib)
B - Health professionals should routinely ask about pain in cancer patients, and the patient's self-report should be the primary source of assessment. (Grade B, Level III)
B - An accurate assessment should be performed to determine the type and severity of pain and its effect on the patient prior to treatment.
(Grade B, Level III)
B - A simple formal assessment tool should be used in the ongoing assessment of pain. (Grade B, Level III)
B - Clinicians should be aware of common pain syndromes, because prompt recognition allows early therapy and minimizes the morbidity of unrelieved pain. (Grade B, Level III)
B - A thorough assessment of the patient's psychosocial state should be carried out. The clinician should look for anxiety and depression and ascertain the patient's beliefs about his or her pain. (Grade B, Level III)
B - Attention should be given to cultural and ethnic factors which may have a bearing on the patient's response to pain and pain control. (Grade B, Level III)
C - Sudden severe pain in patients with cancer should be recognized as a medical emergency and patients should be promptly assessed and treated. (Grade C, Level IV)
GPP - Clinicians should document the efficacy of pain relief at regular intervals after starting or changing treatment. Documentation forms should be readily accessible to all clinicians involved in the patient's care. (GPP)
Principles of Cancer Pain Management
B - The principles of treatment outlined in the World Health Organization (WHO) Cancer Pain Relief Programme should be followed when treating pain in patients with cancer. (Grade B, Level III)
B - Medications for persistent cancer-related pain should be administered on a round-the-clock basis with additional "as needed" doses, because regularly scheduled dosing maintains a constant level of drug in the body and helps to prevent a recurrence of pain. (Grade B, Level III)
GPP - The simplest dosage schedules and least invasive pain management modalities should be used first. (GPP)
GPP - Placebos should not be used in the management of cancer pain. (GPP)
Choice of Analgesic Therapy
B - A patient's treatment should start at the step of the WHO analgesic ladder appropriate for the severity of the pain. (Grade B, Level III)
B - If pain severity increases, the next step of the analgesic ladder should be taken. Another analgesic of the same potency should not be used. (Grade B, Level III)
A - Pharmacologic management of mild pain should include a nonsteroidal anti-inflammatory drug (NSAID) or paracetamol at recommended doses, unless there is a contraindication. (Grade A, Level Ia)
A - Patients receiving an NSAID who are at risk of gastrointestinal side effects should be prescribed famotidine 40 mg twice a day, misoprostol 200 micrograms four times a day, or omeprazole 20 mg once a day. (Grade A, Level Ib)
A - When pain persists or increases, an opioid should be added to the analgesic regimen. (Grade A, Level Ia)
B - All patients with moderate to severe pain should receive a trial of an opioid analgesic, regardless of the aetiology of the pain. (Grade B, Level IIa and IIb)
B - If the effect of an opioid for mild to moderate pain at optimum dose is not adequate, move to step 3 of the analgesic ladder. (Grade B, Level III)
Use of Opioids in the Treatment of Moderate to Severe Pain
B - The opioid of first choice for moderate to severe pain is morphine. (Grade B, Level III)
B - The optimal route of administration is by mouth. There should ideally be two types of oral formulations: immediate-release for dose titration and controlled-release for maintenance treatment. (Grade B, Level III)
B - The opioid dose for each patient should be individually titrated to achieve maximum analgesia and minimum side effects. (Grade B, Level III)
C - Where possible, opioid dose titration should be carried out with an immediate-release morphine preparation given every four hours to maintain constant levels of analgesia. (Grade C, Level IV)
A - Once suitable pain control is achieved by use of immediate-release morphine, conversion to the same total daily dose of controlled-release morphine should be considered. (Grade A, Level Ib)
C - Every patient on opioids for moderate to severe pain should have access to breakthrough analgesia, usually in the form of immediate-release morphine. The breakthrough dose should approximate one-sixth of the total daily dose of oral morphine. (Grade C, Level IV)
C - If patients are unable to take opioids orally, the rectal, transdermal, or subcutaneous route may be used. There is no indication for use of the intramuscular route for chronic cancer pain because the subcutaneous route is associated with less risk and less pain. (Grade C, Level IV)
C - The average relative potency ratio of oral to parenteral morphine is 1:3. (Grade C, Level IV)
B - A small proportion of patients develop intolerable side effects with oral morphine. In such patients a change to an alternative opioid or a change in the route of administration should be considered. (Grade B, Level III)
A - Transdermal fentanyl is an effective alternative to oral morphine but is best reserved for patients with stable opioid requirements. (Grade A, Level Ib)
C - Methadone is an effective alternative drug but is more difficult to use than other opioids because of pronounced inter- and intra-individual differences in its duration of action and relative analgesic potency. Its use by non-specialist practitioners is not recommended. (Grade C, Level IV)
B - Patients receiving opioid agonists should not be given a mixed agonist-antagonist because of the risk of precipitating a withdrawal syndrome and exacerbation of pain. (Grade B, Level IIb)
B - Pethidine should not be used if continued opioid use is anticipated. (Grade B, Level IIa)
B - Spinal (epidural or intrathecal) administration of opioid analgesics in combination with local anaesthetics or clonidine should be considered in patients who derive inadequate analgesia or suffer intolerable side effects despite the optimal use of systemic opioids and non-opioids. (Grade B, Level III)
Specific Issues Regarding Opioid Use
A - Specific interventions to treat the adverse effects of opioid therapy are efficacious. (Grade A, Level Ib)
B - Constipation is a common problem associated with long-term opioid administration and should be treated prophylactically. (Grade B, Level III)
B - When naloxone is given to reverse opioid-induced respiratory depression, it should be titrated to improve respiratory function, but with preservation of analgesia. (Grade B, Level IIb)
C - Mental clouding or confusion due to opioid toxicity should be managed by reducing the dose of opioid, ensuring adequate hydration, and treating the agitation/confusion with a neuroleptic, such as haloperidol. (Grade C, Level IV)
B - Initiation of opioids should not be delayed due to unfounded fears concerning psychological dependence or addiction. (Grade B, Level III)
B - Patients prescribed opioids for pain should be reassured that they will not become psychologically dependent on or addicted to their opioid analgesia. (Grade B, Level III)
Adjuvant Drugs
A - Patients with neuropathic pain should have a trial of a tricyclic antidepressant and/or an anticonvulsant. (Grade A, Level Ia and Ib)
C - A trial of steroids should be considered for raised intracranial pressure, severe bone pain, nerve infiltration or compression, pressure due to soft tissue swelling or infiltration, and spinal cord compression. (Grade C, Level IV)
Bisphosphonates
A - Bisphosphonate treatment should be considered in addition to conventional analgesic techniques for all patients with multiple myeloma and for breast cancer patients who have pain due to metastatic bone disease. (Grade A, Level Ia and Ib)
Anti-tumour Therapy
C - Systemic chemotherapy should be considered for cancers which are highly chemosensitive. (Grade C, Level IV)
C - Hormonal manipulation may contribute to pain relief in hormone sensitive cancers. (Grade C, Level IV)
C - Radiotherapy is effective in relieving pain due to tumour infiltration. (Grade C, Level IV)
C - When using anti-tumour therapy, concomitant use of effective analgesics must not be neglected. (Grade C, Level IV)
Interventional Techniques
C - Professionals who manage patients with cancer pain should be aware of the range of interventional techniques available for the relief of pain and have access to a specialist pain clinic providing a range of interventional techniques. (Grade C, Level IV)
GPP- Non-invasive therapies should precede invasive treatments, except in rare instances. (GPP)
A - Coeliac plexus block should be considered in patients with upper abdominal pain, especially when secondary to pancreatic cancer. (Grade A, Level Ia and Ib)
A - Epidural, intrathecal, and intraventricular opioids should be considered in treatment of cancer pain not controlled with opioids by other routes. (Grade A, Level Ia and Ib)
Non-pharmacologic Management: Physical and Psychosocial Modalities
C - Cutaneous stimulation techniques, such as application of superficial heat and cold, massage, pressure, and vibration, may provide pain relief when the source of pain is associated with muscle tension or spasm. (Grade C, Level IV)
A - Patients should remain active and participate in self-care when possible. (Grade A, Level Ib)
B - Prolonged bed-rest for cancer patients should be avoided because prolonged immobilization may lead to joint contractures, muscle atrophy, cardiovascular deconditioning, and other undesirable effects. (Grade B, Level III)
A - Psychosocial interventions should be used concurrently with pharmacological treatment for pain as part of a multidisciplinary approach to pain management and not as substitutes for analgesics. (Grade A, Level Ib)
B - Education on effective pain control modalities and correction of misconceptions relating to the use of opioids should be a routine part of patient management. (Grade B, Level III)
GPP - Pastoral care team members should participate in health care team meetings that discuss the needs and treatment of patients. They should be conversant with community resources that provide spiritual care and support for patients and their families. (GPP)
Pain in Special Populations
B - Clinicians should give special attention to the assessment and treatment of pain in special populations, including the very young, the very old, the cognitively impaired, and known or suspected substance abusers. Aggressive pain assessment and management are as necessary for them as for the general population. (Grade B, Level III)
B - Behavioural observation should be the primary assessment method for preverbal and nonverbal children and should be used as an adjunct for assessment of verbal children. (Grade B, Level III)
B - In older children, assessment includes self-report using age-appropriate scales, such as the Faces Pain Scale and the Numeric Rating Scale. Observation should be used as an adjunct to self-report. (Grade B, Level IIb)
C - Oral medication in children with cancer pain should follow the WHO analgesic ladder, with dosage adjustments. The basic principles of opioid use are similar to those in adults. (Grade C, Level IV)
GPP - Assessment in the cognitively intact elderly patient with cancer pain should be done in ways similar to that of the general adult population. (GPP)
B - Behavioural observation should be an adjunct to cancer pain assessment in cognitively impaired adults. (Grade B, Level III)
C - Non-opioid analgesic modalities should not be substituted for opioid analgesics to treat severe pain in the suspected or known substance abuser. (Grade C, Level IV)
Definitions:
Grades of Recommendations
Grade A (evidence levels Ia, Ib): Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation.
Grade B (evidence levels IIa, IIb, III): Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation.
Grade C (evidence level IV): Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality.
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group.
Levels of Evidence
Level Ia: Evidence obtained from meta-analysis of randomised controlled trials.
Level Ib: Evidence obtained from at least one randomised controlled trial.
Level IIa: Evidence obtained from at least one well-designed controlled study without randomisation.
Level IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study.
Level III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies.
Level IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.
