Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Psychosocial Issues
Psychological Distress
B - Comprehensive chronic pain assessment should include routine screening for psychological distress.
A - Cognitive behaviour therapy should be considered as part of a comprehensive treatment programme for those with cancer related pain and resulting distress and disability.
Psychological Factors and Adherence to Treatment
D - Patient beliefs concerning pain should be assessed and discussed as part of a comprehensive, biopsychosocial cancer pain assessment.
C - Patients should receive education about the range of pain control interventions available to them.
Assessment of Pain
What is Pain?
For the purposes of this guideline, pain has been defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."
A comprehensive assessment of pain should consider the following domains:
- Physical effects/manifestations of pain
- Functional effects (interference with activities of daily living)
- Psychological factors (level of anxiety, cultural influences, fears, effects on interpersonal relationships, factors affecting pain tolerance, (see Table below)
- Spiritual aspects
Table. Factors Affecting Pain Tolerance
| Aspects That Lower Pain Tolerance |
Aspects That Raise Pain Tolerance |
|
Discomfort
Insomnia
Fatigue
Anxiety
Fear
Anger
Boredom
Sadness
Depression
Introversion
Social abandonment
Mental isolation
|
Relief of symptoms
Sleep
Rest, or paradoxically, physiotherapy
Relaxation therapy
Explanation/support
Understanding/empathy
Diversional activity
Companionship/listening
Elevation of mood
Understanding of the meaning and significance of the pain
Social inclusion
Encouragement to express emotions
|
Adapted from Twycross R, Lack S. Symptom control in far advanced cancer: pain relief London: Pitman; 1983.
Why Assess Pain?
D - Prior to treatment an accurate assessment should be performed to determine the cause, type and severity of pain, and its effect on the patient.
Who Should Assess Pain?
D - The patient should be the prime assessor of his or her pain.
How Should Pain Be Assessed?
D - Patients with cancer pain should have treatment outcomes monitored regularly using visual analogue scales, numerical rating scales or verbal rating scales.
C - Self assessment pain scales should be used in patients with cognitive impairment, where feasible.
C - Observational pain rating scales should be used in patients who cannot complete a self assessment scale.
Principles of Pain Management
B - Patients should be given information and instruction about pain and pain management and be encouraged to take an active role in their pain management.
World Health Organization (WHO) Cancer Pain Relief Programme
D - The principles of treatment outlined in the WHO cancer pain relief programme should be followed when treating pain in patients with cancer.
Using the WHO Analgesic Ladder
B - A patient's treatment should start at the step of the WHO analgesic ladder appropriate for the severity of the pain.
B - Prescribing of analgesia should always be adjusted as the pain severity alters.
D - Analgesia for continuous pain should be prescribed on a regular basis, not 'as required'.
D - Appropriate analgesia for breakthrough pain must be prescribed.
Treatment with Non-Opioid Drugs
Paracetamol and Non-Steroidal Anti-Inflammatory Drugs
A - Patients at all stages of the WHO analgesic ladder should be prescribed paracetamol and/or a non-steroidal anti-inflammatory drug unless contraindicated.
A - Patients taking non-steroidal anti-inflammatory drugs who are at high risk of gastrointestinal complications should be prescribed either misoprostol 800 mcg/day, standard dose proton pump inhibitors or double dose histamine-2 receptor antagonists as pharmacological prophylaxis.
Bisphosphonates
B - Bisphosphonates should be considered as part of the therapeutic regimen for the treatment of pain in patients with metastatic bone disease.
Antidepressants and Anticonvulsants
A - Patients with neuropathic pain should be given either a tricyclic antidepressant (e.g., amitriptyline or imipramine) or anticonvulsant (e.g., gabapentin, carbamazepine or phenytoin) with careful monitoring of side effects.
Cannabinoids
A - Cannabinoids are not recommended for the treatment of cancer pain.
Treatment with Opioid Drugs
Choice of Opioid
Mild to Moderate Pain (Step 2 of the WHO Ladder)
D - For mild to moderate pain, (score 3-6 out of 10 on a visual analogue scale or a numerical rating scale) weak opioids such as codeine should be given in combination with a non-opioid analgesic.
Moderate to Severe Pain (Step 3 of the WHO Ladder)
D - Oral morphine is recommended as first line therapy to treat severe pain in patients with cancer.
D - Diamorphine is recommended as first line subcutaneous therapy to treat severe pain in patients with cancer.
Breakthrough Pain
D - Patients with moderate or severe breakthrough pain should receive breakthrough analgesia.
D - When using oral morphine for breakthrough pain the dose should be one sixth of the around the clock morphine dose and should be increased appropriately whenever the around the clock dose is increased.
Patients with Renal Impairment
C - In the presence of reduced kidney function all opioids should be used with caution and at reduced doses and/or frequency.
Administration of Opioids
D - Continuous subcutaneous infusion of opioids is simpler to administer and equally as effective as continuous intravenous infusion and should be considered for patients unable to take opioids orally.
D - Advice on stability of commonly used drug combinations for continuous subcutaneous infusion should be available to staff who prepare these infusions.
D - Advice on the use of other combinations should be taken from palliative care specialists.
D - Patients with stable pain on oral morphine should be prescribed a once or twice daily modified release preparation.
D - Patients with stable pain on oral oxycodone should be prescribed a twice daily modified release preparation.
Non-Pharmacological Treatment
Radiotherapy for Relieving Pain in Patients with Bone Metastases
B - All patients with pain from bone metastases which is proving difficult to control by pharmacological means should be referred to a clinical oncologist for consideration of external beam radiotherapy or radioisotope treatment.
Cementoplasty
D - Patients with bone pain from malignant vertebral collapse proving difficult to control by pharmacological means should be referred for consideration of vertebroplasty where this technique is available.
D - Patients with bone pain from pelvic bone metastases proving difficult to control by pharmacological means and reduced mobility should be considered for percutaneous cementoplasty.
Anaesthetic Interventions
B - Interventions such as coeliac plexus block and neuraxial opioids should be considered to improve pain control and quality of life in patients with difficult to control cancer pain.
Definitions:
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g., case reports, case series)
4: Expert opinion
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review, or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group
