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Pain control in people with cancer remains a significant problem in health care even though cancer pain can be managed effectively in up to 90 percent of patients. Recognition of the widespread under-treatment of cancer pain has prompted recent corrective efforts from health care disciplines, professional and consumer organizations, and governments throughout the world.
The Clinical Practice Guideline for the Management of Cancer Pain was commissioned by the Agency for Health Care Policy and Research (AHCPR). It follows and makes reference to a 1992 guideline on acute pain management after surgery or trauma, also commissioned by AHCPR. This guideline is designed to help clinicians who work with oncology patients to understand the assessment and treatment of pain and associated symptoms. It also discusses briefly the management of pain in patients with human immunodeficiency virus (HIV) and/or acquired immunodeficiency syndrome (AIDS).
The guideline has ten goals:
Not all cancer pain or associated symptoms can be entirely eliminated, but available approaches, when appropriately and attentively 'applied, effectively relieve pain in most patients. The importance of effective pain management extends beyond analgesia to encompass the patient's quality of life and ability to function in the family and society.
Because patients vary greatly in their diagnoses and stage of disease progression, their responses to pain and interventions, and their personal preferences, the guideline offers a flexible approach to the management of cancer pain that clinicians can use in daily practice and adapt, as appropriate, to the treatment of painful noncancerous conditions.
The guideline emphasizes:
The guideline includes general strategies for pain management, as well as the management of specific pain syndromes, and it addresses issues related to special populations. It also contains a pain management flowchart, analgesic dosage tables, sample pain assessment tools, examples of nondrug interventions, and information about resources for patients and their families.
The first chapter is an overview of the prevalence of cancer and cancer pain. A key recommendation is that clinicians should reassure patients and their families that most pain can be relieved safely and effectively. Barriers to effective cancer pain management identified by the panel include problems related to health care professionals, to patients, and to the health care and drug regulatory system. The panel recommends that curricula for health professionals include sufficient content on pain to prepare clinicians to assess and manage pain effectively. The panel acknowledges that clinicians need to educate patients and their families about pain and its management and to encourage patients to be active participants in their care. Clinicians are encouraged to collaborate with patients and families, taking costs of drugs and technologies into account in selecting pain management strategies. The panel noted the need for Federal, State, and local laws and regulatory policies to be developed so as not to hamper the appropriate use of opioid analgesics for cancer pain. The first chapter presents a flowchart that indicates the need to use multiple modalities concurrently in pain management and emphasizes the need to begin with the least invasive methods capable of controlling the pain, titrating the pain treatment to the patient's needs. The process whereby panelists were selected, the methods used in the development of the guideline, and a summary of the scientific evidence for the interventions are presented.
Chapter 2 emphasizes the need for health professionals to ask patients about pain and to accept the patient's self-report as the primary source of assessment. The need for comprehensive assessment and careful documentation is discussed, with attention to initial evaluation and appraisal of any new pain that emerges. A mnemonic for the recommended clinical approach is given.
A discussion of the assessment of common cancer pain syndromes includes bone metastases, epidural metastases/spinal cord compression, plexopathies, peripheral neuropathies, acute and postherpetic neuralgia, abdominal pain, and mucositis.
The pharmacologic management of pain is presented in Chapter 3. The importance of individualizing the regimen to the patient and of using the simplest dosage schedules and least invasive pain management modalities is emphasized. The World Health Organization's analgesic ladder is discussed, with suggestions about how various drugs should be used alone and in combination. The need to make a distinction between opioid tolerance and physical dependence on the one hand and "addiction" on the other is stressed because the pervasive misconception that these three entities are the same hinders effective pain management.
Chapter 3 describes the use of nonsteroidal anti-inflammatory drugs and opioids, and discusses how to titrate drugs to effect for individual patients. Various routes of administration and the management of drug side effects are discussed. The panel noted that respiratory depression is infrequently a significant limiting factor in pain management because with repeated doses, tolerance develops. This tolerance allows adequate pain treatment without much risk of respiratory compromise. The person dying from cancer should not be allowed to live out life with unrelieved pain because of a fear of side effects; rather, appropriate, aggressive, palliative support should be given. The use of adjuvant drugs to increase the analgesic efficacy of opioids, to treat concurrent symptoms that exacerbate pain, and to provide independent analgesia for specific types of pain is described. Careful discharge planning when a patient moves from one setting to another is emphasized.
Chapters 4 and 5 discuss the nonpharmacologic management of pain. Chapter 4 includes recommendations for the use of physical modalities, including the use of superficial heat and cold, massage, exercise, transcutaneous electrical nerve stimulation, and acupuncture, and psychosocial interventions, including relaxation and imagery, distraction and refraining, patient education, psychotherapy and structured support, and hypnosis. For each modality, brief explanations are given regarding the mechanisms of operation and practical ways in which they can be applied in the patient care setting. The importance of referring patients to peer support groups and providing pastoral counseling for those who wish it is also emphasized.
Chapter 5 discusses more invasive therapies, including palliative radiation, anesthetic techniques including nerve blocks, neurosurgery, and palliative surgery. The panel recommends that, with rare exception, noninvasive treatment should precede invasive palliative approaches.
Chapter 6 describes the management of procedure-related pain. It discusses the use of drugs and other approaches for the relief of pain produced by the multiple invasive procedures that patients undergo as part of their treatment.
The discussion thus far in the guideline is largely focused on adult patients. Chapter 7 includes a discussion of a number of special populations for whom clinicians should give special attention and considerations, including the very young and very old, the cognitively impaired, known or suspected substance abusers, and non-English-speaking persons. When developing a pain treatment plan, clinicians should be aware of the unique needs and circumstances of patients from various ethnic and cultural backgrounds. The need for assessment methods appropriate for neonates, children, and adolescents is stressed. Elderly patients should be considered at risk for undertreatment of pain. Uncontrolled pain is an important factor contributing to feelings of hopelessness, suicidal ideation, and requests for clinician-assisted suicide or euthanasia; therefore, it should be aggressively assessed and treated. Because patients with current substance abuse disorders are at risk for undertreatment of cancer pain, their care should be managed by clinicians knowledgeable in both pain management and substance abuse. Because patients with HIV positive/AIDS often have pain problems similar to those of patients with cancer, recommendations for pain assessment and management in this guideline generally should be used for pain in these patients.
Chapter 8 discusses the need for monitoring the quality of pain management and for developing formal means within each institution to evaluate pain management practices and to obtain patient feedback to gauge the adequacy of pain control. Institutional policy should define who is responsible for pain management, the acceptable level of patient monitoring, and the appropriate roles and limits of practice for health care providers.
The nearly 500 consultants, peer reviewers, and site reviewers who contributed to the development of the guideline are listed. The Attachments contain tables showing the strength of evidence for recommendations, pain assessment instruments, and sample relaxation exercises.