| Assessment of cancer pain |
Use self-assessment tools |
Revista’s faces pain rating scale
Wong-Baker faces pain rating scale
Numerical rating scale
Qualitative scale
Edmonton symptom assessment scale
Brief pain summary |
| Use hetero-assessment tools |
Pain assessment in advanced dementia
Observer scale
Portuguese version of the pain Behavioral Pain Scale |
| Assess the characteristics of the cancer pain |
Intensity
Frequency
Type of pain (somatic, visceral, neuropathic pain or mixed)
Location and/or presence of irradiation
Pain duration and pattern (continuous/end of dose/irruptive)
Relief and exacerbation factors
Response to current and rescue analgesic scheme
Existence of other associated symptoms
Interference in daily life activities |
| Assess psychoemotional state |
Degree of concern with the disease
Degree of anxiety
Previous diagnosis of depression and/or personality disorders
Presence of suicidal ideation
Presence of spiritual concerns |
| Check for the existence of other comorbidities and/or addictive behaviors |
| Check for the completion of previous or current cancer treatments |
| Perform comprehensive analysis of the cancer pain etiology with analytical and imaging results |
| Pharmacological treatment of cancer pain |
Mild pain(WHO Step I – NRS 1-3) |
Paracetamol (max dose: 4g/day
NSAIDS: ibuprofen (max dose: 3200mg) and ketorolac (15-30mg EV 6/6h) maximum of 5 days
Protonic pump inhibitors or H2 receptor blockers in the treatment with NSAIDS Discontinue NSAIDS if
the liver function increases 1.5 of the normal limit |
| Mild or moderate pain (WHO step II - NRS 4-6) |
Weak opioids: codeine (≤360mg/day) or tramadol (≤400mg/day: 100mg 4x/day) PO
If inadequate control, use strong opioids in small doses: morphine (≤30mg/day), oxycodone (≤20mg/
day) and hydromorphone (≤4mg/day) |
| From moderate to severe (WHO step III - NRS 7-10) |
Severe and unstable pain it is recommended fast absorption formulas
Non-opioid pain relievers should be used simultaneously with opioids in continuous pain
The regular dose of strong opioids may be increased in persons with continuous pain (no ceiling dose)
Transdermal Fentanyl or buprenorphine are alternatives in the difficulty swallowing or grade 4 or 5 renal
failure
Tapentadol is a centrally acting opioid analgesic, recommended for neuropathic pain, with an initial
dose of 50-100 mg PO, with a maximum dose of 500 mg/day every 12 hours |
| Pharmacological treatment of cancer pain |
From moderate to severe refractory pain (WHO step IV – NRS 7-10) |
Invasive techniques are recommended for severe pain
1) related to the innervation zones of nerve plexuses;
2) no response to opioid rotation;
3) with need for administration of higher doses of opioids;
4) significant adverse effects with conventional methods
Not recommended in coagulopathy, immunosuppression and life expectation of fewer than 6
months
The spinal pathways (epidural and subarachnoid) allows the neuroaxis blockade. In epidural, it
is only necessary 20-40% of the systemic dose for equianalgesic. For the subarachnoid route, it
should be used 10% of the opioid systemic dose
The effectiveness of local administration of anesthetic agents is higher than in subcutaneous
administration
Morphine and local anesthetics, such as bupivacaine are the most recommended
For visceral pain, it is recommended the use of sympathetic system blockade |
| Titration |
Performed with a supplementation of strong opioid (equivalent to 10-15% of the usual total dose)
of the same drug, but always for quick action
Oral or intravenous
Injection is indicated for quick pain control
Methadone has a variable half-life. Therefore titration is recommended during 5-7 days |
| Rotation ofopioids |
For equianalgesic purpose, the full dose of opioids for 24 hours should be computed
Take into consideration when it is not possible to achieve a satisfactory balance between pain relief
and adverse effects
Start with a lower dose than the one calculated by the equianalgesic tables
Start only with transdermal opioids in pain reasonably controlled |
| Neuropathic pain |
Antidepressants and anticonvulsants are considered first-line adjuvants
It is recommended the inclusion of anticonvulsants in neuropathic stabbing pain (like shock) under
opioids:
1) carbamazepine (100 mg 2 x/day up to a maximum of 400 mg/day) attention only for pain in the
head region up to 1200 mg/day
2) gabapentin (100 to 300 mg in a single dose at night to reduce sedation, it can be titrated to a
maximum of 900mg-3600/day divided in 2 or 3 intakes)
3) pregabalin (start with a dose of 50mg 3x/day and increase to 100mg, up to a maximum of 600mg)
Tricyclic antidepressants (amitriptyline) should be started at low doses 10-25mg/day up to 75mg
(it must be titrated within 1 or 2 weeks to minimize side effects: sedation, dry mouth, and urinary
urgency)
Associate dexamethasone for bone, visceral and neuropathic pain in acute situations (4 to 8mg 2
to 3 x/day)
Ketamine in low doses can produce analgesia and modulate central sensitization, hyperalgesia,
and tolerance to opioids |
| Visceral pain (Malignant Bowel Obstruction) |
Octreotide subcutaneously or intravenously (0.1 to 0.2 mg 8/8h or 12/12h) to reduce gastrointestinal
secretions
Butylscopolamine and the steroids can be used in association, with food intervals and possible
gastric intubation for decompression |
| Breakthrough pain |
It occurs when baseline pain is relatively controlled
It reaches its peak at 5 minutes, with a short duration (between 30-60 min), occurring 3-4 times/day
If it appears at the end of opioid half-life, one should not advance the next shot, but increase the
dose of the long-acting regular opioid and/or reduce the interval between doses
If the triggering stimulus is identified, it is recommended to use a prophylactic rescue dose (10-
20% of the usual daily quick absorption dose), before this stimulus
The need to use frequent rescue doses means that the regular dose schedule should be changed
Strong opioids are recommended for 1st line treatment
Opioid titration, the introduction of adjuvants and regular, timely intake are important control measures
For rescue therapy, it is recommended fast-acting opioids
Use the same fast-acting opioid and keep it in the long-acting formulation
The efficacy of EV morphine compared to transmucosal fentanyl is superior to the 15 minutes. At
30 minutes, there is no statistically significant difference
There is no equianalgesic dose for transmucosal fentanyl, thus it should start with low doses and
be carefully titrated |
| Delivery path |
Preferably select oral administration, it reduces the incidence of adverse effects
Subcutaneous administration is simple and effective for morphine, being the first choice when oral
or transdermal options are not available
EV may be considered when subcutaneous is contraindicated: anasarca, clotting disorders, peripheral
hypoperfusion, need for infusion of high volumes or doses) |
| Pharmacological treatment of cancer pain |
Control of adverse effects |
Obstipation |
Introduce laxatives during the administration of opioids
Persistent obstipation requires the combination of laxatives with different modes
of action
Cleansing enemas or microclisteres as the last resource and in isolated situations
In severe obstipation, it is recommended the exclusion of bowel obstruction
In chronic obstipation, it is recommended opioid rotation
Encourage rich fiber diet, adequate water intake, and moderate physical exercise |
| Nausea and vomiting |
Metoclopramide (10-15mg PO 3 x/day) or haloperidol (0.5-1mg PO 6-8hours) with
attention to the occurrence of dyskinesia in prolonged use
Identify the nausea etiology (CNS disease, chemotherapy, radiotherapy, and
hyperkalemia)
In persistent nausea/vomiting situation, consider the use of serotonin antagonists,
like ondansetron or granisetron
The use of dexamethasone and olanzapine may be considered 2.5-5mg, especially
in cases of bowel obstruction |
| Overdose/sleepiness/prostration |
In renal failure grade 4/5 (glomerular filtration rate < 30 mL/min) administration of
lower doses of opioids, followed by careful titration
Adverse effects of chemotherapy, angiogenesis inhibitors: thrombocytopenia, coagulopathy,
renal, hepatic and cardiovascular toxicity can be enhanced with simultaneous
NSAIDS
Adequate water intake to prevent the accumulation of serum metabolites, responsible
for drowsiness and renal failure |
| Respiratory depression |
Monitor risk factorsAdministration of naloxone (0.4mg/1mL) in 10mL of saline solution and give 1-2mL for 30-60seg. It may be necessary to repeat since the opioids half-life is longer than naloxone (30-60minutos) |
| Non-pharmacological treatment of cancer pain |
Individualization of nursing care
Inclusion of the relevant person in the therapeutic plan
Psychoemotional support
Counseling/education for health self-management/health education opportunity
Phone call follow-up
Phone helpline
Newsletter, with analgesic schema included
Relaxation techniques and guided image
Hypnosis
Transcutaneous electrical nerve stimulation
Therapeutic massage, application of heat
Music therapy
Nurse as case manager in therapy compliance |
| Training in cancer pain |
Evidence-based practice: integration of good practice guidelines
Auditing and feedback on practices for cancer pain control |
