Green, E., Zwaal, C., Beals, C., Fitzgerald, B., Harle, I., Jones, J., . . . Wiernikowski, J. (2010). Cancer-related pain management: A report of evidence-based recommendations to guide practice. The Clinical Journal of Pain, 26, 449–462. 

To assess existing guidelines, related and unrelated to cancer, as a means of developing evidence-based, consensual recommendations regarding the management of cancer-related pain in adults and children with cancer

• Investigators retrieved 25 guidelines for review. Two or three panel members, working independently, scored each set of guidelines by using the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument to assess quality. Panel members evaluated the domains included in each set of guidelines, including target audience of healthcare providers, environment for which the guideline was written, and the population for whom it was written. Based on quality and domains, eight guidelines were selected as sources from which to extract information to use to develop recommendations.
• The database searched was MEDLINE, using the OVID system, 2000–May 2006. In addition, investigators searched the Internet to retrieve unpublished guidelines from Canadian and non-Canadian health organizations. The National Guidelines Clearinghouse, Guideline International Network, and the McMillan Group were included.
• Search keywords were pain, pain management, neoplasm, pediatric, aged, guideline, and practice guideline.

The reference provides AGREE scores for 11 aspects of pain management across the eight published guidelines as well as detailed recommendations for each of the aspects of pain management.

The authors reviewed these guidelines:

• Scottish Intercollegiate Guidelines Network (SIGN): Control of Pain in Patients With Cancer
• The American Geriatrics Society (AGS): The Management of Persistent Pain in Older Persons
• Registered Nurse Association of Ontario (RNAO): Assessment and Management of Pain
• National Breast Cancer Center and National Cancer Control Initiative (NBCC-NCCI), Australia: Clinical Practice Guidelines for the Psychosocial Care of Adults With Cancer
• Canadian Association of Nursing Oncology (CANO): Cancer Pain Management Manual
• American Pain Society (APS): Guideline for the Management of Cancer Pain in Adults and Children
• Canadian Pain Society (CPS): Accreditation Pain Standard: Making It Happen
• Cancer Care Nova Scotia (CCNS): Best Practice Guidelines for the Management of Cancer-Related Pain in Adults

The analysis led to the statements and recommendations that follow.

• Assessment of pain:
  • Patient self-reporting is the most reliable indicator of pain.
  • Assessment should include physical, functional, spiritual, and social domains of pain.
  • Assessment tools must be valid and appropriate to the age of the patient and the patient's population.
• Plan of care:
  • Establish a written plan of pain management. The plan should be interdisciplinary and consistent with individual and family goals. The guidelines list factors to be considered in the plan.
  • Patients, family members, and caregivers should receive a copy of the written pain management plan. The plan should include causes of pain; types and reasons for analgesic medications; instructions regarding dosage and titration; the side effects of analgesics; the name of the person to call if pain is not relieved or side effects occur; instructions about when and how to use nonpharmacologic approaches; instructions about filling and renewing prescriptions; and realistic goals, timelines, and expectations about pain control.
  • The plan should be updated upon reassessment.
  • Adherence to the plan and other factors should be reassessed at regular intervals and with each new report of pain.
• Pharmacologic Interventions
  • A key principle is to titrate analgesic dosage to achieve desired pain relief and minimize unwanted side effects. Selecting analgesics should involve consideration of pain intensity, patient age, comorbidities, concurrent drugs, prior treatment outcomes, patient preferences and convenience, and cost. The guidelines outline specific considerations relating to each of these areas.
  • Use the simplest analgesic dosage schedules and least-invasive modalities; however, using other than the oral route may be appropriate to provide immediate relief. The route should be tailored to the pain situation and the care setting.
  • The intramuscular route is not recommended.
  • The guidelines provide specific recommendations about opiod use, management of breakthrough pain, principles regarding dose titration, and use of long-acting opiods when dosages are stable. The guidelines recommend
    • Using the same opiod  for round-the-clock dosing and breakthrough pain.
    • Considering opiod rotation.
• Safety and efficacy:
  • To prevent barriers to pain relief, providers should know the difference between addiction, tolerance and dependency. The guidelines define each condition.
  • Respiratory impairment should not be a reason to avoid opiod use, but patients with respiratory impairment who are using opiods should be closely monitored.
  • Establish a protocol for the use of naloxone to manage opiod-induced respiratory depression.
• Side effects: Clinicians should anticipate side effects and institute prophylactic treatment to avoid them.
• Coanalgesic agents: These agents are important adjuncts for pain control. Anticonvulsants and antidepressants provide analgesia for specific types of pain. These should be used with extra caution when prescribed for the elderly.
• Nonpharmacologic interventions: Combine nonpharmacologic interventions with pharmacologic methods according to individual preferences and goals, including such things as psychosocial and spiritual support services.
• Specialty care: Provide access to specialists in cases involving complex pain problems, such as palliative radiation, pulse chemotherapy, spinal infusion, etc.
• Documentation: Documentation should comprise all components of the assessment, including the plan of care, information about interventions and patient responses, and a summary of all education provided to the patient and family. Documentation should be updated as often as pain is assessed or changes occur.
• Education: Education should be provided to patients, family members, and informal care providers, to clarify myths and misconceptions about tolerance and addiction and to promote involvement in effective pain management.
• Outcome measures: Use outcome measures as part of a formal process to evaluate and improve the quality of pain management across all disease stages and across all settings.

Authors did not identify any conflicts of interest.

This reference, a set of standards of practice, provides extensive and detailed guidance regarding all aspects of pain management. The standards can be a very useful reference through the entire process of pain management for patients with cancer.

Refer to the original document: This summary does not contain the full detail that the guidelines provide. The guidelines discuss opioid dosage determination in detail and recommend nonpharmacologic methods; however, the guidelines do not make specific recommendations about modality.