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(6), 449–462. 

DOI Link

Purpose & Patient Population

PURPOSE: To provide evidence-based and consensus recommendations for the management of cancer-related pain to guide practice by assessing existing guidelines to develop standards of care

TYPES OF PATIENTS ADDRESSED: All patients with cancer including pediatric cases, the elderly, the cognitively impaired, and culturally diverse patients. Both non-cancer and cancer-related pain guidelines were considered.

Type of Resource/Evidence-Based Process

PROCESS OF DEVELOPMENT: Participants were the Cancer Care Ontario’s Cancer-Related Pain Management Guideline Panel. No conflicts of interest were identified. Twenty-five guidelines were retrieved for review. Each was independently reviewed and scored by two or three panel members using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument to assess quality.
 
DATABASES USED: MEDLINE (Ovid 2000 through May 2006) Internet search was done to retrieve unpublished guidelines from Canadian and international health organizations. The National Guidelines Clearinghouse, Guideline International Network, and the McMillan Group were also included.
 
KEYWORDS: Pain, pain management, neoplasm, pediatric, aged, guideline, practice guideline

Phase of Care and Clinical Applications

APPLICATIONS: Elder care, end of life care, pediatrics

Results Provided in the Reference

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

Guidelines & Recommendations

Assessment of Pain
  • Patient self-report is the most reliable indicator of pain.
  • Valid assessment tools need to be used and need to be age and population appropriate.
Plan of Care
  • Establish a written plan for pain management. Patients, family members, and caregivers should receive a written pain management plan. 
  • 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.  
  • Specific guidelines for opioid use, management of breakthrough pain, principles for dose titration, and use of long acting opioids when dosages are stable are provided. It is recommended that the same opioid for breakthrough pain is used for round-the-clock dosing, and opioid rotation should be considered.
Common Side Effects
  • Side effects should be anticipated, and prophylactic treatment should be instituted.
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 in the elderly.
Nonpharmacologic intervention should be combined with pharmacologic methods based on individual preferences and goals, including such things as psychosocial and spiritual support services.
 
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 should be used in a formal process to evaluate and improve the quality of pain management across all stages of the disease process and across all settings.

Nursing Implications

This reference provides extensive and detailed guidance in all aspects of pain management as a set of standards of practice. This can be a very useful reference for healthcare providers during the entire process of pain management for patients with cancer.
 
Opioid dosage determination is discussed in detail. Nonpharmacologic methods are recommended for consideration; however, specific modality recommendations are not made.