National Comprehensive Cancer Network.( 2011). NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain [v.2.2011]. Retrieved from http://www.nccn.org/professionals/physician_gls/f_guidelines.asp

NCCN categories of evidence and consensus are described. Unless otherwise stated, all recommendations are reported to be category 2A, indicating a low level of evidence and uniform NCCN consensus. Specific process for evidence rating and consensus development is not described in the document. In addition, a search strategy was not described.

The NCCN guidelines document recommends universal screening for pain and provides an algorithm for comprehensive assessment and management approaches based on etiology of pain and current status with regard to pharmacologic management.

For opioid-naïve patients:

• Rapidly titrate short-acting opiods for moderate and severe pain, and consider for mild pain.
• Consider nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for mild pain.
• Consider addition of co-analgesics for all pain levels based on the specific pain syndrome.

For opioid-tolerant patients:

• An algorithm is provided for dose increases based on timing of peak effect and patient response. Initial calculation for titration is 10%–20% of the previous 24-hour dose, and if pain is unchanged or increased, an increased dose of 50%–100%.

For all cases, recommendations include:

• Regular pain medication dosing with rescue medications as needed
• Ongoing reassessment and regimen modification to manage pain and minimize adverse effects

For specific pain syndromes:

• Inflammation–A trial of NSAIDS or glucocorticoid
• Nerve compression or inflammation–A trial of glucocorticoid
• Bone pain without emergency–NSAIDS titrated to effect, consideration of nerve block or local radiation therapy for local pain, trial of biphophonates, hormonal or chemotherapy, and radioisotopes for diffuse bone pain
• Neuropathic pain–A trial of antidepressants, anticonvulsants, or topical agents

The major limitations of these guidelines are:

• Recommendations are mainly consensus based
• Recommendations are associated with low levels of evidence

The NCCN guidelines document provides comprehensive decision making algorithms for assessment, severity grading, and management of cancer-related pain. The guidelines also provide assessment tools, titration schedule examples, and conversion tables for medications and conversion to transdermal fentanyl. An additional offering are suggestions regarding the management of a variety of opioid adverse effects. (A trial of adjunctive medications are suggested for neuropathic pain as a pain management approach.)