Treatment Guideline Chart
Cancer pain is an unpleasant sensory & emotional experience due to actual or potential tissue damage in patients with cancer.
Effective pain management in cancer patients with pain is an essential part of oncologic management due to increasing evidence of survival.
Pancreatic, head & neck cancer has a high prevalence of cancer pain.
During initial evaluation, follow-ups and new therapy initiation of patients with cancer, it is essential that they will be screened & evaluated for pain.

Cancer%20pain Management

Follow Up

  • To ensure that the selected analgesic therapy has given the patient maximum benefit with as few adverse effects as possible, reassessment of pain intensity must be done at specified intervals
  • Patients on long-term opioid therapy should be assessed for abuse, addiction, tolerance or dependence
  • Consider opioid dose reduction by 10-20% in the following situations:
    • Breakthrough analgesic was rarely or never needed
    • Acute pain event has been completed
    • Improvement of pain control through use of non-opioid pain management therapies is evident
    • Well-controlled pain in the setting of stable disease
  • Opioid reduction by 10-20% can be considered in patients not needing or rarely needs breakthrough analgesia, those who completed an acute pain event or response to cancer-directed therapies, or there is noted improvement in pain control with non-opioid agents
  • Opioid reduction by 10-25% can be considered in patients with unmanageable adverse effects and mild pain
    • Re-evaluate after dose reduction and have a close follow-up to make sure there is no pain escalation or withdrawal symptoms despite the dose reduction
  • Opioid reduction by 50-75% is necessary in patients who have significant safety issues

Specialist Referral

  • Patients may be referred to a psychiatrist for psychological support, or to a substance abuse specialist for patients on long-term opioid therapy with signs of drug addiction, abuse, dependence or tolerance
  • Consider physical or occupational therapy consultation for advice on the use of physical modalities
  • Referral to a clinical nutrition specialist for nutrition consult, dietary recommendations and information on herbal, botanical and dietary supplements is recommended
  • Orthopedic consultation should be considered in patients experiencing pain
  • Referral to a pain or palliative care specialist for refractory symptoms or intractable pain or for guidance on Methadone prescribing is recommended
  • Consider referral to a clinical pharmacogenomics specialist to aid in drug selection and dose adjustments based on pharmacogenomic test results
    • Agents for consideration include:
      • CYP2D6: Codeine, Tramadol
      • CYP2C19 and CYP2D6: Amitriptyline, Doxepin
      • CYP2C9: Celecoxib, Meloxicam, Ibuprofen
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