The Agency for Healthcare Research and Quality (AHRQ) recommends physicians follow these guidelines when determining the type and scope of pain therapy:
An essential principle in using medications to manage cancer pain is to individualize the regimen to the patient.
The simplest dosage schedules and least invasive pain management modalities should be used first.
Pharmacological management of mild to moderate cancer pain should include a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen, unless there is a contraindication.
When pain persists or increases, an opioid should be added.
Treatment of persistent or moderate to severe pain should be based on increasing the opioid potency or dose.
Medications for persistent cancer-related pain should be administered on an around-the-clock basis with additional "as-needed" doses because regularly scheduled dosing maintains a constant level of drug in the body and helps to prevent a recurrence of pain.
Patients receiving opioid agonists should not be given a mixed agonist-antagonist because doing so may precipitate a withdrawal syndrome and increase pain.
Meperidine (J2175) should not be used if continued opioid use is anticipated.
Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with addiction.
The oral route is the preferred route of analgesic administration because it is the most convenient and cost-effective method of administration. When patients cannot take medications orally, rectal and transdermal routes should be considered because they are also relatively noninvasive.
Intramuscular administration of drugs should be avoided because this route can be painful and inconvenient, and absorption is not reliable.
Failure of maximal systemic doses of opioids and co- analgesics should precede the consideration of intraspinal analgesic systems.
Because there is great interindividual variation in susceptibility to opioid-induced side effects, clinicians should monitor for these potential side effects.
Constipation is a common problem associated with long-term opioid administration and should be anticipated, treated prophylactically and monitored constantly.
Naloxone, J2310, when indicated for reversal of opioid-induced respiratory depression, should be titrated in doses that improve respiratory function but do not reverse analgesia.
Placebos should not be used in the management of cancer pain.
Patients should be given a written pain management plan.
Communication about pain management should occur when a patient is transferred from one setting to another.
Note: The entire guideline is on the agency's Web site,
www.AHRQ.gov.
