Practice review: Evidence-based and effective management of pain in patients with advanced cancer

Abstract

Background: Pain of a moderate or severe intensity affects over half of patients with advanced cancer and remains undertreated in at least one-third of these patients. Aim: The aim of this study was to provide a pragmatic overview of the evidence supporting the use of interventions in pain management in advanced cancer and to identify where encouraging preliminary results are demonstrated but further research is required. Design: A scoping review approach was used to examine the evidence supporting the use of guideline-recommended interventions in pain management practice. Data sources: National or international guidelines were selected if they described pain management in adult cancer patients and were written within the last 5 years in English. The Cochrane Database of Systematic Reviews (January 2014 to January 2019) was searched for ‘cancer’ AND ‘pain’ in the title, abstract or keywords. A MEDLINE search was also made. Results: A strong opioid remains the drug of choice for treating moderate or severe pain. Bisphosphonates and radiotherapy are also effective for cancer-related bone pain. Optimal management requires a tailored approach, support for self-management and review of treatment outcomes. There is likely a role for non-pharmacological approaches. Paracetamol should not be used in patients taking a strong opioid to treat pain. Cannabis-based medicines are not recommended. Weak opioids, ketamine and lidocaine are indicated in specific situations only. Conclusion: Interventions commonly recommended by guidelines are not always supported by a robust evidence base. Research is required to evaluate the efficacy of non-steroidal anti-inflammatory drugs, anti-convulsants, anti-depressants, corticosteroids, some invasive anaesthetic techniques, complementary therapies and transcutaneous electrical nerve stimulation.

Bone Cancer Pain, Mechanism and Treatment

“…Caution must be exercised with weak opioids as the rate of metabolism by Cytochrome P450 enzymes defines analgesic efficacy and side effects. In addition, codeine seemed effective for only 1 month until strong opioids were necessary for adequate analgesia [90,91]. A randomized RCT trial showed significant impairment of cancer pain by low-dose morphine compared with weak opioids, with similar tolerability and an earlier effect, suggesting low-dose morphine can be used [90,92].…”

Independent Research on Cancer Pain Management in the Setting of Early Palliative Care: A Flywheel to Counteract General Opioid Misuse and Abuse

“…One unintended consequence of the opioid fight against the epidemic has been the major decrease in daily opioid dose prescribed to patients with cancer pain by oncologists [ 3 ]. Based on a search of Cochrane Database of Systematic Reviews (January 2014 to January 2019), complemented by a MEDLINE search in mid 2019, a recent review of eight national and international guidelines on pain management in adult cancer patients, has highlighted that a large majority of interventions commonly recommended by guidelines are not always supported by a robust evidence base [ 4 ]. In our opinion, this is particularly true for the management of moderate cancer pain.…”

Knowledge and Attitudes of Home Care Nurses in Cyprus in the Management of Cancer Pain

“…[5][6][7][8][9] Nurses are generally aware of the severity of symptoms in cancer patients, 3 but effective pain management is inextricably related to accurate and adequate knowledge, positive attitudes as well as assessment and evaluation skills. 10,11 Several studies highlighted shortcomings in the management of cancer pain, with reference to nurses' knowledge, attitudes and beliefs. [12][13][14][15] The findings from relevant international studies, demonstrate a need for improvement with regards to effective pain management.…”

“…9,19 There are also concerns about the absence of evidence based standard guidelines and recommendations for the management of pain for patients with advanced cancer, leaving home care nurses unaided in their responsibility to support patients. 10 However, apart from knowledge and the personal aspect of health care professionals, pain management could be understood better within the general palliative care concept. This could be achieved with a good integration of palliative care into the health care systems and the national cancer strategy within the public health models.…”

“…This could be achieved with a good integration of palliative care into the health care systems and the national cancer strategy within the public health models. 10,20,21 Still, knowledge that is the focus of this study is also important since it empowers nurses making them to feel confident, competent, and more efficient when providing care to cancer patients at home. Knowledge and competence alleviate potential fears about the side effects of various drugs, such as opioids and possibility of addiction.…”