What are the NCCN guidelines on palliative care for cancer pain?

Updated: Aug 13, 2018
  • Author: Winston W Tan, MD, FACP; more...
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Answer

Answer

National Comprehensive Cancer Network (NCCN) guidelines identify general principles of pain management and provide specific recommendations for assessment, management, and reassessment of cancer pain in adults. Major recommendations include the following [7] :

  • Consider interventions in the context of patient-specific goals for comfort, function, and safety
  • Patients with an acute pain crisis may be candidates for hospital admission to achieve goals for comfort and function
  • Identify pain related to an oncologic emergency
  • For pain not related to an oncologic emergency, discriminate opioid-tolerant patients from opioid-naïve patients (ie, those with versus those without long-term exposure to opioids)

Assessment

Assessment recommendations are as follows:

  • All patients should be screened for pain at every contact
  • Pain intensity must be quantified and documented and the quality characterized by the patient, whenever possible
  • Include patient reporting of breakthrough pain, treatments used and their impact on pain; patient reporting of adequate comfort; patient reporting of satisfaction with pain relief; provider assessment of impact on function; and any special issues for the patient relevant to pain treatment
  • Comprehensive pain assessment for persisting pain or new pain should be performed to determine the etiology, pathophysiology, specific cancer pain syndrome, and patient goals for comfort and function

Management

For opioid-tolerant patients who have breakthrough pain of intensity ≥4 (on a scale of 0-10) or whose goals of pain control and function are not met, management is as follows [6] :

  • Administer a rescue dose of a short-acting opioid, equivalent to 10-20% of the total long-acting or regularly schedule oral opioid dose taken in the previous 24 hours
  • Assess efficacy and adverse effects every 60 minutes for oral opioids and every 15 minutes for IV opioids
  • If pain assessment is unchanged or increased, increase the rescue dose by 50-100%
  • If the pain score decreases, repeat the opioid dose and reassess at 60 minutes for oral opioids and 15 minutes for IV opioids
  • If the pain score remains unchanged after two to three cycles, consider changing the route of administration from oral to IV or explore alternative management strategies
  • If the pain score decreases to 0-3, give the current effective dose as needed over 24 hours before proceeding to subsequent management strategies
  • Ongoing need for repeated rescue doses may indicate a need for adjustment of the regularly scheduled opioid dose
  • Consider rapidly acting transmucosal fentanyl for brief episodes of incident pain not attributed to inadequate dosing of around-the-clock opioid

Subsequent management is based on the continued pain rating score and includes the following:

  • Regular doses of opioids, with rescue doses as needed
  • Management of constipation
  • Social support and education for patients and families

For ongoing care, if an acceptable level of comfort and function has been achieved and the patient’s 24-hour opioid requirement is stable, convert to an extended-release oral medication (if feasible) or other extended-release formulation (e, transdermal fentanyl).


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