Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline

Clinical Question

How should chronic pain be managed in the adult cancer survivor?

Screening and Comprehensive Assessment

Recommendation

Clinicians should screen for pain at each encounter. Screening should be performed and documented using a quantitative or semiquantitative tool. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: strong)

Recommendation

Clinicians should conduct an initial comprehensive pain assessment. This assessment should include an in-depth interview that explores the multidimensional nature of the pain (pain descriptors, associated distress, functional impact, and related physical, psychological, social, and spiritual factors) and captures information about cancer treatment history and comorbid conditions, psychosocial and psychiatric history (including substance use), and prior treatments for the pain. The assessment should characterize the pain, clarify its cause, and make inferences about pathophysiology. A physical examination should accompany the history, and diagnostic testing should be performed when warranted. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate)

Recommendation

Clinicians should be aware of chronic pain syndromes resulting from cancer treatments, the prevalence of these pain syndromes, risk factors for individual patients, and appropriate treatment options. A list of common cancer pain syndromes can be found in Table 3 in the original guideline document. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate)

Recommendation

Clinicians should evaluate and monitor for recurrent disease, second malignancy, or late-onset treatment effects in any patient who reports new-onset pain. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate)

Treatment and Care Options

Recommendation

Clinicians should aim to enhance comfort, improve function, limit adverse events, and ensure safety in the management of pain in cancer survivors. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate)

Recommendation

Clinicians should engage patient and family/caregivers in all aspects of pain assessment and management. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate)

Recommendation

Clinicians should determine the need for other health professionals to provide comprehensive pain management care in patients with complex needs. If deemed necessary, the clinician should define who is responsible for each aspect of care and refer patients accordingly. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate)

Nonpharmacologic Interventions

Recommendation

Clinicians may prescribe directly or refer patients to other professionals to provide the interventions outlined in Table 4 in the original guideline document to mitigate chronic pain or improve pain-related outcomes in cancer survivors. These interventions must take into consideration pre-existing diagnoses and comorbidities and should include an assessment for adverse events. (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)

Pharmacologic Interventions: Miscellaneous Analgesics

Recommendation

Clinicians may prescribe the following systemic nonopioid analgesics and adjuvant analgesics to relieve chronic pain and/or improve function in cancer survivors in whom no contraindications, including serious drug–drug interactions exist:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)


• Acetaminophen (paracetamol)


• Adjuvant analgesics, including selected antidepressants and selected anticonvulsants with evidence of analgesic efficacy (such as the antidepressant duloxetine and the anticonvulsants gabapentin and pregabalin) for neuropathic pain conditions or chronic widespread pain

(Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)

Recommendation

Clinicians may prescribe topical analgesics (such as commercially available NSAIDs; local anesthetics; or compounded creams/gels containing baclofen, amitriptyline, and ketamine) for the management of chronic pain. (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)

Recommendation

Corticosteroids are not recommended for long-term use in cancer survivors solely to relieve chronic pain. (Evidence-based; harms outweigh benefits; evidence quality: intermediate; strength of recommendation: moderate)

Recommendation

Clinicians should assess the risks of adverse effects of pharmacologic therapies, including nonopioids, adjuvant analgesics, and other agents used for pain management. (Evidence-based and informal consensus; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)

Recommendation

Clinicians may follow specific state regulations that allow access to medical cannabis or cannabinoids for patients with chronic pain after a consideration of the potential benefits and risks of the available formulations. (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)

Pharmacologic Interventions: Opioids

Recommendation

Clinicians may prescribe a trial of opioids in carefully selected cancer survivors with chronic pain who do not respond to more conservative management and who continue to experience pain-related distress or functional impairment. Tables 5 and 6 in the original guideline document provide guidelines intended to promote safe and effective prescribing. Nonopioid analgesics and/or adjuvants can be added as clinically necessary. (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)

Recommendation

Clinicians should assess the risks of adverse effects of opioids used for pain management. Table 7 in the original guideline document lists opioid-related long-term adverse effects. (Evidence-based and informal consensus; benefits outweigh harms; evidence quality: intermediate strength of recommendation: moderate)

Risk Assessment and Mitigation and Universal Precautions with Opioid Use

Recommendation

Clinicians should assess the potential risks and benefits when initiating treatment that will incorporate long-term use of opioids. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate)

Recommendation

Clinicians should clearly understand terminology such as tolerance, dependence, abuse, and addiction as it relates to the use of opioids for pain control. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate)

Recommendation

Clinicians should incorporate a universal precautions approach to minimize abuse, addiction, and adverse consequences of opioid use such as opioid-related deaths. Clinicians should be cautious in coprescribing other centrally acting drugs, particularly benzodiazepines (see Table 7 in the original guideline document). (Evidence-based and informal consensus; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)

Recommendation

Clinicians should understand pertinent laws and regulations regarding the prescribing of controlled substances. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate)

Recommendation

Clinicians should educate patients and family members regarding the risks and benefits of long-term opioid therapy and the safe storage, use, and disposal of controlled substances. Clinicians are encouraged to address possible myths and misconceptions about medication use and should educate patients about the need to be cautious when using alcohol or sedating over-the-counter medications, or in receiving centrally acting medications from other physicians. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate)

Recommendation

If opioids are no longer warranted, clinicians should taper the dose to avoid abstinence syndrome. The rate of tapering and the use of cotherapies to reduce adverse effects should be individualized for each patient. (Evidence-based and informal consensus; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate).

You can read the full Guideline by clicking on the link :

Paice JA, Portenoy R, Lacchetti C, Campbell T, Cheville A, Citron M, Constine LS, Cooper A, Glare P, Keefe F, Koyyalagunta L, Levy M, Miaskowski C, Otis-Green S, Sloan P, Bruera E. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2016 Sep 20;34(27):3325-45. [114 references]