1. The Task Force thanks those who responded to surveys on cancer pain management, reviewed guideline drafts, contributed oral and written testimony to the Open Forum, and participated in tests of clinical feasibility. These agents may be added at any stage (Table 7Template 7). The electronic search covered a 30-yr period from 1966 through 1995. Washington, DC, National Academy, 1990, 1992; and (2) Woolf SH: Manual for Clinical Practice Guidelines Development. The Task Force supports the use of these analgesic modalities, when appropriate, before employment of more invasive systemic therapies. The guidelines provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data (Appendix 1). The panel of consultants and Task Force members support the importance of home parenteral therapy in increasing analgesia and enhancing patient quality of life. A knowledge of common pain syndromes is a prerequisite for conducting a cancer pain evaluation. Interobserver agreement was established through assessment of interrater reliability testing. Paradigm for the Management of Cancer Pain, V. Management of Cancer-related Symptoms and Adverse Effects of Pain Therapy, VI. Involvement of Specialists from Multiple Disciplines, IV. The literature does not suggest that management of symptoms or adverse effects has an effect on analgesia. Recognition, Assessment, and Management of Psychosocial Factors, IX. Psychosocial interventions for pain management and interventions to treat psychosocial consequences from cancer pain and pain management improve analgesia, reduce adverse effects of pain therapy, and improve quality of life. The literature suggests that a comprehensive cancer pain evaluation is associated with improved analgesia. b. Neuroablation: Neuroablative techniques should be initiated (1) when systemic therapies have failed to provide adequate pain control or when adverse side effects from systemic therapies are unacceptable; (2) after failure of neuraxial drug administration; (3) early in the natural history of the cancer pain in the presence of selected focal somatic lesions (e.g., rib metastases), visceral (e.g., cancer of the pancreas), or neuropathic (e.g., craniofacial) pain that is believed to be highly responsive to neuroablation with limited risk; or (4) patient preference indicates use of neuroablative techniques, if appropriate. The odds of adverse effects (e.g., sedation, nausea, vomiting) were greater for weak opioids versus NSAID groups (odds ratio 1.95, 99% confidence limits 1.45-2.46, Z = 3.10, P < 0.001). These guidelines are intended for varying populations and are developed using differing methodologies. Table 1. Neuraxial drug delivery and neuroablative therapies should not be used: (1) in individuals who are unmotivated or noncompliant or do not possess the cognitive functioning necessary to understand the risks and benefits and (2) when an appropriate logistical system does not exist. On the other hand, consideration of life expectancy is moot with cryoanalgesia because of the potential for nerve regeneration associated with the technique. Tolerance refers to the progressive decline in the potency of an opioid with continued use, such that increasingly greater doses are needed to achieve the same degree of analgesia. Rectal administration usually is considered when oral therapy is temporarily unavailable (e.g., nausea and vomiting refractory to therapy), although long-term use is effective in some patients. If analgesia is not achieved with neural blockade or significant adverse sequelae result, neuroablation should be reconsidered. Washington, DC, US Department of Health and Human Services, Agency for Health Care Policy and Research, publication number 91-0007, March 1991. 2005. Journals (n = 116) represented by the 350 articles included the following disciplines: anesthesiology, 205; oncology, 36; internal medicine, 3; neurology, 4; neurosurgery, 34; nursing, 8; palliative care, 27; pediatrics, 6; pharmacology, 9; psychology, 14; and radiology, 4. Template 4. In Bader et al 2010 87 Miaskowski C, Cleary J, Burney R, Coyne P, Finley R, Foster R et al, 2005. For children who can communicate verbally, age-appropriate pain scales are the recommended self-report instruments when evaluating the efficacy of pain therapy. Brant, JM, Stringer, LH. Table 5. Prophylactic or symptomatic therapy should involve the use of bulk agents, osmotic laxatives (e.g., magnesium or sodium salts, lactulose or sorbitol), and/or stimulant cathartics (e.g., senna or bisacodyl). Pittsburgh, PA. Oncology Nursing Society; 2015:505-529. Reversal of respiratory depression with naloxone does not obviate the need to consider other possible etiologies or pursue further evaluation. Several evidence-based guidelines recommend the use of multimodal pain management that has opioid-sparing effects to decrease the incidence of opioid-related adverse events (American Society of Anesthesiologists Task Force on Acute Pain Management, 2012, National Comprehensive Cancer Network, 2018). A stool softener may be concomitantly used with the aforementioned agents. In an effort to reduce the burden of under assessment and inadequate treatment of pain, the American Pain Society (APS) in 1996 instituted the “pain as the 5th vital sign” campaign based on quality improvement guidelines published the previous year.1 The aim of the campaign was to make pain assessment and measurement as important a measure of patient wellbeing as the existing four vital … e. Myoclonus: Myoclonus is not usually a clinical problem, and reassurance should be given to patients regarding its benign nature. When tolerance to an opioid develops, incomplete cross-tolerance to other opioids concomitantly develops. Significance levels from the weighted Stouffer combined test for clinical efficacy were significant for linkages 3 (multiple disciplines) and 5a (neuraxial drug delivery). A directional result for each study was determined initially by classifying the outcome as either supporting a linkage, refuting a linkage, or neutral. J Clin Oncol. Pain. The decision to implement primary therapy should be based on a comprehensive assessment of risks and benefits and are outside the scope of these guidelines. A procedure based on the Mantel-Haenszel method for combining study results using 2 x 2 tables was used when sufficient outcome frequency information was available. General Recommendations. Recommendations for the oral administration of analgesics are provided by the World Health Organization (WHO) analgesic ladder (Table 4Template 4). Key words: Pain: cancer. Please note that ArticlePlus files may launch a viewer application outside of your web browser. However, even with proper needle placement under fluoroscopic guidance, successful neural blockade does not ensure the subsequent success of a neurodestructive procedure. 7. b. Neuroablation: The literature suggests and consultants and Task Force members support the view that neuroablation by chemical and thermal neurolysis or surgery can provide long-term control of severe cancer pain without a substantial incidence of adverse effects. Comprehensive evaluation and assessment of pain (i.e., history, physical examination, laboratory evaluation) improve analgesia, reduce adverse effects of pain therapy, and improve quality of life. The literature suggests that child-specific interventions are associated with improved analgesia and health outcomes. If respiratory depression occurs in a patient taking stable opioid doses without abrupt resolution of pain due to a major therapeutic maneuver, an explanation other than opioid toxicity should be sought (e.g., pulmonary embolism). Home parenteral therapy improves analgesia, reduces adverse effects of pain therapy, and improves quality of life. Statistical Summary: Combined Test Results. Template 5. Recommendations: The anesthesiologist should give special attention to the assessment of pain in pediatric patients. For long-term therapies, appropriate home care must be available and functionally integrated into the office, hospital, and community. Physical dependence is a physiologic state characterized by withdrawal (abstinence syndrome) after abrupt discontinuation of an opioid. This is exceedingly rare among cancer patients who are given opioids. In such cases, another opioid can be substituted to provide better analgesia. All professionals caring for patients with cancer have an ethical responsibility to acquire and use current knowledge and skills to assess cancer pain and implement evidence-based pain management guidelines while being good stewards of pain treatment options, especially in the use of opioids. Two combined probability tests were employed as follows: (1) Fisher's combined test, producing chi-square values based on logarithmic transformations of the reported P values from the independent studies, and (2) the Stouffer combined test, providing representation of the studies by weighting each of the standard normal deviates by the size of the sample. A report by the American Society of Anesthesiologists Task Force on Pain Management, Cancer Pain Section. The practice of applying universal precautions, a 10-step approach to the assessment and management for patients with chronic pain, 17 has gained increasing attention in the general and cancer population since its conception in 2005. Template 4. Direct drug delivery systems (i.e., neuraxial drug delivery (epidural, subarachnoid, intraventricular), neural blockade (diagnostic blockade, neural blockade for pain management), and neuroablation (chemical, thermal, and surgical neurolysis)) improve analgesia, reduce adverse effects of pain therapy, and improve quality of life. c. A knowledge of oncologic emergencies (e.g., hypercalcemia, spinal cord compression, cardiac tamponade, superior vena cava syndrome) is also required to conduct a comprehensive cancer pain evaluation. End-of-life care is intended to improve patient comfort and quality of life by means of palliative therapies, including but not limited to anxiolytics, skin care, mouth care, massage, and appetite stimulants. Scientific evidence was derived from aggregated research literature with metaanalyses when appropriate, surveys, open presentations, and other consensus-oriented activities. Invasive systemic therapies and direct delivery systems should be used when oral and noninvasive analgesic deliveries do not achieve sufficient analgesia, or side effects make their continued use untenable. 2. Significance levels from the weighted Stouffer combined tests for beneficial outcomes were significant for linkages 3 (multiple disciplines), 6 (symptoms or adverse effects), and 9 (end-of-life care). 6. Longitudinal monitoring of pain (e.g., patient self-report, rating scales, and frequency of pain ratings) improves analgesia, reduces adverse effects of pain therapy, and improves quality of life. 2. Recommendations: Anesthesiologists who engage in cancer pain management should avail themselves of interdisciplinary expertise in their clinical environments. The anesthesiologist should determine whether the patient and/or significant others are motivated and competent to care for sophisticated delivery systems. B. The literature provides supportive evidence for specific elements of the paradigm ( Table 5 Template 5). (Note: the simultaneous use of more than one NSAID or the concomitant use of an NSAID with a glucocorticoid is not recommended because the risk of toxicity is increased, and additional analgesia is not achieved.) To provide evidence-based guidance on the optimum management of chronic pain in adult cancer survivors. (Note: Sufficient literature is not available to assess the effectiveness of neural blockade as either a prognostic procedure or a long-term analgesic modality for the treatment of cancer pain.). Sedation is a common adverse effect associated with the analgesic therapy of cancer pain. Management of cancer-related symptoms, side effects of cancer treatment, and adverse effects from pain therapy (e.g., use of antiemetics and laxatives) improves analgesia, reduces adverse effects of pain therapy, and improves quality of life. Commonly Used Adjuvant Analgesics, a. 8. Rating Scale. 6. The goal of cancer pain management is to relieve pain to a level that allows for an acceptable quality of life. Age-appropriate assessment includes behavioral observation (e.g., facial expressions, crying) and self-reports using age-appropriate scales (e.g., visual analog scale, facial pain scale). When extended life expectancy is anticipated, subarachnoid catheter placement should be considered because epidural catheters may become obstructed. When pain is continuous or occurs frequently, medication generally should be administered around-the-clock with additional "rescue" doses available for breakthrough pain. Paradigm for the management of cancer pain. The aims of these guidelines are to provide guidance to health-care providers (i.e. (Note: the simultaneous use of more than one NSAID or the concomitant use of an NSAID with a glucocorticoid is not recommended because the risk of toxicity is increased, and additional analgesia is not achieved.) Subcutaneous administration provides blood levels similar to intravenous infusion, and the comparative risks and benefits of the continuous parenteral techniques have not been evaluated. It is important to note that the patient's primary physician must be a part of the coordination of pain management. The percentage of consultants supporting each linkage is reported in Table 9. Because it is not effective in all patients and may not be optimal therapy in painful crisis (i.e., the pain emergency), the indications, risks, and potential benefits of alternative interventions must be understood and assessed. A reduction in opioid dose or a switch to a different opioid should be considered in the face of refractory or severe myoclonus. Patient Self-report. Available by calling 800-227-2345. Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. b. Rectal and transdermal: Use of an alternative route of administration, specifically rectal or transdermal, should be chosen before use of invasive therapies. Practice guidelines are not intended as standards or absolute requirements. Home parenteral therapy improves analgesia, reduces adverse effects of pain therapy, and improves quality of life. Home parenteral therapy includes subcutaneous, intravenous, and neuraxial drug delivery techniques, either on an outpatient basis or with the assistance of a home health-care provider. Other potential agents for neuraxial drug delivery are under development. Table 6. Algorithm for comprehensive evaluation and longitudinal assessment of cancer pain. Involvement of specialists in multiple disciplines improves analgesia, reduces adverse effects of pain therapy, and improves quality of life. When pain is continuous or occurs frequently, medication generally should be administered around-the-clock with additional "rescue" doses available for breakthrough pain. Frequency of Pain Ratings. Sufficient data were not available in the literature to conduct Mantel-Haenszel analyses on these linkages. The literature did not consistently report analgesic requirements of the patients studied, which may vary over time as a function of the natural history of the disease. The ladder presents a framework for the rational use of oral medication before application of other techniques of drug administration. Copyright 1996 by the American Society of Anesthesiologists, Inc. When extended life expectancy is anticipated, subarachnoid catheter placement should be considered because epidural catheters may become obstructed. American Pain Society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Pain diaries and counseling should be considered to enhance medication compliance, if needed. Patient Self-report. C. Focus. For children unable to communicate verbally, observation of patient behavior should be the primary assessment tool. b. Rectal and transdermal analgesia: The literature suggests that rectal and transdermal modes of analgesia are effective alternatives to oral analgesics. It is important to note that the patient's primary physician must be a part of the coordination of pain management. b. Rectal and transdermal: Use of an alternative route of administration, specifically rectal or transdermal, should be chosen before use of invasive therapies. Although great strides have been made in increasing awareness of the need for effective cancer pain control, barriers persist that lead to undertreatment. Physical dependence is a physiologic state characterized by withdrawal (abstinence syndrome) after abrupt discontinuation of an opioid. Clinical observations confirm that most patients with stable pain do not require dose escalation to maintain relief. Assessment of Scientific Evidence and Consultant Opinion, Appendix 2. The Task Force and panel of consultants support the conduct of a comprehensive pain evaluation. Liquids or suspensions should be employed whenever possible, because many children find them more palatable than pills. Other potential agents for neuraxial drug delivery are under development. Indirect drug delivery systems rely on blood-borne carriage of analgesic to receptors after (1) systemic absorption, (2) formation of a depot for sustained and continuous release, or (3) administration into the blood stream. The Task Force identifies four fundamental features that should guide the comprehensive evaluation of the patient with cancer pain. Administration of oral medications to children should follow the schema of the WHO analgesic ladder, with particular attention paid to age-appropriate dosing regimens. A report by the American Society of Anesthesiologists Task Force on Pain Management, Cancer Pain Section. The clinical guidelines and recommendations in this document are organized into three focal areas: Oral medications should be used as the first line approach in most patients when initiating analgesic therapy. Practice guidelines: cancer pain management. Consultants, in general, were highly supportive of the linkages (i.e., agreed that they provided analgesic benefit, reduced risk of adverse outcomes, improved other cancer-related symptoms, improved quality of life, and were important issues for the guidelines to address). 5. Combined probability tests were applied to continuous data, and an odds-ratio procedure was applied to dichotomous study results. Readers with special interest in the statistical analyses used in establishing these guidelines can receive further information by writing to the American Society of Anesthesiologists: 520 North Northwest Highway, Park Ridge, Illinois 60068-2573. The findings of the literature analyses were supplemented by the opinions of Task Force members as well as by surveys of the opinions of a panel of consultants with expertise in cancer pain management (n = 72). a. Constipation: All patients with an increased risk for constipation should receive prophylaxis (Appendix 2). Background: The American Pain Society (APS) set out to revise and expand its 1995 Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain and to facilitate improvements in the quality of pain management in all care settings. An assessment must be made as to whether appropriate professional services and supplies are obtainable in specific locales, because special planning may be required in rural areas. Edited by Field MJ, Lohr KN. The consultants were asked to indicate which, if any, of the evidence linkages would change their clinical practices if the guidelines were instituted. However, aspects of these guidelines may be useful when comprehensive pain management cannot be offered. c. Physical examination: A physical examination should include general medical and neurologic examinations and a specific examination of the site of pain and surrounding anatomic regions. The manual search covered a 48-yr period from 1948 through 1995. a. Results of the psychosocial assessment should be considered when formulating a pain treatment plan. Neural blockade should be performed at the time of potential neuroablation and should not be performed as a separate procedure. Invasive systemic therapies and direct delivery systems should be used when oral and noninvasive analgesic deliveries do not achieve sufficient analgesia, or side effects make their continued use untenable. Management of cancer pain: ESMO Clinical Practice Guidelines. 7. Dosage should be immediately reduced, and opioids should be weaned to avoid respiratory depression, which may occur in the setting of abrupt pain relief. Tax ID Number: 13-1788491. Definition of Cancer Pain. The decision to implement primary therapy should be based on a comprehensive assessment of risks and benefits and are outside the scope of these guidelines. Neural blockade is used alone for short-term pain management with specific indications (see below). Metaanalysis was not performed on linkage 4 (indirect drug delivery systems) for either efficacy or outcomes because literature was not conducive to an appropriate assessment. Table 7. Indirect drug delivery systems rely on blood-borne carriage of analgesic to receptors after (1) systemic absorption, (2) formation of a depot for sustained and continuous release, or (3) administration into the blood stream. For purposes of literature aggregation, potentially relevant clinical studies were identified via electronic and manual searches of the literature. Rate of return of the survey was 65% (n = 46 of 71). The Task Force has not given preference to literature based on any particular system of definition or classification of cancer pain. Practice guidelines: cancer pain management. Consultant Responses to Evidence Linkages Survey (n = 58). In some cases, ondansetron or meclizine can be helpful. g. Urinary retention: Urinary retention is also rare with chronic opioid administration and should be treated by administration of a direct cholinomimetic agent, such as bethanecol. Recognition and Management of Special Features of Pediatric Cancer Pain Management, Appendix 1. Addiction implies compulsive behavior and psychological dependence. General Recommendations. A Guide to Oncology Symptom Management. Common pain syndromes include but are not limited to bone metastases, abdominal (visceral) pain, neuropathic pain (e.g., peripheral neuropathies, acute herpes zoster and postherpetic neuralgia, plexopathies), and mucositis. To provide evidence-based guidance on the optimum management of chronic pain in adult cancer survivors. WHO has developed Guidelines for the pharmacologic and radiotherapeutic management of cancer pain in adults and adolescents to provide evidence-based guidance to initiating and managing cancer pain. Anesthesiology. Table 2. Purposes of the Guidelines. The patient and family must be educated in the use of the home therapy system. Transdermal fentanyl should be used in patients with stable pain states who are (1) noncompliant with oral medication, (2) unable to swallow or absorb, or (3) may benefit from a trial of fentanyl. Sufficient data were not available in the literature to conduct Mantel-Haenszel analyses on these linkages. Physical dependence does not imply addiction. —Quality improvement programs to improve treatment of acute pain and cancer pain should include five key elements: (1) Assuring that a report of unrelieved pain raises a "red flag" that attracts clinicians' attention; (2) making information about analgesics convenient where orders are written; (3) promising patients responsive analgesic care and urging them to communicate pain; (4) implementing … Elements. 1. Recommendations: The management of cancer pain must be integrated into a comprehensive care system that may include hospice and psychosocial support for patients and their families. Pharmacologic interventions designed for children's use include but are not limited to (1) adjustment of dosage to those levels specific for children and (2) interventions designed to be less invasive or to alleviate patient fears or anxieties about their pain therapy (e.g., topical anesthetics as premedication). The recommendations for intravenous administration are the same as for subcutaneous administration. Collaboration with palliative care providers is recommended to maximize patient comfort and improve patient and family quality of life. Address reprint requests to the American Society of Anesthesiologists: 520 North Northwest Highway, Park Ridge, Illinois 60068-2573. Every attempt should be made to minimize repetitive exposure to needles, if possible. In certain specific circumstances, neuraxial drug delivery or neuroablative therapies should be considered at the initiation of therapy or early in the natural history of the pain (see below). Rate of return of the survey was 65% (n = 46 of 71). For some age groups and populations (e.g., the cognitively or developmentally impaired), external observation may be preferable. American Cancer Society's Guide to Pain Control. The American Society of Interventional Pain Physicians (ASIPP) is pleased to announce a partnership with Willow Risk Advisors to create an exclusive policy available to ASIPP members. Geneva, World Health Organization, 1990 (technical report series, no. The consultants were asked to indicate which, if any, of the evidence linkages would change their clinical practices if the guidelines were instituted. Mental clouding or cognitive impairment can vary from mild mental clouding to frank delirium. Arch Intern Med 165(14):1574-1580. The literature supports the efficacy of interventions designed to manage symptoms related to primary disease and its treatment. (Note: Besides consideration of a change in opioid, an increase in pain intensity should prompt a reevaluation of the cause of pain.). The purpose of these guidelines is to: (1) optimize pain control; (2) minimize side effects, adverse outcomes, and costs; (3) enhance functional abilities and physical and psychological well-being; and (4) enhance the quality of life for cancer patients. Of the 20% of respondents who reported an anticipated increase in time spent on a typical case, the mean was 36.1 min (range 10-120 min). Neuroablation refers to the chemical, thermal, or surgical destruction of neural tissue. The weighted Stouffer test for linkage 9 (end-of-life care) was not significant. Cancer pain management remains an area where, in selected difficult cases, destructive neurosurgical procedures can be appropriate because the limited life expectancy minimises the risk of secondary deafferentation pain. The recommendations for intravenous administration are the same as for subcutaneous administration. (Note: Respiratory depression is rare in the cancer patient receiving chronic opioid therapy (Appendix 2)). Weighted effect size estimates ranged from r = 0.13 to r = 0.34, demonstrating small-to-moderate effect size estimates. 86 Cancer pain management (general). Oral medications: Oral medications such as acetaminophen, acetylsalicylic acid or other nonsteroidal antiinflammatory drugs (NSAIDs) should be employed first for mild to moderate pain. The literature, Task Force members, and consultants are supportive of the efficacy of palliative therapies for cancer patients approaching the end of life. 2016;124:535–552. 2. 3. Cancer: supportive care; symptom management. 9. The purpose of these guidelines is to: (1) optimize pain control; (2) minimize side effects, adverse outcomes, and costs; (3) enhance functional abilities and physical and psychological well-being; and (4) enhance the quality of life for cancer patients. However, if myoclonus impairs function, prevents sleep, or increases pain, clonazepam or valproate should be administered. Template 6. a. A Guide to Oncology Symptom Management. d. A thorough knowledge of the modalities that can be employed in the treatment of painful crisis (i.e., pain emergency) is also necessary. Pain intensity scales. Copyright 1996 by the American Society of Anesthesiologists, Inc. Template 3. Opioid therapy is considered the mainstay approach for patients with moderate or severe pain. The literature provides supportive evidence for specific elements of the paradigm (Table 5Template 5). None reported that the guidelines would reduce the amount of time spent per case. A. Patient-controlled analgesia (intravenous or subcutaneous) is a viable alternative when children are of sufficient cognitive age. 2. 1. Once an opioid and a route of administration are chosen, the dose should be increased until a favorable response occurs or when unmanageable or intolerable adverse effects ensue. b. Psychosocial evaluation: A psychosocial evaluation should include: (1) the presence of psychological symptoms (e.g., anxiety, depression), (2) indicators of psychiatric disorder (e.g., delirium, major depression), (3) investigation of the "meaning" of the pain to the patient and his or her significant others, (4) changes in mood state, (5) premorbid and current coping mechanisms, (6) family function, (7) the availability of psychosocial support systems, and (8) assessment of the patient's expectations and preconceptions regarding pain management (e.g., fear of addiction surrounding opioids, psychostimulants). An acceptable significance level was set at P < 0.01 (one-tailed), and effect-size estimates were calculated. Consultants, in general, were highly supportive of the linkages (i.e., agreed that they provided analgesic benefit, reduced risk of adverse outcomes, improved other cancer-related symptoms, improved quality of life, and were important issues for the guidelines to address). Recognition, Assessment, and Management of Psychosocial Factors, IX. Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. 1. The literature relating to linkages 3 (involvement of specialists from multiple disciplines), 5a (neuraxial, i.e., epidural and subarachnoid drug delivery), 6 (management of symptoms or adverse effects), and 9 (end-of-life care) contained enough studies with well defined experimental designs and statistical information to conduct formal metaanalyses. 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