Cancer pain management: General principles and risk management for patients receiving opioids
- Russell K Portenoy, MD
Russell K Portenoy, MD
- Chief Medical Officer
- MJHS Hospice and Palliative Care
- Professor of Neurology and Family and Social Medicine
- Albert Einstein College of Medicine
- Zankhana Mehta, MD
Zankhana Mehta, MD
- Department of Palliative and Supportive Medicine
- Geisinger Medical Center
- Ebtesam Ahmed, PharmD, MS
Ebtesam Ahmed, PharmD, MS
- Associate Clinical Professor
- St. John's University College of Pharmacy
- Clinical Pharmacy Specialist Innovative Institute for Palliative Care
Pain is highly prevalent in the cancer population. Virtually all patients with malignant disease experience recurrent episodes of acute pain, which may accompany surgery, invasive procedures, or complications, such as a pathological fracture. In addition, chronic pain that is severe enough to warrant opioid therapy is experienced by 30 to 50 percent of patients undergoing active antineoplastic therapy and by 75 to 90 percent of those with advanced disease [1,2].
The causes of chronic pain are diverse in this population, and both prevalence and severity vary with the type of neoplasm, stage and extent of disease, prior treatment, comorbidities, and other factors. Tissue injury produced by the neoplasm is the primary etiology in about three-fourths of patients with chronic cancer pain, and the remainder have pain related to the late effects of antineoplastic therapy or to painful comorbidities. (See "Assessment of cancer pain".)
Opioid therapy is the first-line approach for moderate or severe chronic cancer pain. While opioids are effective analgesics, they are potentially abusable drugs. The public health consequences of opioid abuse drive the imperative that all physicians assume responsibility for risk management when these drugs are prescribed for legitimate medical purposes. (See "Cancer pain management with opioids: Optimizing analgesia".)
This topic review will cover the general principles of cancer pain management and provide an overview of risk assessment and management in patients treated with opioids. An overview of assessment of cancer pain, a review of specific cancer pain syndromes, the clinical use of opioid analgesics, non-opioid analgesics (including adjuvant analgesics) and non-pharmacologic methods of cancer pain management are covered elsewhere. (See appropriate topic reviews.)
THE PROBLEM OF UNDERTREATMENT
Adequate pain relief can be achieved in 70 to 90 percent of patients when well-accepted treatment guidelines for cancer pain are followed [3-9]. Given that most recommended therapies for cancer pain are within the scope of both specialty and primary care medical practice, the treatment of cancer pain should be viewed as a best practice for all medical disciplines involved in the care of this population.
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- THE PROBLEM OF UNDERTREATMENT
- PAIN MANAGEMENT WITHIN THE CONTEXT OF PALLIATIVE CARE
- GENERAL PRINCIPLES OF PAIN MANAGEMENT
- RISK ASSESSMENT AND MANAGEMENT FOR PATIENTS RECEIVING OPIOIDS
- Drug abuse
- Risk assessment
- Risk management
- - Preventing lethal overdose
- DRIVING SAFETY
- INFORMATION FOR PATIENTS