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Cancer pain management: General principles and risk management for patients receiving opioids

Russell K Portenoy, MD
Zankhana Mehta, MD
Ebtesam Ahmed, PharmD, MS
Section Editor
Janet Abrahm, MD
Deputy Editor
Diane MF Savarese, MD


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.)


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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Literature review current through: Nov 2017. | This topic last updated: Nov 10, 2017.
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  1. van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, et al. High prevalence of pain in patients with cancer in a large population-based study in The Netherlands. Pain 2007; 132:312.
  2. Teunissen SC, Wesker W, Kruitwagen C, et al. Symptom prevalence in patients with incurable cancer: a systematic review. J Pain Symptom Manage 2007; 34:94.
  3. World Health Organization. Cancer pain relief, 2nd, World Health Organization, Geneva 1996.
  4. American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 6th, American Pain Society, Glenview, IL 2008.
  5. Fine P, Portenoy RK. Opioid analgesia. New York: McGraw Hill, 2004. http://www.stoppain.org/pcd/content/forpros/opioidbook.asp (Accessed on April 21, 2011).
  6. Quigley C. Opioids in people with cancer-related pain. BMJ Clin Evid 2008; 2008.
  7. National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
  8. Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol 2012; 13:e58.
  9. Ripamonti CI, Bandieri E, Roila F, ESMO Guidelines Working Group. Management of cancer pain: ESMO Clinical Practice Guidelines. Ann Oncol 2011; 22 Suppl 6:vi69.
  10. Fairchild A. Under-treatment of cancer pain. Curr Opin Support Palliat Care 2010; 4:11.
  11. Kirou-Mauro AM, Hird A, Wong J, et al. Has pain management in cancer patients with bone metastases improved? A seven-year review at an outpatient palliative radiotherapy clinic. J Pain Symptom Manage 2009; 37:77.
  12. Apolone G, Corli O, Caraceni A, et al. Pattern and quality of care of cancer pain management. Results from the Cancer Pain Outcome Research Study Group. Br J Cancer 2009; 100:1566.
  13. Fisch MJ, Lee JW, Weiss M, et al. Prospective, observational study of pain and analgesic prescribing in medical oncology outpatients with breast, colorectal, lung, or prostate cancer. J Clin Oncol 2012; 30:1980.
  14. O'Brien T. Cancer pain and opioid use--a global issue. QJM 2013; 106:603.
  15. Greco MT, Roberto A, Corli O, et al. Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer. J Clin Oncol 2014; 32:4149.
  16. van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, et al. Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis. J Pain Symptom Manage 2016; 51:1070.
  17. Oldenmenger WH, Sillevis Smitt PA, van Dooren S, et al. A systematic review on barriers hindering adequate cancer pain management and interventions to reduce them: a critical appraisal. Eur J Cancer 2009; 45:1370.
  18. Breuer B, Chang VT, Von Roenn JH, et al. How well do medical oncologists manage chronic cancer pain? A national survey. Oncologist 2015; 20:202.
  19. Potter VT, Wiseman CE, Dunn SM, Boyle FM. Patient barriers to optimal cancer pain control. Psychooncology 2003; 12:153.
  20. Breuer B, Fleishman SB, Cruciani RA, Portenoy RK. Medical oncologists' attitudes and practice in cancer pain management: a national survey. J Clin Oncol 2011; 29:4769.
  21. Pastrana T, Wenk R, Radbruch L, et al. Pain Treatment Continues To Be Inaccessible for Many Patients Around the Globe: Second Phase of Opioid Price Watch, a Cross-Sectional Study To Monitor the Prices of Opioids. J Palliat Med 2017; 20:378.
  22. Gibson S, McConigley R. Unplanned oncology admissions within 14 days of non-surgical discharge: a retrospective study. Support Care Cancer 2016; 24:311.
  23. Kelley AS, Morrison RS. Palliative Care for the Seriously Ill. N Engl J Med 2015; 373:747.
  24. Information on institution-based palliative care programs available on the website of the Center to Advance Palliative Care. www.capc.org (Accessed on September 06, 2011).
  25. Information on community-based hospice programs available on the website of the National Hospice and Palliative Care Organization. http://www.nhpco.org/templates/1/homepage.cfm (Accessed on September 06, 2011).
  26. Kroenke K, Zhong X, Theobald D, et al. Somatic symptoms in patients with cancer experiencing pain or depression: prevalence, disability, and health care use. Arch Intern Med 2010; 170:1686.
  27. WHO analgesic pain ladder available online. www.who.int/cancer/palliative/painladder/en/ (Accessed on September 06, 2011).
  28. Jadad AR, Browman GP. The WHO analgesic ladder for cancer pain management. Stepping up the quality of its evaluation. JAMA 1995; 274:1870.
  29. Bandieri E, Romero M, Ripamonti CI, et al. Randomized Trial of Low-Dose Morphine Versus Weak Opioids in Moderate Cancer Pain. J Clin Oncol 2016; 34:436.
  30. Jost L, Roila F, ESMO Guidelines Working Group. Management of cancer pain: ESMO clinical recommendations. Ann Oncol 2008; 19 Suppl 2:ii119.
  31. Krakowski I, Theobald S, Balp L, et al. Summary version of the Standards, Options and Recommendations for the use of analgesia for the treatment of nociceptive pain in adults with cancer (update 2002). Br J Cancer 2003; 89 Suppl 1:S67.
  32. Cormie PJ, Nairn M, Welsh J, Guideline Development Group. Control of pain in adults with cancer: summary of SIGN guidelines. BMJ 2008; 337:a2154.
  33. Ellison NM. Regulatory issues for prescribing schedule II opioids at the end of life #198. J Palliat Med 2010; 13:605.
  34. Califf RM, Woodcock J, Ostroff S. A Proactive Response to Prescription Opioid Abuse. N Engl J Med 2016; 374:1480.
  35. ASCO Policy Stattement on Opioid Therapy: Protecting access to treatment for cancewr-related pain. Policy statement available online at http://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/2016_ASCO%20Policy%20Statement%20on%20Opioid%20Therapy.pdf (Accessed on July 20, 2016).
  36. Copenhaver DJ, Karvelas NB, Fishman SM. Risk Management for Opioid Prescribing in the Treatment of Patients With Pain From Cancer or Terminal Illness: Inadvertent Oversight or Taboo? Anesth Analg 2017; 125:1610.
  37. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain--United States, 2016. JAMA 2016; 315:1624.
  38. Blackhall LJ, Alfson ED, Barclay JS. Screening for substance abuse and diversion in Virginia hospices. J Palliat Med 2013; 16:237.
  39. Sacco P, Cagle JG, Moreland ML, Camlin EAS. Screening and Assessment of Substance Use in Hospice Care: Examining Content from a National Sample of Psychosocial Assessments. J Palliat Med 2017; 20:850.
  40. Tan PD, Barclay JS, Blackhall LJ. Do Palliative Care Clinics Screen for Substance Abuse and Diversion? Results of a National Survey. J Palliat Med 2015; 18:752.
  41. Carmichael AN, Morgan L, Del Fabbro E. Identifying and assessing the risk of opioid abuse in patients with cancer: an integrative review. Subst Abuse Rehabil 2016; 7:71.
  42. Kwon JH, Tanco K, Park JC, et al. Frequency, Predictors, and Medical Record Documentation of Chemical Coping Among Advanced Cancer Patients. Oncologist 2015; 20:692.
  43. Katz NP, Adams EH, Benneyan JC, et al. Foundations of opioid risk management. Clin J Pain 2007; 23:103.
  44. Passik SD, Kirsh KL, Donaghy KB, Portenoy RK. Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse. Clin J Pain 2006; 22:173.
  45. Portenoy RK. Acute and chronic pain. In: Lowinson & Ruiz’s Substance Abuse: A Comprehensive Textbook, 5th, Ruiz P, Strain E (Eds), Lippincott, Williams and Wilkins, Philadelphia 2011. p.695.
  46. Miaskowski C. The use of risk-management approaches to protect patients with cancer-related pain and their healthcare providers. Oncol Nurs Forum 2008; 35 Suppl:20.
  47. Gilson AM, Joranson DE. U.S. policies relevant to the prescribing of opioid analgesics for the treatment of pain in patients with addictive disease. Clin J Pain 2002; 18:S91.
  48. Chou R, Fanciullo GJ, Fine PG, et al. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain 2009; 10:131.
  49. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med 2005; 6:432.
  50. Moore TM, Jones T, Browder JH, et al. A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Med 2009; 10:1426.
  51. Turk DC, Swanson KS, Gatchel RJ. Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. Clin J Pain 2008; 24:497.
  52. Butler SF, Budman SH, Fernandez KC, et al. Development and validation of the Current Opioid Misuse Measure. Pain 2007; 130:144.
  53. Meltzer EC, Rybin D, Saitz R, et al. Identifying prescription opioid use disorder in primary care: diagnostic characteristics of the Current Opioid Misuse Measure (COMM). Pain 2011; 152:397.
  54. Butler SF, Budman SH, Fanciullo GJ, Jamison RN. Cross validation of the current opioid misuse measure to monitor chronic pain patients on opioid therapy. Clin J Pain 2010; 26:770.
  55. Butler SF, Budman SH, Fernandez KC, et al. Cross-Validation of a Screener to Predict Opioid Misuse in Chronic Pain Patients (SOAPP-R). J Addict Med 2009; 3:66.
  56. Passik SD, Kirsh KL. Assessing aberrant drug-taking behaviors in the patient with chronic pain. Curr Pain Headache Rep 2004; 8:289.
  57. Kirsh KL, Jass C, Bennett DS, et al. Initial development of a survey tool to detect issues of chemical coping in chronic pain patients. Palliat Support Care 2007; 5:219.
  58. Barclay JS, Owens JE, Blackhall LJ. Screening for substance abuse risk in cancer patients using the Opioid Risk Tool and urine drug screen. Support Care Cancer 2014; 22:1883.
  59. Kennedy AJ, Arnold RM, Childers JW. Opioids for Chronic Pain in Patients with History of Substance Use Disorders, Part 1: Assessment and Initiation #311. J Palliat Med 2016; 19:888.
  60. Kennedy AJ, Arnold RM, Childers JW. Opioids for Chronic Pain in Patients with History of Substance Use Disorders, Part 2: Management and Monitoring #312. J Palliat Med 2016; 19:890.
  61. Galski T, Williams JB, Ehle HT. Effects of opioids on driving ability. J Pain Symptom Manage 2000; 19:200.
  62. Schisler RE, Groninger H, Rosielle DA. Counseling patients on side effects and driving when starting opioids #248. J Palliat Med 2012; 15:484.
  63. Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Are opioid-dependent/tolerant patients impaired in driving-related skills? A structured evidence-based review. J Pain Symptom Manage 2003; 25:559.
  64. Sjogren P, Thomsen AB, Olsen AK. Impaired neuropsychological performance in chronic nonmalignant pain patients receiving long-term oral opioid therapy. J Pain Symptom Manage 2000; 19:100.
  65. Byas-Smith MG, Chapman SL, Reed B, Cotsonis G. The effect of opioids on driving and psychomotor performance in patients with chronic pain. Clin J Pain 2005; 21:345.
  66. Canadian Guideline for safe and effective use of opioids for chronic non-cancer pain. National Opioid Use Guideline Group. April 30, 2010. Available online at www.nationalpaincentre.mcmaster.ca/opioid/documents.html (Accessed on May 03, 2012).
  67. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009; 10:113.