Management of Chronic Pain in Survivors of Adult Cancers

Publication Date: July 25, 2016
Last Updated: December 16, 2022

Diagnosis

Clinicians should screen for pain at each encounter. Screening should be performed and documented using a quantitative or semiquantitative tool.

( IC , I , B , S )
3336

Treatment

Treatment and Care Options

Clinicians should aim to enhance comfort, improve function, limit adverse events, and ensure safety in the management of pain in cancer survivors.

( IC , I , B , M )
3336
Clinicians should engage patient and family/caregivers in all aspects of pain assessment and management. ( IC , I , B , M )
3336
Clinicians should determine the need for other health professionals to provide comprehensive pain management care in patients with complex needs. ( IC , I , B , M )
  • If deemed necessary, the clinician should define who is responsible for each aspect of care and refer patients accordingly.
3336

Nonpharmacologic Interventions

Clinicians may prescribe directly or refer patients to other professionals to provide the interventions outlined in Table 2 to mitigate chronic pain or improve pain-related outcomes in cancer survivors.

( EB , I , B , M )
  • These interventions must take into consideration pre-existing diagnoses and comorbidities.
3336

Pharmacologic Interventions

Miscellaneous Analgesics

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:

( EB , I , B , M )
  • Nonsteroidal anti-inflammatory drugs
  • 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. Qualifying statement. The panel acknowledges that many other systemic nonopioids, including many other antidepressants and anticonvulsants, drugs in many other classes (such as the so-called muscle relaxants, benzodiazepines such as clonazepam, N-methyl-D-aspartate receptor blockers such as ketamine, and a-2 agonists such as tizanidine), and varied neutraceutical and botanicals marketed as complementary or alternative medicines, are taken by some cancer survivors with chronic pain and may benefit some of those who receive them. However, the efficacy of these agents and their long-term effectiveness have not been established.
3336
Clinicians may prescribe topical analgesics (such as commercially available nonsteroidal antiinflammatory drugs; local anesthetics; or compounded creams/gels containing baclofen, amitriptyline, and ketamine), for the management of chronic pain. ( EB , I , B , M )
3336
Corticosteroids are NOT recommended for long-term use in cancer survivors solely to relieve chronic pain. ( EB , I , H , M )
3336

Clinicians should assess the risks of adverse effects of pharmacologic therapies, including nonopioids, adjuvant analgesics, and other agents used for pain management.

( EB , I , B , M )
3336
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. ( EB , I , B , M )
Qualifying statement. As of this writing, 23 states and the District of Columbia allow for medical cannabis, although it is illegal on the federal level. Currently, there is insufficient evidence to recommend medical cannabis for the first-line management of chronic pain in cancer survivors. However, evidence suggests it is worthy of consideration as an adjuvant analgesic or in the management of refractory pain conditions. There is also insufficient evidence to recommend one particular preparation of cannabis over another, and the Food and Drug Administration has not approved any drug product containing or derived from botanical marijuana.
3336
Opioids

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.

( EB , I , B , M )
  • Tables 3 and 4 provide guidelines intended to promote safe and effective prescribing. Nonopioid analgesics and/or adjuvants can be added as clinically necessary.
3336
Clinicians should assess risks of adverse effects of opioids used for pain management. Table 5 lists opioid-related long-term adverse effects. ( EB , I , B , M )
Qualifying statement. Although there is literature describing dysimmune effects and tumor proliferative effects from opioid drugs (both of which may be of particular concern in the cancer survivor population), there is insufficient evidence to determine whether there are clinically important risks. The expert panel believes that further clinical investigation is required to assess these concerns. In the absence of actionable data, physicians should be made aware of these evolving questions, and patients and their families may be informed about them as part of a discussion of the potential harms of long-term opioid therapy, as described in Table 5.
3336

Overview

Title

Management of Chronic Pain in Survivors of Adult Cancers

Authoring Organization

American Society of Clinical Oncology