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 This is an original JCO publication from 2016. Please visit the JCO website to access the full article.


Management of Chronic Pain in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline

 

 Authors

Judith A. Paice, Russell Portenoy, Christina Lacchetti, Toby Campbell, Andrea Cheville, Marc Citron, Louis S. Constine, Andrea Cooper, Paul Glare, Frank Keefe, Lakshmi Koyyalagunta, Michael Levy, Christine Miaskowski, Shirley Otis-Green, Paul Sloan, and Eduardo Bruera

THE BOTTOM LINE

Management of Chronic Pain in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice

Guideline Question

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

Target Population

Any adult who has been diagnosed with cancer and is experiencing pain that lasts ≥ 3 months, irrespective of cause.

Target Audience

Health care practitioners who provide care to cancer survivors.

Methods

An expert panel was convened to develop clinical practice guideline recommendations on the basis of a systematic review of the medical literature.

Key Recommendations

1. SCREENING AND COMPREHENSIVE ASSESSMENT

Recommendation 1.1. 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 1.2. Clinicians should conduct an initial comprehensive pain assessment. This assessment should include an in-depth interview that explores the multidimensional nature of 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 1.3. Clinicians should be aware of chronic pain syndromes resulting from cancer treatments, the prevalence of these syndromes, risk factors for individual patients, and appropriate treatment options. A list of common cancer pain syndromes can be found in Table 3. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate)

Recommendation 1.4. 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)

2. TREATMENT AND CARE OPTIONS

Recommendation 2.1. 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 2.2. 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 2.3. 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 2.4. Clinicians may prescribe directly or refer patients to other professionals to provide the interventions outlined in Table 4 to mitigate chronic pain or improve pain-related outcomes in cancer survivors. These interventions must take into consideration pre-existing diagnoses and comorbidities. (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)

Pharmacologic Interventions

Miscellaneous Analgesics

Recommendation 2.5. 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
      • 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)

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 α-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.

Recommendation 2.6. 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. (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)

Recommendation 2.7. 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 2.8. 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 2.9. 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)

Qualifying statement. As of this writing, 23 states and the District of Columbia allow for medical cannabis,50 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.

Opioids

Recommendation 2.10. 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 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 2.11. Clinicians should assess risks of adverse effects of opioids used for pain management. Table 7 lists opioid-related long-term adverse effects. (Evidence-based and informal consensus; benefits outweigh harms; evidence quality: intermediate strength of recommendation: moderate)

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 7.

3. RISK ASSESSMENT, MITIGATION, AND UNIVERSAL PRECAUTIONS WITH OPIOID USE

Recommendation 3.1. 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 3.2. 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 3.3. 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 (Table 7). (Evidence-based and informal consensus; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)

Recommendation 3.4. 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 3.5. 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)

Qualifying statement. Education and information about treatment should ideally take into account the patient’s literacy level and the need for interpreters and should be provided in a culturally congruent manner.

Recommendation 3.6. 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. (Evidencebased and informal consensus; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate)

Additional Resources: More information, including a Data Supplement with additional evidence tables, a Methodology Supplement with information about evidence quality and strength of recommendations, slide sets, and clinical tools and resources, is available at www.asco.org/chronic-pain-guideline and www.asco.org/guidelineswiki. Patient information is available at www.cancer.net

ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate

SUMMARY OF RECOMMENDATIONS

Clinical DomainRecommendationEvidence Rating
Screening and Comprehensive AssessmentClinicians should screen for pain at each encounter. Screening should be performed and documented using a quantitative or semiquantitative tool.

Type: Informal consensus; benefits outweigh harms

Evidence quality: Insufficient

Strength of Recommendation: Strong

Clinicians should conduct an initial comprehensive pain assessment. This assessment should include an in-depth interview, which explores the multidimensional nature of pain (pain descriptors, associated distress, functional impact and related physical, psychological, social and spiritual factors) and captures information about cancer treatment history and co-morbid conditions, psychosocial and psychiatric history (including substance use), and prior treatments for the pain. The assessment should characterize the pain, clarify its etiology and make inferences about pathophysiology. A physical examination should accompany the history and diagnostic testing should be done when warranted.

Type: Informal consensus; benefits outweigh harms

Evidence quality: Insufficient

Strength of Recommendation: Moderate

Clinicians should be aware of chronic pain syndromes resulting from cancer treatments, their prevalence, risk factors for individual patients, and appropriate treatment options.

Type: Informal consensus; benefits outweigh harms

Evidence quality: Insufficient

Strength of Recommendation: Moderate

Clinicians should evaluate and monitor for recurrent disease, second malignancy or late onset treatment effects in any patient who reports new onset pain

Type: Informal consensus; benefits outweigh harms

Evidence quality: Insufficient

Strength of Recommendation: Moderate

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

Type: Informal consensus; benefits outweigh harms

Evidence quality: Insufficient

Strength of Recommendation: Moderate

Clinicians should engage patient and family/caregivers in all aspects of pain assessment and management.

Type: Informal consensus; benefits outweigh harms

Evidence quality: Insufficient

Strength of Recommendation: Moderate

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.

Type: Informal consensus; benefits outweigh harms

Evidence quality: Insufficient

Strength of Recommendation: Moderate

Non-Pharmacologic Interventions
Clinicians may prescribe directly or refer to other professionals to provide interventions, in disciplines such as physical medicine and rehabilitation, integrative therapies, interventional therapies, psychological approaches, and neurostimulatory, to mitigate chronic pain or improve pain-related outcomes in cancer survivors. The use of these interventions must consider pre-existing diagnoses and comorbidities and should include an assessment for adverse events.

Type: Evidence-based; benefits outweigh harms

Evidence quality: Intermediate

Strength of Recommendation: Moderate

Pharmacologic Interventions

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

  • 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

Type: Evidence-based; benefits outweigh harms

Evidence quality: Intermediate

Strength of Recommendation: Moderate

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.

Type: Evidence-based; benefits outweigh harms

Evidence quality: Intermediate

Strength of Recommendation: Moderate

Corticosteroids are not recommended for long term use in cancer survivors solely to relieve chronic pain.

Type: Evidence-based; harms outweigh benefits

Evidence quality: intermediate

Strength of Recommendation: Moderate

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

Type: Evidence-based and Informal consensus; benefits outweigh harms

Evidence quality: Intermediate

Strength of Recommendation: Moderate

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.

Type: Evidence-based; benefits outweigh harms

Evidence quality: Intermediate

Strength of Recommendation: Moderate

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. Non-opioid analgesics and/or adjuvants can be added as clinically necessary

Type: Evidence-based; benefits outweigh harms

Evidence quality: Intermediate

Strength of Recommendation: Moderate

Clinicians should assess risks for adverse effects of opioids used for pain management.

Type: Evidence-based and Informal consensus; benefits outweigh harms

Evidence quality: Intermediate

Strength of Recommendation: Moderate

Risk Assessment, Mitigation and Universal Precautions with Opioid UseClinicians should assess the potential risks and benefits when initiating treatment that will incorporate long term use of opioids.

Type: Informal consensus; benefits outweigh harms

Evidence quality: Insufficient

Strength of Recommendation: Moderate

Clinicians should clearly understand terminology such as tolerance, dependence, abuse and addiction as it relates to the use of opioids for pain control.

Type: Informal consensus; benefits outweigh harms

Evidence quality: Insufficient

Strength of Recommendation: Moderate

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.

Type: Evidence-based and Informal consensus; benefits outweigh harms

Evidence quality: Intermediate

Strength of Recommendation: Moderate

Clinicians should understand pertinent laws and regulations regarding prescribing controlled substances.

Type: Informal consensus; benefits outweigh harms

Evidence quality: Insufficient

Strength of Recommendation: Moderate

Clinicians should educate patients and family members regarding the risks and benefits of long-term opioid therapy, 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 taking centrally-acting medications from other physicians.

Type: Informal consensus; benefits outweigh harms

Evidence quality: Insufficient

Strength of Recommendation: Moderate

If opioids are no longer warranted, clinicians should taper the dose to avoid abstinence syndrome. The rate of tapering and use of cotherapies to reduce adverse effects should be individualized for each patient.

Type: Evidence-based and Informal consensus; benefits outweigh harms

Evidence quality: Intermediate

Strength of Recommendation: Moderate


ASCO Guideline Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action.  The use of words like “must,” “must not,” “should,” and “should not” indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary.  ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.


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