Pain Management in Palliative Care

Mild

• Paracetamol or NSAIDs are the drugs of choice for mild cancer pain. Paracetamol should be used in combination with opioids in the other steps of WHO analgesic ladder unless contraindicated

Moderate to Severe

• Oral morphine should be the first line therapy for moderate to severe cancer pain.
• Oxycodone and fentanyl are alternatives to morphine for moderate to severe cancer pain. 
• Transdermal fentanyl should only be considered for use when opioid requirements are stable.
• Pethidine and nalbuphine should be avoided in chronic cancer pain management

Algorithm of Cancer Pain Management

Morphine Titration

• Morphine therapy should be initiated at the dose of 5 - 10 mg 4-hourly using the oral IR formulation.
• In the elderly, a lower starting dose of 2.5 - 5 mg 4 - 6-hourly of the IR formulation should be used.
• Rapid titration using IV or SC morphine is preferred in patients presenting with severe cancer pain for initial control of pain

Maintenance & Breakthrough Pain

• Patients with chronic cancer pain should receive regular ‘around the clock’ (ATC) opioid therapy.
• Once the effective 24 hours dose is established, patients may be converted to a 12-hourly SR formulation.
• Rescue medication for breakthrough pain should be available for all patients with chronic cancer pain at a dose between 1/12 and 1/6 of the total 24-hour dose.
• Opioid switching should be considered when side effects limit further dose escalation of a particular opioid.
• Conversion from one opioid to another or between different routes of administration should be guided by equianalgesic conversion tables

 Adjuvants

Reference

CPG Managemnet of Cancer PAIN 2010