Pain Management in Cancer Involves:

1. Specific anti-cancer treatment (surgery, irradiation, chemotherapy)
2. Non-specific treatment without affecting the cancer (analgesics, co-analgesics, local anesthetic blocks, etc.)

1. Diagnose cause of pain accurately. Progressive pain in cancer patient usually means progressive disease. There may be no abnormal physical signs. Continually assess and reassess
2. Treat pain early with effective drugs in proper dose at appropriate intervals - "round the clock" and NOT "prn." Doses should be individualized and depend on patient's response. Frequency of administration depends on duration of analgesic effect of drug chosen. Anticipate pain and control it rather than waiting for it to become well established
3. In general, do not mix narcotics; choose one and use it properly
4. Anticipate and treat side-effects:
   1. Constipation - prescribe a bowel regimen when a narcotic is prescribed; tolerance to narcotic-induced constipation does not occur, hence constipation must be treated aggressively as long as the patient is using a narcotic
   2. Nausea - always prescribe an anti-nausea preparation when the narcotic is prescribed; tolerance to narcotic-induced nausea may occur within a few days or week of narcotic use and anti-nausea compound can then be withdrawn; nausea alone is not a sign of narcotic allergy, but is a side effect
   3. Drowsiness and confusion - may occur during first few days of narcotic use or when dose increased; tolerance to narcotic- induced confusion and/or drowsiness often occurs within a few days or week of narcotic use; ensure that no other medical problem accounts for drowsiness and confusion (e.g. hypercalcemia, liver or renal failure, brain metastases)
5. Watch for complications of narcotic use:
   1. Overdose with respiratory depression and/or coma rarely occurs when principles of treatment are followed properly; pain is a good antidote to the respiratory depressant effects of narcotic
   2. Prevent withdrawal symptoms by gradual reduction of narcotic dose when narcotic no longer required (e.g. after pain-relieving procedures such as nerve blocks, cordotomy, etc.)
   3. Myoclonus (irregular jerky movements, especially of limbs) can occur when any narcotic is used for a prolonged time, especially with high dose; this is not an indication to discontinue narcotic. It is difficult to control but may be helped by benzodiazepines (e.g. clonazepam, nitrazepam, lorazepam). It is most troublesome when meperidine (Demerol) is used long-term; this is one of several reasons why meperidine (Demerol) is a poor analgesic choice in chronic pain of cancer.
      Convulsions may indicate toxic reaction to narcotic (most commonly when Demerol is used), but are more likely due to cerebral metastases
6. Ensure sleep; no hypnotic works, however, when pain is present
7. Use co-analgesics (e.g., tricyclics, steroids, etc.); they often help to reduce narcotic requirement.
   Try not to use a drug which increases sedation without enhancing analgesic effect (e.g., oxazepam, diazepam, chlorpromazine)
8. Never use placebos. Listen to what the patient, relatives, etc. tell you about the pain. Pain can only be felt by someone who has it
9. Pain is usually considered an ominous symptom by cancer patients; it may or may not signify recurrent or progressive disease; discuss its significance with the patient once accurate diagnosis of cause of pain is made.
   Explain goals of pain treatment - to relieve pain with minimal or no side-effects.
   Reassure patient, relative, etc. that addiction is not a practical consideration in cancer patients who are being treated for pain. Tolerance to narcotic may develop but can usually be managed successfully by switching to alternate narcotic. Concern that narcotic will "lose its effect," is not a valid reason for withholding dose escalation
10. Assist patient, relative, etc. in keeping daily record of drug regimen, extent and quality of pain, and side-effects of medication
11. Use expertise of others - e.g. nurse, physiotherapist, social worker, chaplain, dietitian, psychologist, etc.
12. Be available, especially when new drug and/or dose prescribed. Adjustments in narcotic dose are often required after initiation of narcotic treatment, and after switching to another narcotic