Camp-Sorrell D, … Anesthesiology. The manual search covered a 48-yr period from 1948 through 1995. Other potential agents for neuraxial drug delivery are under development. Turk and DB Carr. Scientific evidence was derived from aggregated research literature with metaanalyses when appropriate, surveys, open presentations, and other consensus-oriented activities. Age-appropriate instruments should be used in children. Recognition is given to the nonspecific effects of listening and showing concern for the welfare of the patient. The use of practice guidelines cannot guarantee any specific outcome. Template 1. Weighted effect size estimates ranged from r = 0.13 to r = 0.34, demonstrating small-to-moderate effect size estimates. For some age groups and populations (e.g., the cognitively or developmentally impaired), external observation may be preferable. 2016;34(7):3325-45. The clinical guidelines and recommendations in this document are organized into three focal areas: American Cancer Society. Intravenous administration may be preferred when the patient has permanent venous access. C. Focus. 1. Frequency of Pain Ratings. (Note: Respiratory depression is rare in the cancer patient receiving chronic opioid therapy (Appendix 2)). Intraventricular administration of opioids may be considered in patients with head and neck cancer and Ommaya reservoirs. These American Society of Anesthesiologists guidelines provide evidence and recommendations for cancer pain management involving the oral and other routes of administration. Transitory nausea and vomiting should be treated initially with standard antiemetics, such as promethazine, prochlorperazine, haloperidol, metoclopramide, or hydroxyzine. Comprehensive evaluation and assessment of pain (i.e., history, physical examination, laboratory evaluation) improve analgesia, reduce adverse effects of pain therapy, and improve quality of life. Tax ID Number: 13-1788491. The percent of consultants expecting no change associated with each linkage were as follows: comprehensive evaluation, 76%; longitudinal monitoring, 78%; multiple disciplines, 89%; administration of systemic opioids, 100%; neuraxial drug delivery, 87%; neurolytic techniques, 87%; management of symptoms/adverse effects, 89%; psychosocial factors, 89%, use of parenteral therapy, 94%, end-of-life care, 80%, and pediatric pain management, 83%. Liquids or suspensions should be employed whenever possible, because many children find them more palatable than pills. However, aspects of these guidelines may be useful when comprehensive pain management cannot be offered. The literature does not suggest that management of symptoms or adverse effects has an effect on analgesia. The mean number of patients treated annually by the consultants was reported to be 557.5 (min/max = 10/5,000). Neuroablation is preceded by diagnostic neural blockade. The decision to implement primary therapy should be based on a comprehensive assessment of risks and benefits and are outside the scope of these guidelines. Recognition and Management of Special Features of Pediatric Cancer Pain Management, Appendix 1. Consultants, in general, were highly supportive of the linkages (i.e., agreed that they provided analgesic benefit, reduced risk of adverse outcomes, improved other cancer-related symptoms, improved quality of life, and were important issues for the guidelines to address). There is insufficient literature to evaluate the efficacy of the longitudinal monitoring of pain. C. Focus. Psychostimulants can be administered to reverse mental clouding in the absence of sedation but should not be administered to agitated patients. a. Neuraxial drug delivery: The literature is supportive of the efficacy of neuraxial analgesic delivery (i.e., epidural, subarachnoid, intraventricular). Order this book online, or check your hospital or local library Oral medications: Oral medications such as acetaminophen, acetylsalicylic acid or other nonsteroidal antiinflammatory drugs (NSAIDs) should be employed first for mild to moderate pain. The Task Force and panel of consultants offer similar support. Accepted for publication December 1, 1995. f. Pruritus: Pruritus is rarely a problem with chronic opioid administration, and consideration should be given to an initial trial of diphenhydramine if it occurs. 2005. Treatment of factors contributing to nausea (e.g., constipation) should be considered when appropriate. To provide evidence-based guidance on the optimum management of chronic pain in adult cancer survivors. Physical dependence does not imply addiction. The goal of cancer pain management is to relieve pain to a level that allows for an acceptable quality of life. Washington, DC, US Department of Health and Human Services, Agency for Health Care Policy and Research, publication number 91-0007, March 1991. The Task Force identifies four fundamental features that should guide the comprehensive evaluation of the patient with cancer pain. General Recommendations. A directional result for each study was determined initially by classifying the outcome as either supporting a linkage, refuting a linkage, or neutral. The recommendations for intravenous administration are the same as for subcutaneous administration. The practitioner should be aware of the potential adverse sequelae of opioids and their appropriate treatment. a. Copyright 1996 by the American Society of Anesthesiologists, Inc. The anesthesiologist should determine whether the patient and/or significant others are motivated and competent to care for sophisticated delivery systems. Management of cancer-related symptoms, side effects of cancer treatment, and adverse effects from pain therapy (e.g., use of antiemetics and laxatives) improves analgesia, reduces adverse effects of pain therapy, and improves quality of life. Recommendations: The anesthesiologist should give special attention to the assessment of pain in pediatric patients. For children who can communicate verbally, age-appropriate pain scales are the recommended self-report instruments when evaluating the efficacy of pain therapy. Regional analgesic techniques are referred to in these guidelines as neural blockade (e.g., intercostal blocks, celiac plexus blocks) and are distinct from neurolytic blocks. If analgesia is not achieved with neural blockade or significant adverse sequelae result, neuroablation should be reconsidered. Self-report should be obtained at regular intervals. Involvement of specialists in multiple disciplines improves analgesia, reduces adverse effects of pain therapy, and improves quality of life. Longitudinal monitoring of pain (e.g., patient self-report, rating scales, and frequency of pain ratings) improves analgesia, reduces adverse effects of pain therapy, and improves quality of life. General Recommendations. Anesthesiology 1996; 84:1243–1257 doi: https://doi.org/10.1097/00000542-199605000-00029. In addition, the literature suggests that specific interventions used to treat the adverse effects of pain therapy are efficacious. An acceptable significance level was set at P < 0.01 (one-tailed), and effect-size estimates were calculated. The cryoanalgesic procedure often must be repeated because the endoneurium is spared, allowing regrowth over time. Subcutaneous administration of opioids may be used in the home setting. The 2018 ESMO Clinical Practice Guidelines on Cancer Pain are based on the most recent data available. Tolerance, physical dependence, and addiction are concerns expressed by patients and physicians and must be understood to optimize therapy. (Note: the simultaneous use of more than one NSAID or the concomitant use of an NSAID with a glucocorticoid is not recommended because the risk of toxicity is increased, and additional analgesia is not achieved.) Results of the psychosocial assessment should be considered when formulating a pain treatment plan. These agents may be added at any stage (Table 7Template 7). Reports of pain made by the patient should be the primary source of pain assessment and should take precedence, whenever possible, over inferences and observations made by others. Clinical scenarios or syndromes with an increased risk for the development of constipation include: (1) cachexia and/or debilitation, (2) poor performance status (especially the bedridden patient), (3) intraabdominal neoplasm, (4) a history of prior abdominal radiation, (5) autonomic neuropathy, (6) poor fluid intake, and (7) the concurrent use of constipating agents. In the opinion of the Task Force and consultants, effective cancer pain management requires a clear understanding of the etiology and pathophysiology of the pain. Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. Table 7. Agreement among Task Force members and two methodologists was established by interrater reliability testing. Recognition, Assessment, and Management of Psychosocial Factors, IX. Dose titration may be required periodically because of the natural history of the primary disease or the development of tolerance. Am J Clin Pathol 2012;137:516-542. b. Neuroablation: Neuroablative techniques should be initiated (1) when systemic therapies have failed to provide adequate pain control or when adverse side effects from systemic therapies are unacceptable; (2) after failure of neuraxial drug administration; (3) early in the natural history of the cancer pain in the presence of selected focal somatic lesions (e.g., rib metastases), visceral (e.g., cancer of the pancreas), or neuropathic (e.g., craniofacial) pain that is believed to be highly responsive to neuroablation with limited risk; or (4) patient preference indicates use of neuroablative techniques, if appropriate. For children who can communicate verbally, age-appropriate pain scales are the recommended self-report instruments when evaluating the efficacy of pain therapy. 1. The CPG discusses the assessment and treatment of acute and chronic, neuropathic and nociceptive pain, as … 2. The Guidelines recognize that the management of chronic pain occurs within the broader context of health care, including psychosocial function and quality of life. 8. The purpose of these guidelines is to: (1) optimize pain control; (2) minimize side effects, adverse outcomes, and costs; (3) enhance functional abilities and physical and psychological well-being; and (4) enhance the quality of life for cancer patients. ), Portland, Oregon; Robert A. Caplan, M.D., Seattle, Washington; Hui-Ming Chang, M.D., Houston, Texas; Richard T. Connis, Ph.D. (Methodologist), Woodinville, Washington; Patricia Harrison, M.D., Buffalo, New York; Robert N. Jamison, Ph.D, Boston, Massachusetts; Elliot J. Krane, M.D., Stanford, California; Srdjan Nedeljkovic, M.D., Boston, Massachusetts; Richard Patt, M.D., Houston, Texas; and Russell K. Portenoy, M.D., New York, New York. In the opinion of the Task Force and consultants, effective cancer pain management requires a clear understanding of the etiology and pathophysiology of the pain. Although great strides have been made in increasing awareness of the need for effective cancer pain control, barriers persist that lead to undertreatment. The presence of epidural metastases necessitates subarachnoid catheterization. Template 2. 1. Rating Scale. 2005. To provide evidence-based guidance on the optimum management of chronic pain in adult cancer survivors. The World Health Organization (WHO) analgesic ladder consists of a hierarchy of oral pharmacologic interventions designed to effectively treat pain of increasing magnitude. Camp-Sorrell D, … 2. For some age groups and populations (e.g., the cognitively or developmentally impaired), external observation may be preferable. Please note that ArticlePlus files may launch a viewer application outside of your web browser. Arch Intern Med 165(14):1574-1580. The literature suggests that child-specific interventions are associated with improved analgesia and health outcomes. The panel of consultants and Task Force members support the importance of home parenteral therapy in increasing analgesia and enhancing patient quality of life. Several evidence-based guidelines recommend the use of multimodal pain management that has opioid-sparing effects to decrease the incidence of opioid-related adverse events (American Society of Anesthesiologists Task Force on Acute Pain Management, 2012, National Comprehensive Cancer Network, 2018). Neuraxial drug delivery and neuroablative therapies should not be used: (1) in individuals who are unmotivated or noncompliant or do not possess the cognitive functioning necessary to understand the risks and benefits and (2) when an appropriate logistical system does not exist. The patient and family must be educated in the use of the home therapy system. History: A complete history includes a general medical and oncologic history with a description of the extent of disease and prognosis. d. A thorough knowledge of the modalities that can be employed in the treatment of painful crisis (i.e., pain emergency) is also necessary. Home parenteral therapy provides an infrastructure for the logistical support and clinical management of complex drug delivery systems in a nonhospital setting. The ladder presents a framework for the rational use of oral medication before application of other techniques of drug administration. Table 6. The Task Force and consultants are supportive of the value of managing cancer-related symptoms and adverse drug effects as part of the comprehensive management of cancer pain. Recommendations for the oral administration of analgesics are provided by the World Health Organization (WHO) analgesic ladder (Table 4Template 4). The guidelines apply to patients of all ages and with all types of cancer. General Recommendations. 2018. Myoclonus, pruritus, and urinary retention occur infrequently in patients receiving chronic opioid therapy. Palliative therapies may be provided in the form of comprehensive programs, such as hospice or nursing-care outreach programs. The rate of return of the surveys was 81% (n = 58 of 72). Epidural or subarachnoid drug administration may be performed by either percutaneous catheterization, reservoir, or implantation of a catheter and pump. Submitted for publication November 28, 1995. Drug overdose deaths have become an epidemic in the United States. A procedure based on the Mantel-Haenszel method for combining study results using 2 x 2 tables was used when sufficient outcome frequency information was available. Available by calling 800-227-2345. In Bader et al 2010 87 Miaskowski C, Cleary J, Burney R, Coyne P, Finley R, Foster R et al, 2005. The recommendations for intravenous administration are the same as for subcutaneous administration. Oral pharmacologic interventions: The literature suggests and consultant opinion supports the view that oral pharmacologic interventions applied according to the WHO analgesic ladder are associated with adequate analgesia. For children unable to communicate verbally, observation of patient behavior should be the primary assessment tool. There is insufficient literature to evaluate the efficacy of the longitudinal monitoring of pain. When adequate analgesia cannot be achieved or intolerable side effects occur with indirect methods of drug delivery, direct drug delivery systems should be considered. These guidelines focus on the knowledge base, skills, and range of interventions that are the essential elements of effective management of pain and pain-related problems in patients with cancer. 3. When pain is continuous or occurs frequently, medication generally should be administered around-the-clock with additional "rescue" doses available for breakthrough pain. Recommendations: Before changing from the oral route of administration, the anesthesiologist should ascertain the availability of family and professional support systems. The Task Force supports the use of these analgesic modalities, when appropriate, before employment of more invasive systemic therapies. Neuroablation refers to the chemical, thermal, or surgical destruction of neural tissue. b. Sedation: Sedation should be treated by (1) eliminating contributory factors such as nonessential drugs and metabolic disturbances, (2) reducing the dose of an opioid by 25-50% if analgesia is satisfactory, (3) lowering the requirement for opioids by the addition of a nonopioid analgesic or adjuvant analgesic, (4) switching to another opioid, (5) the use of psychostimulants, or (6) considering more invasive modalities if sedation is refractory to therapy. 1. On the other hand, consideration of life expectancy is moot with cryoanalgesia because of the potential for nerve regeneration associated with the technique. Results of the psychosocial assessment should be considered when formulating a pain treatment plan. Adverse drug effects directly resulting from cancer pain therapies include but are not limited to sedation, nausea and vomiting, pruritus, constipation, urinary retention, and respiratory depression. Comprehensive Evaluation and Assessment of the Patient with Cancer Pain, III. Metaanalysis was not performed on linkage 4 (indirect drug delivery systems) for either efficacy or outcomes because literature was not conducive to an appropriate assessment. However, aspects of these guidelines may be useful when comprehensive pain management cannot be offered. In Bader et al 2010 87 Miaskowski C, Cleary J, Burney R, Coyne P, Finley R, Foster R et al, 2005. a. Neuraxial drug delivery: Neuraxial drug delivery should be used: (1) when severe pain cannot be controlled with systemic drugs because of dose-limiting toxicity, (2) when there is immediate need for local anesthetic (some neuropathic pains), (3) after failed neuroablation, or (4) patient preference indicates its use. American Cancer Society’s Guide to Controlling Cancer Pain. Opioids and local anesthetics can be delivered directly to the vicinity of neural tissue, obviating the need for systemic absorption as a means to reach receptor sites. Developed by the Task Force on Pain Management, Cancer Pain Section: F. Michael Ferrante, M.D., F.A.B.P.M. Pain is a serious consequence of cancer and its treatment. The World Health Organization (WHO) analgesic ladder consists of a hierarchy of oral pharmacologic interventions designed to effectively treat pain of increasing magnitude. Table 7. The Task Force thanks those who responded to surveys on cancer pain management, reviewed guideline drafts, contributed oral and written testimony to the Open Forum, and participated in tests of clinical feasibility. The literature suggests that home parenteral therapy is effective for analgesia without notable risk of adverse effects. (Note: Continuous-release morphine preparations cannot be crushed and still maintain their continuous release properties.) Elements. The feasibility of implementing these guidelines into clinical practice was assessed by an opinion survey of the cancer pain consultant panel (n = 71). Neural blockade should be used prognostically to determine the possible efficacy of neuroablation. Template 3. Management of cancer pain: ESMO Clinical Practice Guidelines. The American Cancer Society is a qualified 501(c)(3) tax-exempt organization. If analgesia is not achieved with neural blockade or significant adverse sequelae result, neuroablation should be reconsidered. The panel of consultants and Task Force members endorse the importance of collaboration between anesthesiologists and other health-care providers in the management of cancer pain. 5. In addition, the Guidelines do not apply to pediatric patients and do not address the administration of intravenous … Significance levels from the weighted Stouffer combined tests for beneficial outcomes were significant for linkages 3 (multiple disciplines), 6 (symptoms or adverse effects), and 9 (end-of-life care). Opioid Analgesics Commonly Used to Manage Cancer Pain*. In an effort to reduce the burden of under assessment and inadequate treatment of pain, the American Pain Society (APS) in 1996 instituted the “pain as the 5th vital sign” campaign based on quality improvement guidelines published the previous year.1 The aim of the campaign was to make pain assessment and measurement as important a measure of patient wellbeing as the existing four vital … Direct drug delivery systems (i.e., neuraxial drug delivery (epidural, subarachnoid, intraventricular), neural blockade (diagnostic blockade, neural blockade for pain management), and neuroablation (chemical, thermal, and surgical neurolysis)) improve analgesia, reduce adverse effects of pain therapy, and improve quality of life. No search for unpublished studies was conducted, and no reliability tests for locating research results were done. (Note: Respiratory depression is rare in the cancer patient receiving chronic opioid therapy (Appendix 2)). The Task Force and panel of consultants offer similar support. 2 nd ed. Published in 2018 - Ann Oncol (2018) 29 (Suppl 4): iv166–iv191 Authors: M. Fallon, R. Giusti, F. Aielli, P. Hoskin, R. Rolke, M. Sharma & C. I. Ripamonti, on behalf of the ESMO Guidelines Committee The 2018 ESMO Clinical Practice Guidelines on Cancer Pain are based on the most recent data available. The American Pain Society is a multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering. c. Physical examination: A physical examination should include general medical and neurologic examinations and a specific examination of the site of pain and surrounding anatomic regions. The Guidelines do not apply to patients with acute pain from an injury or postoperative recovery, cancer pain, degenerative major joint disease pain, headache syndromes (e.g ., migraine and cluster), temporomandibular joint syndrome, or trigeminal or other neuralgias of the head or face. b. Rectal and transdermal analgesia: The literature suggests that rectal and transdermal modes of analgesia are effective alternatives to oral analgesics. Opioids should not be withheld from cancer patients for fear of producing respiratory depression, tolerance, physical dependence, or addiction. Background The American Pain Society (APS) set out to revise and expand its 1995 Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain and to facilitate improvements in the quality of pain management in all care settings.. Methods Eleven multidisciplinary members of the APS with expertise in quality improvement or measurement participated in the update. The Task Force and consultants are supportive of the effectiveness of pediatric cancer pain therapies in improving analgesia and quality of life. Direct drug delivery systems involve administration of an agent to the neuraxis or in the vicinity of "target" neural tissue. Assessing and monitoring a patient's palliative care needs are essential parts of the evaluative/therapeutic process. New recommendations are given for the key pain assessment question, step 2 of the analgesic ladder and for ketamine and cannabinoid use. 86 Cancer pain management (general). Template 5. Mental clouding or cognitive impairment can vary from mild mental clouding to frank delirium. c. Nausea and vomiting: Persistent nausea is rare, and prophylactic therapy is not indicated. The American Society of Interventional Pain Physicians (ASIPP) is pleased to announce a partnership with Willow Risk Advisors to create an exclusive policy available to ASIPP members. Oral pharmacologic interventions: The literature suggests and consultant opinion supports the view that oral pharmacologic interventions applied according to the WHO analgesic ladder are associated with adequate analgesia. Examples of chemical neuroablative procedures include but are not limited to intercostal neurolysis, neurolytic celiac plexus block, neurolytic superior hypogastric plexus block, neurolytic ganglion impar (ganglion of Walther) block, craniofacial neurolytic techniques, and subarachnoid rhizolysis. (Note: The enteral route should be used in patients with percutaneous feeding tubes and inability to swallow, as long as absorption still occurs.) The last set of WHO guidelines focused on cancer pain management were issued in 1996. Methods An ASCO-convened expert panel conducted a systematic literature search of studies investigating chronic pain management in cancer survivors. 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