NCCN updates adult cancer pain guidelines

  • Swarm RA & al.
  • J Natl Compr Canc Netw
  • 1 Aug 2019

  • International Clinical Digest
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  • Newly updated clinical practice guidelines for adult cancer pain from the National Comprehensive Cancer Network (NCCN) identify central principles for comprehensive, multimodal management of adult cancer pain, using both pharmacologic and nonpharmacologic interventions.

Why this matters

  • Pain undertreatment remains an issue for significant numbers of patients with cancer and may be exacerbated by inappropriate application of recommendations intended to prevent opioid overprescription and overuse.

Key recommendations

  • Consider optimal use of nonpharmacologic and pharmacologic interventions.
  • Mild-moderate pain: consider nonopioid and adjuvant therapies unless contraindicated; consider short-acting opioids if needed.
  • Consider hospital admission for severe pain.
  • Manage opioid-induced side effects.
  • Chronic persistent pain: consider short-/long-acting opioid with rescue dose for breakthrough pain.
  • Frequently assess the need for opioid analgesic; consider opioid rotation.
  • Nonopioid analgesics: use acetaminophen with caution.
  • NSAIDs: avoid concomitant use of NSAIDs with aspirin; caution advised in patients age ≥60 years or at high risk for cardiac toxicities.
  • Adjuvant analgesics: check for drug interactions, carefully use serotonergic medication.
  • Cannabinoids and medical cannabis: limited and conflicted supporting data.
  • Opioids: adopt individualized approach to select opioid starting dose, frequency, and titration to achieve a balance between pain relief and medication adverse effects.
  • Use morphine/hydromorphone/hydrocodone/oxymorphone/codeine with caution in patients with renal impairment.
  • Discuss integration of nonpharmacologic intervention strategies with patients.

Coauthored with Chitra Ravi, MPharm