ALGORITHM: August 2010

Pain in Adults with Cancer: Screening and Assessment

Screen for pain using ESAS at each visit

ESAS score 1 to 3 ESAS score 4 to 6 ESAS score 7 to 10

Assessment using Acronym O, P, Q, R, S, T, U and V (adapted from Fraser Health)

Onset When did it begin? How long does it last? How often does it occur?

Provoking/Palliating What brings it on? What makes it better? What makes it worse?

Quality What does it feel like? Can you describe it?

Region / Radiation Where is it? Does it spread anywhere?
What is the intensity of this symptom (On a scale of 0 to 10, with 0 being none and 10 being worst possible)? Right Now? At Best? At Worst?
Severity On Average? How bothered are you by this symptom? Are there any other symptom(s) that accompany this symptom?
What medications or treatments are you currently using? How effective are these? Do you have any side effects from the
Treatment medications/treatments? What medications/treatments have you used in the past?
Understanding / What do you believe is causing this symptom? How is this symptom affecting you and/or your family?
Impact on You
What is your goal for this symptom? What is your comfort goal or acceptable level for this symptom (On a scale of 0 to 10 with 0 being none
Values and 10 being worst possible)? Are there any other views or feelings about this symptom that are important to you or your family?
* Physical Assessment (focus on area of pain to determine cause and type of pain ); Pertinent History (risk factors); Assess risks for addiction; Associated symptoms: e.g.
nausea, vomiting, constipation, numbness, tingling, urinary retention.

Mild Pain Moderate Pain Severe Pain

 Patient not using analgesia effectively  Pain or analgesics interfering with function  Patient in acute distress/ discomfort
 Mild pain not interfering with ADL’s and ADL’s  Pain onset is sudden and acute
 Patient states he/she cannot manage pain with  Acute exacerbation of previous levels
present treatment regime  Has developed a new site for pain
 Associated motor weakness
 Analgesics interfering with ADL’s

Interventions for all patients, as appropriate

NON-PHARMACOLOGICAL
 Psycho-social-spiritual interventions (patient education, counseling, recreational activities, relaxation therapy imagery, social interaction, spiritual counselling).
 Other therapies (physiotherapy, occupational therapy, massage, aromatherapy, music therapy, acupuncture, transcutaneous electrical nerve stimulation, reflexology, Reiki, hypnotherapy).
 Other interventions such as radiation therapy, vertebroplasty, surgery and anesthetic interventions should be considered in patients with difficult to control pain.
Patient Education
 Taking routine and breakthrough analgesics, adverse effect management, non pharmacologic measures that can be used in conjunction with pharmacologic treatment.

PHARMACOLOGICAL
 The severity of pain determines the strength of analgesic required specified by the World Health Organization (WHO) Analgesic Ladder.
 The type and cause of the pain will influence the choice of adjuvant analgesic (e.g. nociceptive, neuropathic, bone metastases).
 In the presence of reduced kidney function all opioids should be used with caution and at reduced doses and/or frequency.
 Fentanyl, methadone and oxycodone are the safest opioids of choice in patients with chronic kidney disease.
 Methadone requires an experienced prescriber, check for significant drug interactions before prescribing any drug to a patient on methadone.
 When using a transmucosal fentanyl formulation for breakthrough pain the effective dose should be found by upward titration independent of the regular opioid dose.
 For those with stabilized severe pain and on a stable opioid dose or those with swallowing difficulties or intractable nausea and vomiting, fentanyl transdermal patches may be
appropriate, provided the pain is stable.
 Classify the pain – nociceptive, neuropathic or mixed?
 The type and cause of the pain will influence the choice of adjuvant analgesic (e.g. nociceptive, neuropathic, bone metastases).
 The choice of antidepressant or anticonvulsant should be based on concomitant disease, drug therapy and drug side effects and interactions experienced.
 There is insufficient evidence to support a recommendation for topical opioids.
 There is insufficient evidence to support first or second line therapy of cancer pain with cannabinoids but they may have a role in refractory pain, particularly refractory neuropathic pain.
 Transdermal fentanyl should not be used in opioid naïve patients.
 Specialist palliative care advice should be considered for the appropriate choice, dosage and route of opioid in patients with reduced kidney function or in patients with difficult to control
pain.

ADVERSE EFFECTS OF OPIOIDS

 Many opioid-naïve patients will develop nausea or vomiting when starting opioids, tolerance usually occurs within 5-10 days. Patients commencing an opioid for moderate to severe pain
should have access to an antiemetic to be taken if required.
 The majority of patients taking opioids for moderate to severe pain will develop constipation. Little or no tolerance develops. The commonest prophylactic treatment for preventing
opioid-induced constipation is a combination of stimulant (senna or bisocodyl) and osmotic laxatives (lactulose or PEG 3350).
 Pain in Adults with Cancer: Care Map

Mild Pain Moderate Pain Severe Pain

Care Pathway 1 Care Pathway 2 Care Pathway 3

PHARMACOLOGICAL PHARMACOLOGICAL PHARMACOLOGICAL

Treatment with Treatment with strong opioids
non-opioids Treatment with opioids
 If the person is opioid naïve:  If the person is opioid naïve: Oral: Morphine 5-10 mg PO q4h
 Acetaminophen and and 5mg PO q1h PRN OR hydromorphine 1.0-2.0 mg PO q4h
o Morphine starting dose is usually 5mg and 1.0 mg PO q1h PRN OR Subcutaneous: Morphine 2.5 - 5
NSAIDS including COX-2 Q4h with 2.5-5mg Q1H prn for
inhibitors should be mg subcut q4h & 2.5 mg subcut q30min PRN OR
breakthrough pain. For elderly or hydromorphone 0.5 - 1.0 mg subcut q4h & 0.5 mg subcut q30min
considered at the lowest debilitated patients consider a starting
effective dose. PRN.
dose of 2.5mg Q4h.
 If the patient is taking an opioid with q4h dosing, increase the
o Hydromorphone starting dose is 1mg
 The need for ongoing or long Q4h with 0.5-1mg Q1h prn for
regular and breakthrough doses by 25%. Change frequency of
term treatment should be the breakthrough to q1h PRN if PO and q30min PRN if subcut.
breakthrough pain. For elderly or
reviewed periodically, if no debilitated patients consider a starting  If the patient is taking a sustained release opioid, increase this
significant response in one dose of 0.5 mg Q4h. dose by 25%. Change the breakthrough dose to 10-15% of the
week drugs should be regular 24h dose, either q1h PRN PO or q30 min PRN subcut.
stopped. o Oxycodone starting dose is 2.5 mg or one
half tablet Q4H with 2.5 mg or one half  Titrate the dose every 24h to reflect the previous 24h total dose
tablet Q2H prn for breakthrough.(The received
 Long term use of NSAIDs
should require gastric lowest dose oxycodone tablets available,  If unmanageable opioid-limiting adverse effects are present (e.g.
mucosa protection. either in combination with nausea, drowsiness, myoclonus), consider switching to another
acetaminophen or alone, contain 5mg of opioid and re-titrate or consult palliative care.
oxycodone, equivalent to ~5-10mg of  For patients with severe uncontrolled pain consider switching
 There is insufficient
morphine). back to an equivalent daily dose of immediate release morphine
evidence to recommend
bisphosphonates for first line  If the person is taking an opioid: to allow more rapid titration of dose or switch to a sc
therapy for pain o As an immediate release preparation with preparation/infusion.
management. q4h dosing, increase the regular and  Meperidine and pentazocine should generally not be used in
breakthrough doses by 25%. cancer patients with chronic or acute pain.
o As a sustained release opioid, increase  If there is difficulty getting the pain under control consider a
this dose by 25%. Change the consultation to palliative care.
Treatment with opioids breakthrough dose to 10% of the regular
24h dose, either q1-2h PRN PO or q30
 For mild to moderate pain, min PRN subcut.
weak opioids such as codeine o Patients with stable pain and analgesic SEVERE PAIN CRISIS
or tramadol could be given in usage, receiving oral morphine,
1. A severe pain crisis requires prompt use of analgesics, adjuvant
combination with a non- oxycodone or hydromorphone should
therapies, reassurance and a calm atmosphere.
opioid analgesic. have the drug converted to a sustained or
controlled release formulation given 2. Consider a consultation to palliative care or a cancer pain
 If pain is not controlled q12h for ease of administration. The short specialist.
with these combinations go acting breakthrough dose is usually 10%
to “Moderate Pain” re: of the total daily dose. 3. If IV access is present, and the person is opioid naïve give stat
initiation and treatment morphine 5-10 mg IV q10min until pain is relieved; if the
o The frequency of breakthrough doses for person is on opioids give the po prn dose IV q10min until pain
with opioids. oral opioids is Q1-2h prn. After is relieved. Monitor carefully.
conversion to a long acting preparation, if
pain is not well controlled, reassess the 4. If no IV access available, and the person is opioid naïve give
patient and consider why multiple stat morphine 5-10 mg subcut q20-30min until pain is relieved;
breakthrough doses are being used and if the person is on opioids give the po prn dose subcut q20-
the effectiveness of the breakthrough 30min until pain is relieved.
doses.
5. Titrate dose by 25% every 1 - 2 doses until pain is relieved.
o If indicated after proper assessment, the
daily dose can be titrated by adding 20 to 6. When pain is controlled: If the patient is taking a sustained
30% of the breakthrough doses used in release opioid increase this dose by 25% and change to q4h
the preceding 24 hrs to the daily dosing po or subcut. Do Not try to manage a severe pain crisis
sustained release formulation. with a long-acting opioid. Change the breakthrough dose to half
o Make frequent assessments and of the regular dose, either q1h PRN PO or q30 min PRN subcut.
adjustments to the opioid dose until the
pain is better controlled.

Follow-Up and ongoing Monitoring

If pain remains unrelieved despite the approaches outlined above, request the assistance of a palliative care consultation team.

For full references and more information please refer to CCO’s Symptom Management Guide-to-Practice: Pain document.
Disclaimer: Care has been taken by Cancer Care Ontario’s Algorithm Development Group in the preparation of the information contained in this Algorithm. Nonetheless, any
person seeking to apply or consult the guidance for practice document is expected to use independent clinical judgment and skills in the context of individual clinical circumstances
or seek out the supervision of a qualified specialist clinician. CCO makes no representation or warranties of any kind whatsoever regarding their content or use or application and
disclaims any responsibility for their application or use in any way.