When managing adult cancer survivors with pain lasting 3 or more months, clinicians should employ conservative interventions before considering opioids, according to new clinical practice guidelines released by the American Society of Clinical Oncology (ASCO).
An expert panel developed the recommendations based on clinical experience and evidence collected from 35 systematic reviews, 9 randomized controlled trials, and 19 comparative studies. The guidelines were published online on July 25 by the Journal of Clinical Oncology.
Among the key recommendations were the following:
- Clinicians should screen for pain at each encounter in addition to conducting an initial comprehensive pain assessment, which should consist of an interview exploring factors related to pain, cancer treatment history, comorbid conditions, psychosocial and psychiatric history, and prior pain treatments.
- Clinicians should also engage and educate the patient and family/caregivers, aiming to increase comfort and function while ensuring safety. They should refer patients with complex needs accordingly.
- Nonpharmacological interventions to mitigate chronic pain or improve pain-related outcomes may include physical medicine and rehabilitation (e.g., physical therapy), integrative therapies (e.g., massage), interventional therapies (e.g., nerve blocks), psychological approaches (e.g., cognitive behavioral therapy), and neurostimulatory therapies (e.g., transcutaneous electrical nerve stimulation).
- Systemic nonopioid analgesics (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen/paracetamol) may also relieve chronic pain and/or improve function when no contraindications are present. The efficacy and long-term effectiveness of many other systemic nonopioids (e.g., muscle relaxants, benzodiazepines) have not been established. Corticosteroids are not recommended for long-term use.
- A trial of opioids may be prescribed to carefully selected cancer survivors whose chronic pain does not respond to more conservative management. Clinicians should assess the potential risks and benefits and take precautions to minimize adverse consequences and abuse.
- For neuropathic pain conditions or chronic widespread pain, adjuvant analgesics can include antidepressants such as duloxetine and the anticonvulsants gabapentin and pregabalin.
- To manage chronic pain, clinicians may also prescribe topical analgesics, such as commercially available NSAIDs, local anesthetics, or compounded creams/gels containing baclofen, amitriptyline, and ketamine.
- Although there is insufficient evidence to recommend medical cannabis for the first-line management of chronic pain in cancer survivors, clinicians may consider it as an adjuvant analgesic or when managing refractory pain conditions. They should follow state regulations that allow access to medical cannabis or cannabinoids after considering the potential risks and benefits of available formulations.