Page 333 Acute Pain Management
P. 333
symptom control from 42% to over 80% of patients (Khot et al, 2002 Level IV) and complications
including perforation (3.76%), stent migration (11.81%) and reobstruction (7.34%) (Sebastian et
al, 2004 Level IV).
Mucositis
Mucositis may be due to side effects of chemoradiotherapy for solid and blood malignancies.
For management see Section 9.6.7.
9.7.7 Interventional therapies for acute cancer pain
Although pain is adequately controlled in the majority of patients with advanced cancer, those
with an acute exacerbation of pain or prolonged intractable pain may benefit from an
interventional procedure, including local anaesthetic nerve blocks, neuraxial infusions,
neurolytic or neurosurgical procedures (Chambers, 2008).
A systematic review of the comparative efficacy of epidural, subarachnoid and
intracerebroventricular (ICV) opioid infusions for cancer pain found no controlled trials, so
conclusions were drawn from uncontrolled trials and case series of patients with ICV, epidural,
or subarachnoid opioid infusions (Ballantyne & Carwood, 2005 Level IV). Excellent analgesia was
reported in 73%, 72% and 62% of patients after ICV, epidural and subarachnoid opioids,
respectively, and there were few treatment failures in all groups. Adverse effects more
common with epidural and subarachnoid infusions were persistent nausea, urinary retention,
pruritus and constipation, whereas respiratory depression, sedation and confusion were more
common with ICV therapy.
Currently, intrathecal infusions of several classes of agents by a variety of drug delivery
systems may provide effective analgesia to cancer patients with previously refractory pain,
poor tolerance of oral or systemic analgesia and poor performance status. Consensus
guidelines have been established for the use of intrathecal opioids, local anaesthetics,
clonidine, baclofen and other medications in cancer patients (Stearns et al, 2005).
The issue of analgesia for breakthrough pain in patients with intrathecal analgesia was
addressed in a small case series, where either an intrathecal local anaesthetic bolus or
sublingual ketamine was used successfully (Mercadante et al, 2005 Level IV).
Key messages
1. Oral transmucosal fentanyl is effective in treating acute breakthrough pain in cancer CHAPTER 9
patients (S) (Level I [Cochrane Review]).
2. Radiotherapy and bisphosphonates are effective treatments of acute cancer pain due to
bone metastases (N) (Level I [Cochrane Review]).
3. Opioid doses for individual patients with cancer pain should be titrated to achieve
maximum analgesic benefit with minimal adverse effects (S) (Level II).
4. Analgesic medications prescribed for cancer pain should be adjusted to alterations of pain
intensity (U) (Level III).
Acute pain management: scientific evidence 285
