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with cancer (Miser et al, 1994 Level II). Outcomes for second and subsequent procedures were
improved if adequate analgesia was provided for the first procedure (Weisman et al, 1998
Level III‐2).

10.8.3 Treatment-related pain
Pain related to side effects of chemotherapy and radiotherapy is a source of high distress to
children with cancer (Collins et al, 2000 Level IV; Ljungman et al, 2000 Level IV). Mucositis is a
common side effect of many chemotherapeutic regimens (Cella et al, 2003), can be difficult to
assess (Tomlinson et al, 2008), and is a frequent indication for IV opioid therapy.
Opioid requirements are often high and escalate with the severity of mucositis (Dunbar et al,
1995 Level IV; Coda et al, 1997 Level II). In patients aged 12 to 18 years, morphine by PCA or
continuous infusion provided similar analgesia, but morphine intake and opioid‐related side
effects were lower in the PCA group (Mackie et al, 1991 Level II). A systematic review (which
included this study and additional adult studies) found no difference in pain control between
PCA and continuous infusion, but reduced hourly opioid requirement and shorter duration of
pain with PCA (Clarkson et al, 2007 Level I).
PCA morphine and hydromorphone had similar efficacy (Collins et al, 1996 Level II) but sufentanil
was less effective (Coda et al, 1997 Level II). Prolonged administration is often required (6 to
74 days) (Dunbar et al, 1995 Level IV). If excessive or dose‐limiting side effects occur, rotation to
another opioid (morphine to fentanyl or fentanyl to hydromorphone) can produce
improvement in the majority of patients, without loss of pain control (Drake et al, 2004 Level IV).
Postoperative pain related to surgical procedures for diagnostic biopsies, insertion of long‐
term IV access devices and tumour resection is also a frequent source of treatment‐related
pain. In children with cancer requiring morphine infusions, the highest rate of breakthrough
pain was found in postoperative cases, of which 92% had solid tumours (Flogegard & Ljungman,
2003 Level IV). In children with cancer, supplemental IV opioid boluses (either nurse‐
administered or via PCA) were safely combined with epidural bupivacaine and fentanyl
infusion to control postoperative pain. One of 117 patients developed respiratory depression
(due to a drug‐dose error), but patients were closely monitored and had pre‐existing tolerance
to opioids (Anghelescu et al, 2008 Level IV).
For management of acute cancer pain in general see Section 9.7; for the management of acute
mucositis pain see Section 9.6.7.
CHAPTER 10 Key messages

1. PCA and continuous opioid infusions are equally effective in the treatment of pain in
mucositis, but opioid consumption is less with PCA (U) (Level I).
2. PCA morphine and hydromorphone are equally effective for the control of pain associated
with oral mucositis (U) (Level II).

362 Acute Pain Management: Scientific Evidence