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The Agency for Health Care Policy and Research in Silver Spring, MD, recommends physicians follow these guidelines when determining the type and scope of pain therapy:
• An essential principle in using medications to manage cancer pain is to individualize the regimen to the patient.
• The simplest dosage schedules and least invasive pain management modalities should be used first.
• Pharmacologic management of mild to moderate cancer pain should include an NSAID or acetaminophen, unless there is a contraindication.
• When pain persists or increases, an opioid should be added.
• Treatment of persistent or moderate to severe pain should be based on increasing the opioid potency or dose.
• Medications for persistent cancer-related pain should be administered on an around-the-clock basis with additional "as-needed" doses, because regularly scheduled dosing maintains a constant level of drug in the body and helps to prevent a recurrence of pain.
• Patients receiving opioid agonists should not
be given a mixed agonist-antagonist because doing so may precipitate a withdrawal syndrome and increase pain.
• Meperidine should not be used if continued opioid use is anticipated.
• Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with addiction.
• The oral route is the preferred route of analgesic administration because it is the most convenient and cost-effective method of administration. When patients cannot take medications orally, rectal and transdermal routes should be considered because they are also relatively noninvasive.
• Intramuscular administration of drugs should
be avoided because this route can be painful and inconvenient, and absorption is not reliable.
• Failure of maximal systemic doses of opioids and coanalgesics should precede the consideration of intraspinal analgesic systems.
• Because there is great interindividual variation in susceptibility to opioid-induced side effects, clinicians should monitor for these potential side effects.
• Constipation is a common problem associated with long-term opioid administration and should be anticipated, treated prophylactically, and monitored constantly.
• Naloxone, when indicated for reversal of opioid-induced respiratory depression, should be titrated in doses that improve respiratory function but do not reverse analgesia. Placebos should not be used in the management of cancer pain.
• Patients should be given a written pain management plan.
• Communication about pain management should occur when a patient is transferred from one setting to another.