Neobook — clinical reference

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R52.1/R52.2/R52.9

DESCRIPITION

Cancer pain is usually persistent and progressive. Pain assessment requires training in:

Psycho-social assessment
Assessment of need of type and dose of analgesics
Pain severity assessment

Under-recognition of pain and under-dosing with analgesics is common in chronic cancer pain.

Analgesics should be given regularly rather than only when required in patients with ongoing pain.

GENERAL MEASURES

The need for treatment is determined by pain severity rather than the presence of pain.
Do not withhold pharmacological treatment for pain.
Pain is what the patient says it is.
Arrange counselling/hospice care.
Occupational therapy may be required.
Manage contributing psycho-social factors.

Note:

Appropriate care should be provided from the time of diagnosis.

Home palliative care is provided by the family or caregiver with the support of health care professionals: Medicines used in palliative care.

MEDICINE TREATMENT

Pain should be controlled as rapidly as possible.
If pain is not adequately controlled within 2 days, proceed to the next step.
Cancer pain in children is managed by the same principles but using lower doses of morphine than adults.

STEPWISE APPROACH IN MANAGEMENT OF CANCER PAIN

Adults

Step 1: Non-opioid

Paracetamol, oral, 500 mg–1 g, 4–6 hourly as required (to a maximum of 4 g in 24 hours).
- Maximum dose: 15 mg/kg/dose.

LoE:IIb²²

AND/OR

NSAIDs, e.g.:
Ibuprofen, oral, 400 mg, 8 hourly with or after a meal

LoE:IIb²³

Step 2: Add weak opioid to Step 1

Tramadol, oral, 50–100 mg, 6 hourly as a starting dose (Doctor prescribed).
- May be increased to a maximum daily dose of 400 mg.

CAUTION

Use with caution when administered with antidepressants e.g. amitriptyline to avoid over sedation.

LoE:IIb²⁴

Step 3: Replace weak opioid with strong opioid, i.e. morphine, and add to paracetamol and/or ibuprofen

Morphine, oral, 4 hourly (Doctor prescribed).
- Start with 5–10 mg.
- Titrate the dose and dose frequency against the effect on pain.

If dosage is established and patient is able to swallow:

Morphine, long-acting, oral, 12 hourly (Doctor prescribed).
- Start with 10–20 mg/dose.
- Titrate the dose and dose frequency against the effect on pain.

LoE:IIb²⁵

If breakthrough pain occurs: See Breakthrough pain

Elderly adults or severe liver impairment:

Morphine solution, oral, 4 hourly. (Doctor prescribed).
- Start with 2.5-5 mg/dose.
- Titrate the dose and dose frequency against the effect on pain.

Note:

- There is no maximum dose for morphine – Titrate the dose against the effect on pain.

- For the management of morphine overdose, see: Exposure to poisonous substances.

Children

Stepwise approach to pain management is recommended:

LoE:IVb²⁶

Step 1: Non-opioid

Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See: dosing table.
NSAIDs, e.g.:
Ibuprofen, oral, 5–10 mg/kg/dose 8 hourly with or after a meal. See: dosing table. Where anti-inflammatory effect is required.
- Can be used in combination with paracetamol or opioids.
- Discontinue if not effective after 2–3 days.

LoE:IIb²⁷

Step 2: Add opioid to paracetamol and/or ibuprofen

Morphine, oral, 0.2–0.4 mg/kg/dose 4–6 hourly according to severity of the pain. See: dosing table (Doctor prescribed).

LoE:IIb²⁸

Adjuvant therapy:

Children

See the Paediatric Hospital STGs and EML, Pain control.

Adults

In addition to analgesia as above:

Amitriptyline, oral, 10 mg at night. (Doctor initiated).
- Titrate up to a maximum of 75 mg at night.

LoE:IVb²⁹

Significant nausea and vomiting:

Adults

Metoclopramide oral, 10 mg, 8 hourly as needed.
- Maximum daily dose: 0.5 mg/kg

Children

For treatment of nausea and vomiting in the palliative care setting, see: Nausea and vomiting.

Constipation:

A common problem due to long-term use of opioids, which can be prevented and should always be treated.
For management of constipation in palliative care, see Constipation.

Children

Lactulose, oral, 0.5 mL/kg/dose once daily. See: dosing table.
- If poor response, increase frequency to 12 hourly.

Adults

Lactulose, oral, 10-20mL once daily.
- If poor response, increase frequency to 12 hourly.

Pruritus:

Children

Chlorphenamine, oral, 0.1 mg/kg/dose 6–8 hourly. See: dosing table

Adults

Chlorphenamine, oral, 4 mg, 6–8 hourly

CAUTION
Do not give an antihistamine to children <2 years of age.

Anxiety related to pain:

Children

Diazepam, oral, 0.04 mg/kg/dose 8–12 hourly (Doctor prescribed).

Weight kg	Dose mg	Tablet 2 mg	Age months/ years
>9–17.5 kg	0.5 mg	¼ tablet	>12 months–3 years
>17.5–25 kg	1 mg	½ tablet	>5–7 years
>25–35 kg	1.5 mg	¾ tablet	>7–11 years
>35 kg	2 mg	1 tablet	>11 years

May be increased up to 0.2 mg/kg/dose 8–12 hourly.
Beware of respiratory depression if given with morphine.

If an increase in dosage is required follow the weight band dosing guidance of 0.2 mg/kg/dose (see table below).

Diazepam, oral, 0.2 mg/kg/dose 8–12 hourly (Doctor prescribed).
- Beware of respiratory depression if given with morphine.

Weight kg	Dose mg	Use one of the following tablets:		Age months/ years
Weight kg	Dose mg	2 mg	5 mg	Age months/ years
>9–11 kg	2 mg	1 tablet	-	>12–18 months
>11–14 kg	2.5 mg	-	½ tablet	>18 months–3 years
>14–17.5 kg	3 mg	1½ tablets	-	>5–7 years
>17.5–25 kg	4 mg	2 tablets	-	>5–7 years
>25 kg	5 mg	-	1 tablet	>7 years

Adults

Diazepam, oral, 2–5 mg every 12 hours for a maximum of two weeks (Doctor prescribed)

Click here to access the pdf.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 1.0_07 November 2024

Chapter 20: Pain_20.4 Chronic Cancer Pain

Chronic Cancer Pain

MEDICINE TREATMENT

STEPWISE APPROACH IN MANAGEMENT OF CANCER PAIN

CAUTION

Drugs mentioned

ICD-10 codes