Selected Guidelines [*].

* Stepped Care for Back Pain: Activating Approaches for Primary Care. Korff MV, Moore JC. Ann Intern Med 2001; 134:911-917

This paper proposes a stepped-care approach for patients with back pain who are treated in primary care settings. It is based on the principle of starting with low-intensity, low-cost interventions and "stepping up" to more intense, costly, or complex interventions when patients show an inadequate response. This approach is intended to provide a bridge between appropriate medical management and activating interventions intended to restore normal function in persons with recurrent or chronic back pain.

Back pain is a chronic-recurrent condition, and the long-term outcomes of patients with back pain are not as favorable as once believed. Almost 30% of patients seen in primary care settings for back pain have persistent back pain, and 15% to 20% continue to have moderate-to-severe activity limitations one or more years after seeking treatment.

The stepped-care approach provides:

(1) Suggestions for integrating behavioral interventions aimed at restoring function in work and family life into routine medical care;

(2) A way to target the limited professional resources for helping patients achieve favorable functional outcomes for those who have the greatest needs;

(3) A way to sequence interventions so that the intensity, complexity, and costs of care are guided by each patient's observed outcome; and

(4) Each patient with a level and type of care to produce a favorable outcome.

Systematic reviews of randomized, controlled trials conclude the following:

(1) Activating interventions improve functional outcomes for patients with chronic or recurrent back pain.

(2) Patients who stay active and continue normal activities have reduced disability and return to work faster than those who are prescribed bed rest.

(3) Structured exercise programs benefit patients with back pain.

(4) Fear-avoidance beliefs are associated with reduced activity and increased disability.

(5) A program of brief education, strengthening and flexibility exercises and relaxation reduces the number of work days missed.

(6) Brief cognitive-behavioral programs result in fewer days missed at work.

(7) An intense rehabilitative intervention that targets a return to work may be appropriate for patients at risk for chronic work-role disability.

(8) Identifying and treating comorbid psychological illnesses, such as major depression, may help improve functional outcomes.

A Stepped-Care Approach for Managing Back Pain in Primary Care

Step 1: Targets all patients with back pain. Clinicians are encouraged to:

(1) Identify and address specific patient worries and encourage them to return to normal activities;

(2) Offer self-care educational materials to the patient.

Step 2: Targets patients with back pain who still have activity limitations at six to eight weeks.

Physicians and/or case managers are encouraged to:

(1) Help patients identify difficulties, set functional goals, and define and carry out plans to achieve their goals;

(2) Provide support for resumption of activities and exercise;

(3) Conduct the support in a group setting or individually using self-care educational materials.

Step 3: Targets patients with back pain who have substantial disability in work or family roles.

Physicians and/or case managers should:

(1) Provide interventions to restore work and family role function;

(2) Provide a graded exercise program;

(3) Refer patients for rehabilitation or psychological treatment.

* Principles of Pain Control in Palliative Care for Adults. Guidance Prepared by A Working Group of the Ethical Issues in Medicine Committee of the Royal College of Physicians, London, England. J R Coll Phys Lond 2000 Jul-Aug; 34(4):350-2

These principles of pain control are designed for all clinicians who treat terminally ill patients with non-malignant diseases as well as those with advanced cancer. This paper offers guidance for the appropriate use of analgesia.

Prognosis: Many patients become aware that they are dying before the clinicians caring for them. Those patients with an incurable illness will usually have a short prognosis if the following conditions are present: progressive weight loss; profound weakness; drowsiness and reduced cognition; diminished intake of food and fluids; and difficulty swallowing medications.

Management Goals: (1) Control the patient's symptoms; (2) make the quality of life as good as possible; and (3) enable the patient to do what he or she wants to do.

Communication: Discuss the prognosis of death with the patient and family even if the patient acknowledges the fact. Discuss patients' aims and goals that they wish to achieve. Know how patients want to be treated in the future. Allow patients to retain their dignity and remain as much in control of their situation as they can. Let patients know that they will not be abandoned and that their wishes will be paramount when decisions need to be made.

Continuation of Patient Medication: Symptom control is the main goal of treatment. Medications that will control or prevent distressing symptoms should be administered. Drugs for many long-term conditions, such as antihypertensives, can be discontinued.

Understanding Pain: About two thirds of terminally ill patients experience pain. When a patient's pain is complex or difficult to control, clinicians may consider advice from other sources such as multidisciplinary specialist palliative care teams.

Steps to Control Pain: (1) Begin with a careful assessment to determine the reason for pain. (2) Consider the World Health Organization's analgesic ladder as a helpful guide when adjusting analgesia to match the patient's pain. (3) The guide includes three steps:

I. Non-opioid analgesia, eg, paracetamol;

II. Opioid for mild-to-moderate pain, eg, dihydrocodeine; and

III. Opioid for moderate-to-severe pain, eg, morphine.

Use of Morphine:

* Opioids, particularly morphine, are the mainstay in managing severe pain in terminally ill patients.

* When used to treat severe pain morphine is not addictive. It is safe when titrated against the patient's pain. It has not been shown to shorten the life of a dying patient when appropriately administered.

* If morphine is withdrawn abruptly there may be symptoms of addiction.

* When administering morphine for the first time it is recommended to start with immediate release morphine (IR) so that the dose can be adjusted frequently

* Most patients new to morphine will need a starting dose of 5-10 mg every four hours.

* Morphine JR should be given regularly every four hours. A double dose can be administered at bedtime so patients can sleep undisturbed.

* The same dose of morphine JR should be given in addition, between the regular doses, if patients are in pain.

* The regular schedule should not be altered, even though an extra dose has been given.

* If the pain is not controlled, the total morphine taken in the previous 24 hours should be added up and increased by 30-50%.

* When the pain is controlled, and the patient's 24-hour morphine requirement is determined, a modified release preparation can be used.

* Morphine IR should always be available for rescue analgesia and before certain activities, such as wound dressings.

* Side effects of morphine, particularly constipation and nausea, must be treated at the same time.

* The dose of morphine should be increased progressively if higher doses produce better control and not intolerable side effects.

* The multidisciplinary team should conduct frequent and regular reassessments until the pain is adequately controlled.

* Strong analgesics have side effects which good pain control seeks to minimize by careful dose titration and the use of antiemetics, laxatives, etc.

* The patient's preference must be respected regarding the balance between pain relief and side effects.

Alternatives to Morphine Use:

* If increasing the morphine dose does not improve the pain, but produces worse side effects, treatment may involve adding an adjuvant drug, such as a nonsteroidal anti-inflammatory drug (NSAID) for bone pain, or an antidepressant or antiepileptic drug for neuropathic pain. Some patients may respond to radiotherapy.

* Specialists may be consulted on approaches such as nerve blocks or spinal analgesia.

* If increasing the morphine dose does improve the pain, but side effects are intolerable, such as delirium, the clinician may consider switching to an alternate opioid.

* If the patient is in pain because other problems make the patient distressed and unable to deal with the pain, the problems may be psychological, spiritual, or physical.

* Other physical symptoms, eg, nausea or a sore mouth, should be carefully assessed and managed.

* Depression or extreme anxiety can be missed in a severe physical illness, but should be treated appropriately.

* Difficulties with family relationships or spiritual anxieties may cause great distress requiring appropriate support.

Alternatives to Oral Administration:

* Many patients become unable to swallow medication in the last hours or days of life and may require a non-oral route. Such conditions include severe dysphasia; intractable vomiting; intestinal obstruction; malabsorption; and the inability to comply with an oral regimen.

* The intravenous route should not be the first choice as an alternative because it is an uncomfortable, invasive procedure and not as easily managed out of the hospital.

* Transdermal medication such as fentanyl, is useful for patients with stable analgesic requirements who have difficulty swallowing or have intractable nausea.

* Continuous subcutaneous infusion, usually of diamorphine, which allows certain other drugs to be administered through the same syringe, may be a convenient alternative in the last days of life.

* Rectal administration of medication may be used if the patient dislikes pumps or similar machinery.

Continuous Subcutaneous Infusion of Analgesia:

* Continuous subcutaneous infusion of analgesia is a very common method of controlling symptoms in the last hours or days of life when patients cannot swallow.

* Battery-operated syringe drivers are widely available for drug administration, are simple to operate, and are set to run over 24 hours.

* A wide range of drugs can be used by this method, such as diamorphine, sedatives such as a benzodiazepine, hyoscine, or glycopyrronium for death rattle, and antiemetics.

* No more than two drugs should be mixed in the same syringe; however, three are occasionally used.

* If diamorphine does not adequately control the pain, the dose may be increased by 30-50% in a fresh syringe and set to run again over 24 hours.

* Subcutaneous injections can be given if the patient needs rescue analgesia.

Consultation With a Specialist:

* Careful opioid titration is likely to produce good pain control in approximately 80% of the patients.

* If pain is complex or difficult to control, a specialist may help find the optimal regimen.

* Guidelines for Assistance to Terminally Ill Children With Cancer: A Report of the SIOP Working Committee on Psychosocial Issues in Pediatric Oncology. Masera G, Spinetta J, Jankovic M, et al. Med Pediatr Oncol 1999; 32:44-48

These guidelines focus around two periods in the final phase of life for a child dying of cancer. The first period is when treatment is no longer effective, and the decision is made to move to palliative care. The second period covers the beginning of palliative care to the child's death. The duration and quality of life and the rights of the child to careful, compassionate management are emphasized.

I. Assisting the Terminally Ill Child During the Period of Transition From Curative to Palliative Care

* A child's care moves from curative to palliative care when the child cannot be successfully treated with available therapies and needs specific palliative treatments for physical or mental distress.

* Communication, support, and pain control in the final phases of care for a dying child should be a uniform philosophy in health care facilities.

* Parents, the health care team, and the family physician should be involved in and updated on decisions made from the beginning of treatment throughout the course of the disease.

* Depending on age and level of development, the child should be involved in the decision.

* The child should be informed as much as possible about the seriousness of the situation. However, if the child wishes to remain less informed, this wish should be respected.

* Family members sometimes make inappropriate decisions, such as shielding the child or stopping curative treatment prematurely. Health care workers should be understanding and communicative to avoid conflicts.

* Curative treatment beyond the point when a cure is no longer possible ("ruthless obstinacy" treatment) should be avoided.

II. Assisting the Terminally Ill Child During the Period of Palliative Care and Assisting the Family After Death

* Medical decisions regarding palliative care should be made with the parents and the comprehensive health care team.

* The control of physical and psychological pain is paramount.

* Health care workers must control all emerging symptoms, eg, vomiting, constipation, and bladder control.

* Children who wish to remain at home should be allowed to do so whenever possible. The physician should insure continual support either directly or through other supportive services (eg, home care unit, hospice, or visiting nurses).

* Parents and the health care team should be attuned to the child in the terminal phase through verbal and nonverbal communication.

* Follow-up visits and telephone calls by the physician should be offered to the parents whose child is dying at home. Routine contact with the family should continue for at least two years after a child's death.

* The physician and health care workers should provide bereavement counseling to the family following the child's death or offer referral for professional psychological counseling.

* Parents and siblings should discuss the level of care that was given to the child with the physician. Surviving family members should also discuss their needs.

* Members of the health care team should be prepared to hear and deal with anger, accusations, and blame during follow-up sessions.

* Bereaved parents and siblings should be encouraged to initiate self-help groups.

* Health care workers should reflect on the treatment choices that were made in order to deal with their own grief.

* Each center's health care team should be prepared to modify philosophical goals and guidelines when necessary, based upon review of individual cases and parental comments.

* The Management of Chronic Pain in Older Persons. AGS Panel on Chronic Pain in Older Persons. American Geriatrics Society. J Am Geriatr Soc 1998 May; 46(5):635-51. (Note: These guidelines are also published in: Geriafrics 1998 Oct; 53 [Suppl 3[S8-24.)

The AGS Panel developed these guidelines to improve clinical assessment and management of chronic pain in older adults. They are divided into four sections: Assessment of Chronic Pain in Older Persons, Pharmacologic Treatments of Chronic Pain in Older Persons, Nonpharmacologic Strategies for Pain Management in Older Persons, and Recommendations for Health Systems That Care for Older Persons.

I. Assessment of Chronic Pain in Older Persons:

* There are no objective biological markers for pain.

* The most reliable and accurate evidence of pain and its intensity is the patient's report.

* Some older patients may be reluctant to report pain for fear of diagnostic tests or medications.

* Clinicians should assess any older person for evidence of chronic pain.

* Persistent or recurrent pain that has a significant impact on function or quality of life should be viewed as a significant problem.

* A variety of terms, such as burning, discomfort, aching, soreness, heaviness, and tightness should be used to screen the elderly for pain.

* For patients with cognitive or language impairments, nonverbal pain behavior, recent changes in function, and vocalizations may indicate pain (eg, changes in gait, withdrawn or agitated behavior, moaning, groaning, or crying).

* A report from a caregiver is necessary if the patient has cognitive or language impairment.

* Conditions that require specific interventions should be identified and treated.

* Underlying diseases should be managed optimally.

* Patients in need of specialized services or skilled procedures should be referred for consultation from a specialist (eg, patients with debilitating psychiatric complications, patients who are abusing or are addicted to a legal or illicit substance, and patients with life-altering intractable pain).

* All patients with chronic pain should have a comprehensive pain assessment that includes the following:

* A medical history and physical examination with focus on the neuromuscular and musculoskeletal systems;

* Classification of pain according to intensity, character, frequency, location, duration, and precipitating and relieving factors;

* A thorough analgesic medication history, including over-the-counter and "natural" remedies;

* An evaluation of physical function which includes pain-associated disabilities, including activities of daily living (eg, Lawton IADLs) and performance measures of function (eg, Up-and-Go Test);

* An evaluation of psychosocial function including patient's mood, especially for depression and assessment of the patient's social networks, including dysfunctional relationships;

* A quantitative assessment of pain using a standard pain scale (eg, visual analogue scale, numerical scale, word descriptor), or scales tailored to the needs of patients with cognitive or language barriers;

* Estimates of pain based on clinical impressions or surrogate reports should not be used unless the patient can't make his or her needs known.

* Patients with chronic pain and their caregivers should use a pain log or diary with regular entries for intensity, medication use, response to treatment, and associated activities.

* Patients with chronic pain should be reassessed regularly for improvement, deterioration, or complications attributable to treatment.

II. Pharmacologic Treatment of Chronic Pain in Older Persons:

* All older patients with diminished quality of life because of chronic pain are candidates for pharmacologic therapy.

* The least invasive route (usually the oral route) should be used.

* Fast-onset, short-acting analgesic drugs should be used for episodic pain.

* Acetaminophen is the preferred drug for relieving mild-to-moderate musculoskeletal pain. The maximum dose should not exceed 4,000 mg per day.

* High-dose, long-term nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided. When used chronically, they should be used only as needed.

* Short-acting NSAIDs may be preferable to avoid dose accumulation.

* Only one NSAID at a time should be given. Maximum dose may be unattainable due to toxicity.

* NSAIDs should not be used in patients with impaired renal functions, a history of peptic ulcer disease or bleeding diathesis.

* Opioid analgesic drugs may be helpful in relieving moderate-to-severe pain.

* Opioid analgesic drugs may result in mild sedation and impaired cognitive performance. Patients should not drive, be alerted for falls and accidents, and be monitored for profound sedation, unconsciousness, or respiratory depression.

* Long-acting or sustained-release analgesic preparations should be prescribed only for continuous pain. Fast-onset, short-acting preparations should be used for breakthrough pain (eg, end-of-dose failure, incident and spontaneous pain).

* Titration should be based on the persistent need for analgesia. Use of medications for breakthrough pain should be based on the pharmacokinetics and pharmacodynamics of the specific drugs in the older patient.

* Constipation should be prevented with a prophylactic bowel regimen. Bulking agents should be avoided, while fluid intake, exercise, ambulation, and physical activities should be encouraged. Motility agents should only be used after a rectal examination and disimpaction and not if obstruction is present.

* Severe nausea may need to be treated with antiemetic medications while mild nausea usually resolves spontaneously in a few days. If nausea persists, a trial of an alternative opioid or antiemetic drug could be considered.

* Severe pruritus may be treated with antihistamine medications.

* Myoclonus may be relieved with an alternate opioid drug or clonazepam in severe cases.

* Fixed-dose combinations, such as acetaminophen and an opioid may be used for mild-to-moderate pain.

* Patients taking analgesic medications should be monitored closely and re-evaluated frequently for drug efficacy and side effects on a regular basis. Patients on long-term opioid therapy should be evaluated periodically for dangerous drug-use patterns.

* Non-opioid analgesic medications, such as carbamazepine, may be appropriate for some patients with neuropathic pain and other chronic pain syndromes. Therapy should begin with the lowest possible doses and increased slowly; they are often more useful when used in combination with other pain management therapies.

III. Nonpharmacologic Strategies for Pain Management in Older Persons

* All patients with diminished quality of life due to chronic pain are candidates for nonpharmacologic pain management strategies.

* Patient education that includes methods of pain assessment, goals of treatment, treatment options, expectations, analgesic drug use, and self-help techniques, such as using heat, cold, massage, relaxation, and distraction should be provided. Precautions against thermal injury should be explained.

* Nonpharmacologic interventions can be used alone or with pharmacologic strategies for chronic pain management.

* Cognitive-behavioral therapies should be a part of the care for older patients with chronic pain. They should be applied as a structured program by a professional, and should include plans to prevent selfdefeating behavior.

* Exercise should be initiated in patients with chronic pain and should be conducted over five to 12 weeks by a supervised trained professional. The programs should be tailored to the needs and preferences of the patient.

* A trial of physical or occupational therapy is recommended for the rehabilitation of impaired range of motion, specific muscle weakness, or other physical impairments associated with chronic pain.

* Traditional insight-oriented psychotherapy should not be used alone to manage chronic pain.

* Other nonpharmacologic therapies, such as chiropractic, acupuncture, or transcutaneous nerve stimulation, may be helpful.

IV Recommendations for Health Systems That Care for Older Persons:

* Health care facilities should support policies and procedures for routine screening, assessment, and treatment of chronic pain in all older patients.

* Pain management should be a major part of the development of clinical pathways in health organizations.

* Health care facilities, such as ambulatory care facilities, hospitals, nursing homes, and home-care agencies, should periodically conduct quality assurance or quality improvement activities in pain management.

* Diagnosis-driven reimbursement systems should be revised to improve incentives for pain management and symptom control; reimbursement should be appropriate.

* Health systems should ensure accessibility to specialty pain services.

* Specialty pain services should be accredited and adhere to guidelines defined by quality review organizations.

* Pain-management education for all health care professionals at all levels should be improved.

* Professional health school curricula should provide substantial training in chronic pain management, and health systems should provide continuing education in pain assessment and management.

* Accreditation bodies should include pain management curriculum content as evaluation criteria.

* Pain management should be available to consumers.

* Programs and regulations designed to decrease illicit drug use should be revised to eliminate barriers to chronic pain management for the elderly.

* State medical license boards should publish professional standards for prescribing controlled substances for pain.

* State medical license boards must eliminate clinicians' trepidation over conduct review.

* Law and drug enforcement agencies should recognize their role in facilitating and providing easy access to the legitimate use of controlled substances and should provide public information for clinicians and the public regarding legal and illegal prescribing, dispensing, storage, disposal, and use of controlled substances.

* The Management of Chronic Pain in Patients With Breast Cancer. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Canadian Society of Palliative Care Physicians. Canadian Association of Radiation Oncologists. CMAJ 1998 Feb 10; 158 (Suppl 3):S71-81.

These guidelines have been developed to help health professionals develop strategies to control chronic pain caused by breast cancer.

Recommendations:

* The nature and severity of the pain should be carefully evaluated using the history and physical examination. Identify psychosocial and emotional factors and evaluate adequacy of pain control.

* The cause of pain should be identified and treated whenever feasible.

* The first priority of treatment is to control pain quickly and the second is to prevent its recurrence. Analgesic medication should be given on a regular schedule around-the-clock with additional doses for breakthrough pain.

* The World Health Organization's three-step approach to using analgesics is recommended.

* The first choice for opioid administration should be an oral route, and then tansdermal or rectal administration may be considered.

* When parenteral administration is necessary for opioids, intravenous or subcutaneous routes are recommended. Intramuscular administration is not recommended.

* Careful observation and titration are necessary when switching from one opioid to another.

* If converting a patient from long-term oral use of morphine or hydromorphone to parenteral use, a ratio of 3:1 should be used.

* After initiating morphine or making any change of dose or route of administration, the dosage should be evaluated after 24 hours.

* Tolerance to opioids must not be confused with physical or psychological dependency.

* Patients should be made aware of possible side effects of medications and encouraged to keep a record of medications, dosages, and adverse effects.

* Adjuvant analgesics (eg, corticosteroids, antidepressants, anticonvulsants, or local anesthetics) should be administered, when necessary, with an opioid or nonopioid analgesic.

* Noninvasive techniques such as psychosocial interventions and physical modalities may offer significant relief.

* Neuroinvasive procedures are rarely required and should be considered only when other interventions have failed.

* Practice Guidelines for Chronic Pain Management. A Report by the American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Anesthesiology 1997; 86:995-1004.

The Task Force developed these guidelines for anesthesiologists and health care providers who deliver care under the direct supervision of anesthesiologists. The guidelines are designed to:

1. Optimize pain control, realizing that a pain-free state may not be achievable;

2. Minimize adverse outcomes and costs;

3. Enhance functional abilities and physical and psychological well-being; and

4. Enhance the quality of life for patients with chronic pain.

Diagnosis

Chronic pain is defined as persistent or episodic pain of a duration or intensity that adversely affects the function or well-being of the patient, attributable to any nonmalignant etiology.

I. A Comprehensive History and Physical Examination of the Patient With Chronic Pain:

A. The following should be included in a comprehensive examination:

* The patient's general medical condition and extent of concurrent medical and surgical diagnoses;

* Any chronic pain syndromes which may be related to pathology or dysfunction in one or more organ systems or to psychological conditions;

* Other medical or surgical conditions that may include pain and mimic chronic pain syndromes;

* Any diagnosis and management of a painful crisis;

* Any diagnoses and management of medical emergencies and complications arising from the underlying cause of pain or treatment.

B. A comprehensive evaluation and treatment plan should include the following:

* A complete pain history with a general medical history emphasizing the chronology and symptomatology of the complaint;

* The onset, quality, intensity, distribution, duration, course, and affective components of the pain as well as details about exacerbating and relieving factors;

* A record of symptoms, such as motor, sensory and autonomic changes;

* Previous diagnostic tests, results of previous therapies, and current therapies to be reviewed by the anesthesiologist;

* A psychosocial evaluation which includes any information about the presence of psychological symptoms (anxiety, depression, or anger); psychiatric disorders; personality traits or states; coping mechanisms, and the meaning of the pain; family, vocational, or legal issues; involvement of rehabilitation agencies; expectations of the patient, significant others, employer, attorney and other agencies;

* The above mentioned findings should be used to determine the possible etiologies and effects of the pain;

* Once a diagnosis has been established, a treatment plan should be formulated with input from the patient, other involved professionals, significant others or rehabilitation counselors. Outcome goals and treatment should be discussed with the patient.

II. Diagnostic Evaluation:

* Anesthesiologists should have knowledge of various diagnostic evaluations, including diagnostic neural blockades, imaging modalities, pharmacodiagnosis, electrodiagnosis, and laboratory studies.

* Neural blockade with a local anesthetic, including somatic and autonomic blocks, may be useful in determining the site and etiology of chronic pain.

* Anesthesiologists should review and interpret the diagnostic data when clinically indicated.

III. Counseling and Coordination of Care:

* Anesthesiologists should provide appropriate counseling to a patient regarding the pain syndrome diagnosis, treatment options, rehabilitation, and follow-up goals.

The anesthesiologist should coordinate care with other health professionals, rehabilitation and vocational agencies, and social and legal entities.

* A longitudinal assessment of outcome should be kept.

IV. Periodic Monitoring and Measurement of Clinical Outcomes:

* Periodic monitoring of the effects of therapy and patient status will result in improved pain management and reduced adverse health effects from therapy.

* Accurate and complete records of pain therapies should be kept.

* The primary source of pain assessment should be reports of pain from the patient and should be obtained at periodic intervals.

* Monitoring may include a patient's verbal report of treatment efficacy, other pain records, or reports of side effects associated with pain management.

* Analyses of aggregate outcomes are essential for continuous quality improvement of chronic pain management in a clinical setting.

V. Multidisciplinary Pain Management:

* Multidisciplinary care includes contributions to patient pain care by more than one health care discipline; a program of pain care by more than one health care discipline; or a combination of both.

* Anesthesiologists should be involved in a patient's evaluations, provisions, and interpretations of diagnostic procedures, clinical pharmacology, provisions of alternative drug delivery methods, temporary or long-term neural blockades, and neuromodulatory techniques.

VI. Multimodality Pain Management:

* The combined use of neural blockades, medications, or rehabilitative therapies should be considered when analgesia with acceptable adverse effects is no longer attained with single modalities.

* A multimodal  approach may reduce the potential for adverse effects resulting from escalating frequency or from dosage levels of a single modality.

VII. Adjuvant Analgesics: Antidepressants, Membrane Stabilizing Agents, and Nonsteroidal Anti-inflammatory Drugs (NSAIDs):

* Antidepressants, membrane stabilizing agents, and NSAIDs are recommended to reduce pain and improve sleep.

* NSAIDs and membrane stabilizing agents, such as anticonvulsants, may be used to reduce pain.

* The beneficial and adverse effects should be monitored with all agents.

VIII. Regional Sympathetic Blockade:

* A regional sympathetic blockade (eg, lumbar sympathetic block, stellate ganglion block, intravenous regional block) is effective in providing analgesia.

* Periodic monitoring should be conducted to assess analgesic benefits and adverse effects, such as sensory or motor block; failed blockage of sympathetic outflow, especially to the upper extremity; local anesthetic toxicity; and site infections.

IX. Corticosteroid Injection Therapy:

* Locally injected corticosteroids are effective in providing analgesia and enhancing patient functioning and quality of life.

* A directed neurologic evaluation should precede local injections of corticosteroids.

* A follow-up evaluation is necessary to monitor health effects, including analgesia, function, and adverse effects on local tissues and the hypothalmic pituitary adrenal axis.

X. Neurostimulation Therapy:

* Neurostimulation therapy, such as transcutaneous electrical nerve stimulation (TENS) and spinal-cord stimulation (SCS) techniques, and peripheral nerve stimulation (PNS) techniques, are recommended for analgesia.

* An office or home trial of TENS should be considered as an early management option.

* PNS should be used on patients with a peripheral mononeuropathy who have responded to a diagnostic sequence of local neural blockade and a stimulation trial.

* SCS should not be a first-line treatment, but may be considered after failure of oral medications.

* SCS may be effective in managing patients with peripheral neuropathic pain or with pain coming from the spinal cord (arachnoiditis, syringomyelia, spinal cord injury, and multiple sclerosis).

* SCS should be preceded by a trial with a percutaneous electrode system.

XI Opioid Therapy:

* Opioid therapy may be used when analgesia from other modalities (eg, NSAIDs, TENS) is no longer adequate to manage chronic pain.

* Systemic or neuraxial opioids should be administered based on patient need.

* Personnel should be available to respond to patients' needs during administration of opioids in compliance with applicable local, state, and federal regulations

* Analgesic benefits of opioids should be balanced against the potential adverse sequelae of long-term opioid use.

* Patients treated with opioids may require frequent follow-up evaluation.

* A second opinion from another expert in pain management may be considered.

XII. Neuroablative Techniques:

* Neuroablation should be preceded by verification of needle placement using local anesthetic, imaging, or electrical stimulation.

* Successful temporary blockade does not guarantee the success of succeedino- neuroablation.

* Reported adverse effects are rare, but include motor, sensory, and autonomic dysfunction (paralysis, deafferentation pain, loss of sphincter control, or impotence), regeneration pain, and neuralgias.

* Neuroablative techniques should be part of a comprehensive approach to managing pain and used only as a last resort after other therapies have failed.

* Follow-up assessments of pain and other health effects should be conducted.

* Practice Guidelines for Cancer Pain Management. A Report by the American Society of Anesthesiologists Task Force on Pain Management, Cancer Pain Section. Anesthesiology 1996; 84:1243-57

These guidelines are recommended for anesthesiologists and health care workers who deliver care to patients of all ages with all types of cancers under the direct supervision of anesthesiologists. They are designed to help clinicians optimize pain control; minimize side effects, adverse outcomes and costs; enhance functional abilities and physical and psychological well-being; as well as the quality of life for cancer patients.

I. Comprehensive Evaluation and Assessment of the Patient With Cancer Pain:

* Effective cancer pain management requires a clear understanding of the etiology and pathophysiology of the pain.

* A comprehensive evaluation should include the patient's general medical condition and an assessment of the extent of the disease.

* Knowledge of common pain syndromes (eg, bone metastases, abdominal {visceral} pain, neuropathic pain {peripheral neuropathies, acute herpes zoster and postherpetic neuralgia, and plexopathies}, and mucositis), is necessary in conducting a cancer pain evaluation.

* Knowledge of modalities that can be used in treating a painful crisis is necessary.

* A pain history should include quality of the pain, such as burning or aching; pain intensity; spatial relationships of the pain; factors that palliate or provoke pain; temporal characteristics of pain; pain duration; course of the pain; and associated features of the pain such as numbness, weakness, or vasomotor changes.

* A psychosocial evaluation should include the presence of anxiety or depression; indicators of delirium or major depression; an investigation of the meaning of pain to the patient and family; changes in mood state; premorbid and current coping mechanisms; family function; availability of psychosocial support systems; and an assessment of the patient's expectations and preconceptions about pain management.

* A physical examination should include general medical and neurologic examinations and a specific examination of the site of pain and surrounding areas.

* Findings of the history and physical examination should be used to determine the probable etiology and pathophysiology of the patient's pain.

* Additional diagnostic tests may be necessary to ascertain or confirm the etiology of the pain and its relationship to any underlying disease.

* A treatment plan that includes the expected outcome, contingencies, and plans for reassessment should be developed and discussed with the patient.

II. Longitudinal Monitoring of Pain:

* Longitudinal monitoring of pain will result in improved pain management and reduced adverse effects from therapy.

* Reports of pain from the patient should be the primary source of pain assessment and should be obtained at regular intervals.

* Longitudinal monitoring of pain intensity should be based on rating scales that are easy to use and interpret. Examples include discrete numeric scales (eg, 0-10), categorical scales (none, mild, moderate, severe, worst possible), and continuous visual analog scales of pain or pain relief.

III. Involvement of Specialists from Multiple Disciplines:

* Anesthesiologists and other health care providers should collaborate on the management of cancer pain.

* The patient's primary physician must be a part of the team coordinating pain management.

IV. Paradigm for the Management of Cancer Pain:

Indirect Delivery Systems: Systemic Analgesia

* Oral medications:

* Acetaminophen, acetylsalicylic acid, or other nonsteroidal anti-inflammatory drugs (NSAIDs) should be used first for mild-to-moderate pain.

* Simultaneous use of more than one NSAID or the concomitant use of an NSAID with a glucocorticoid is not recommended due to an increased risk of toxicity.

* An opioid conventionally used for moderate pain (eg, codeine, dihydro-codeine, oxycodone compounded with a coanalgesic, or hydrocodone) is recommended if pain is not relieved.

* Doses of opioids should be increased in increments of 25-50%.

* When pain is not relieved, increases, or is severe, an opioid conventionally used for severe pain (eg, morphine, hydro-morphone, methadone, oxycodone not compounded with a coanalgesic, fentanyl, or levorphanol) is recommended.

* Any change in an opioid response should prompt a reevaluation of the cause of pain.

* When analgesia with acceptable adverse effects is no longer attained with the oral route, or if the patient cannot swallow or absorb medication, an alternate systemic route of administration, such as an enteral route should be selected.

* If dose-limiting toxicity precludes effective treatment, a trial of a different opioid, a reduction of adverse effects by optimization of adjuvants, neuraxial drug delivery, or neuroablative therapy are recommended.

* Rectal and transdermal routes:

* These alternative routes of administration should be selected before invasive therapies.

* Transdermal fentanyl should be used in patients with stable pain who are non-compliant with oral medications, unable to swallow or absorb, or may benefit from a trial of fentanyl.

* Subcutaneous routes:

* These routes of administration should be considered for patients unable to swallow or absorb opioids and who may benefit from a continuous infusion of an opioid. This route may be considered also for patients with dynamic pain requiring frequent rescue doses for breakthrough pain.

* Recommendations for intravenous administration are the same as for subcutaneous administration.

* Intramuscular injection is not recommended as either short- or long-term therapy for cancer pain management due to discomfort, variable blood concentrations, and fluctuating levels of analgesia.

Direct Delivery Systems:

* Neuraxial drug delivery:

* This type of, drug administration should be used when severe pain cannot be controlled with systemic drugs because of dose-limiting toxicity; when there is an immediate need for local anesthetic; after failed neuroablation; or when it is a patient's preference.

* Neuraxial drug delivery should not be used in patients who are unmotivated or noncompliant or do not possess the cognitive functioning necessary to understand the risks and benefits, and when an appropriate logistical system does not exist.

* Personnel need to be available around-the-clock during neuraxial drug delivery.

* Efficacy and appropriate dose range should be determined by trial injection or use of a temporary delivery system before insertion of an indwelling neuraxial drug delivery system.

* Patients should have access to "rescue" doses for breakthrough pain.

* Neuroablation:

* Neuroablative techniques should be used under the following conditions:

* systemic therapies have failed to provide adequate pain control;

* adverse side effects from systemic therapies are unacceptable;

* failure of neuraxial drug administration;

* early in the natural history of the cancer pain in the presence of selected focal somatic lesions (eg, rib metastases), visceral (eg, cancer of the pancreas), or neuropathic (eg, craniofacial) pain that is believed to be highly responsive to neuroablation with limited risk; or

* a patient prefers neuroablative techniques.

* Chemical, radiofrequency and surgical neuroablation should be deferred until the anticipated life expectancy is short.

* Neural blockade should be used prognostically to ascertain the possible efficacy of neuroablation.

* Successful neural blockade does not guarantee the success of a neurodestructive procedure.

* Neural blockade should be performed at the time of potential neuroablation and not as a separate procedure. If analgesia is not achieved, neuroablation should be reconsidered.

V. Management of Cancer-related Symptoms and Adverse Effects of Pain Therapy:

* Opioids should not be withheld from cancer patients for fear of producing respiratory depression, tolerance, physical dependency, or addiction.

* Adverse effects of pain therapy should be quickly identified and assessed.

* All patients with an increased risk for constipation should receive prophylaxis.

* Bulk agents, osmotic laxatives, and/or stimulant cathartics in conjunction with a stool softener may be used for prophylactic or symptomatic therapy.

* Sedation should be treated by eliminating contributory factors, such as nonessential drugs and metabolic disturbances; reducing the dose of an opioid by 25-50% if analgesia is satisfactory; lowering the requirement for opioids by adding a nonopioid analgesic or adjuvant analgesic; switching to another opioid; using psychostimulants; or considering more invasive modalities.

* Transitory nausea and Vomiting can be treated initially with standard antiemetics, such as promethazine, prochlorperazine, haloperidol, metoclopramide, or hydroxyzine.

* Psychostimulants can be given to reverse mental clouding in the absence of sedation, but should not be given to agitated patients.

* Myoclonus is not usually a clinical problem, however, if it impairs function, prevents sleep, or increases pain, clonazepam or valproate should be given. A reduction in the opioid dose or a switch to a different opioid should be considered in refractory or severe cases.

* If pruritus occurs with opioid administration, an initial trial of diphenhydramine is recommended.

* Urinary retention should be treated with a direct cholinomimetic agent, such as bethanecol.

* The least amount of naloxone should be given if respiratory depression occurs in order to preserve analgesia and avoid withdrawal.

VI. Recognition, Assessment, and Management of Psychosocial Factors:

* Psychosocial interventions for managing cancer pain include pain diaries, hypnosis, biofeedback, relaxation training, psychotherapy, and behavior management.

* Management of psychosocial consequences of cancer pain includes Using nonpharmacologic interventions such as psychotherapy and pastoral counseling, psychotropic medications and antidepressants.

* Psychosocial manifestations related to cancer may require referral to a mental health professional.

VII. Home Parenteral Therapy:

* Parenteral therapy is effective for analgesia without notable risk of adverse effects.

* Home parenteral therapy includes subcutaneous, intravenous, and neuraxial drug delivery techniques on an outpatient basis or with help from a home health care provider.

* The patient and family must be educated on a home therapy system.

VIII. End-of-Life Care:

* Palliative therapies such as anxiolytics skin care, mouth care, massage, and appetite stimulants are recommended as the patient approaches the end of life.

* Pain management should be integrated with palliative care needs.

* Collaboration with palliative care providers is recommended to maximize the patient's comfort, and improve the quality of life for both the patient and family members.

IX. Recognition and Management of Special Features of Pediatric Cancer Pain Management:

* Age-appropriate assessment should include behavioral observation, such as facial expressions or crying, and self-reports using age appropriate scales, such as visual analog or facial pain scales.

* Administration of oral medications to children should follow the World Health Organization's analgesic ladder.

* Liquids or suspensions should be used whenever possible because many children find them more palatable than pills.

* Continuous-release morphine preparations cannot be crushed and maintain the continuous release properties.

* Repetitive exposure to needles should be minimized.

* Depending on age, patient-controlled analgesia should be considered as an alternative.

* Invasive system therapies and direct delivery systems should be used when oral and noninvasive analgesic deliveries do not achieve sufficient analgesia or cause side effects.

* Psychological and other nonpharmacologic methods of pain management are recommended as adjuvants.

* Management of Cancer Pain. Clinical Practice Guideline No. 9. AHCPR Publication No. 94-0592, Rockville, MD. Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, March 1994. Jacox A, Carr DB, Payne R, et al.

An interdisciplinary panel of clinicians, patients, and experts in health policy developed this guideline to help any clinician that works with an oncology patient in any setting to understand the assessment and treatment of pain and associated symptoms. The recommendations include the use of analgesics and adjuvant drugs, cognitive/behavior strategies, physical modalities, palliative radiation and antineoplastic therapies, nerve blocks, and palliative and ablative surgery.

The guideline is designed to inform clinicians of the following:

* Most cancer pain can be relieved;

* The fear that addiction is a result of medications used to control cancer pain is unfounded;

* Cancer pain accompanies both disease and treatment, changes over time and may have more than one cause;

* Unrelieved pain can affect the physical, psychological, social, and spiritual wellbeing of the patient;

* Prompt and effective assessment, diagnosis and treatment of pain in cancer patients are important;

* Patients with cancer and their families need to communicate new or unrelieved pain in order to ensure prompt evaluation and effective treatment;

* Literature and expert opinions for managing cancer pain are available;

* Options for pain relief are available and patients and their families need to become involved in selecting them;

* A model for cancer pain management to guide therapy in selected painful, life-threatening conditions, such as AIDS is available;

* Information and guidelines on the use of controlled substances in treating cancer pain that distinguish the use of these drugs for legitimate medical purposes from their abuse as illegitimate drugs are available;

* Health policy and research issues that affect management of cancer pain have been developed.

Guideline Highlights

I. Prevalence of Cancer Pain:

* Clinicians should reassure patients and their families that most pain can be relieved safely and effectively.

* Curricula for health professionals should include sufficient content on pain to prepare clinicians to assess and manage pain effectively.

* Clinicians need to educate patients and their families about pain and its management and encourage patients to be active participants in their care.

* Clinicians are encouraged to consider the costs of drugs and technologies when selecting pain management strategies with the patient and family.

* Federal, state and local laws and regulatory policies need to be developed in order not to hamper the use of opioid analgesics for cancer pain.

II. Assessment:

* Health professionals need to question patients about their pain and use that information as the primary source of assessment.

* A comprehensive assessment and careful documentation with emphasis on initial evaluation and appraisal of any new pain that emerges is necessary.

* Common cancer pain syndromes include bone metastases, epidural metastases/spinal cord compression, plexopathies, peripheral neuropathies, acute and postherpetic neuralgia, abdominal pain, and mucositis.

III. Pharmacologic Management:

* Pharmacologic management of pain should be individualized to the patient using the simplest dosage schedules and the least invasive pain management modalities.

* The World Health Organization's analgesic ladder is recommended for administration of oral medications.

* Health care workers must draw the distinction between opioid tolerance, physical dependence, and addiction.

* Respiratory depression is infrequently a significant limiting factor in pain management.

* Nonsteroidal anti-inflammatory drugs and opioids may be used to control pain.

* A patient dying from cancer should not be allowed to live with unrelieved pain because of fear of side effects; instead, appropriate, aggressive, palliative support should be given to the patient.

* Adjuvant drugs can be used to increase the analgesic efficacy of opioids, to treat concurrent symptoms that exacerbate pain, and to provide independent analgesia for specific types of pain.

* Careful discharge planning from one setting to another is essential.

IV. Nonpharmacologic Management of Pain:

* Nonpharmacologic management of pain includes physical modalities, such as the use of superficial heat and cold, massage, exercise, transcutaneous electrical nerve stimulation, and acupuncture.

* Psychosocial interventions include relaxation and imagery, distraction and refraining, patient education, psychotherapy and structured support, and hypnosis.

* Patients need to be referred to peer support groups and have access to pastoral counseling if requested.

* More invasive therapies include palliative radiation, anesthetic techniques including nerve blocks, neurosurgery, and palliative surgery.

* With rare exception, noninvasive treatment should precede invasive palliative approaches.

V. Cultural Differences:

* Clinicians should give special attention and considerations to a number of special populations. These groups include the very young and very old, the cognitively impaired, known or suspected substance abusers, and non-English-speaking persons.

* Assessment methods appropriate for neonates, children, and adolescents are needed.

* Elderly patients should be considered at risk for undertreatment of pain.

* Uncontrolled pain should be assessed and treated aggressively because it can contribute to feelings of hopelessness, suicidal ideation, and requests for clinician-assisted suicide or euthanasia.

* Patients with current substance abuse disorders are at risk for undertreatment of cancer pain.

* Recommendations for pain assessment and management for patients with AIDS are similar to those for cancer patients.

VI. Monitoring Pain Management:

* The quality of pain management needs to be monitored and each institution needs to evaluate pain management practices and obtain patient feedback to gauge the adequacy of pain control.

* Institutional policy should define who is responsible for pain management, the acceptable level of patient monitoring, and the roles and limits of practice for health care providers.

(*.) Prepared by Elaine McClellan-Holm.