Mao J. Opioid-induced abnormal pain sensitivity: implications in clinical opioid therapy. Pain ; : — Davies DD. Incidence of major complications of neurolytic coeliac plexus block. Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Reg Anesth ; 22 : — Critical evaluation of chemical neurolysis of the sympathetic axis for cancer pain. Cancer Control ; 7 : — An alternative approach to ganglion impar neurolysis under computed tomography guidance for recurrent vulva cancer. Anesthesiology ; : — Validation of World Health Organization guidelines for pain relief in head and neck cancer.
A prospective study. Ann Otol Rhinol Laryngol ; : — Doyle D.
Nerve blocks in advanced cancer. Practitioner ; : — Intercostal nerve block in patients: indications, technique, and complications. Anesth Analg ; 41 : 1 — Persistent paraplegia after an aqueous 7. Arch Phys Med Rehabil ; 83 : — Antila H Kirvela O. Neurolytic thoracic paravertebral block in cancer pain.
A clinical report. Acta Anaesthesiol Scand ; 42 : — Paravertebral somatic nerve block: a clinical, radiographic, and computed tomographic study in chronic pain patients. Anesth Analg ; 68 : 32 — Pulsed radiofrequency of the dorsal root ganglia is superior to pharmacotherapy or pulsed radiofrequency of the intercostal nerves in the treatment of chronic postsurgical thoracic pain.
Pain Physician ; 9 : — Techniques for neurolytic neural blockade. Philadelphia : Lippincott-Raven ; : — Anaesthetic techniques for pain control. Oxford Textbook of Palliative Medicine 3rd ed. Oxford : Oxford University Press ; : — Polyanalgesic Consensus Conference an update on the management of pain by intraspinal drug delivery—report of an expert panel.
J Pain Symptom Manage ; 27 : — A randomized, double-blind, placebo-controlled study of intrathecal ziconotide in adults with severe chronic pain. J Pain Symptom Manage ; 31 : — Du Pen S. The specific management of three common syndromes encountered in practice is discussed. Pain may be due to direct invasion, secondary pathological fracture or damage to adjacent structures. Vertebral pain syndromes may result in local or radicular pain, with accompanying neurological features.
Incident pain is common, especially when weight-bearing is affected; use of breakthrough analgesia with fast-acting opioids such as transmucosal fentanyl is key. Specific therapeutic considerations include radiotherapy and bisphosphonates and, from an interventional perspective, vertebral augmentation procedures or orthopaedic surgery for fracture stabilisation.
As a result of visceral invasion, the pain experienced in locally advanced pancreatic cancer is commonly described as gnawing epigastric pain.
 Interventional techniques for cancer pain management are regarded as part of a multimodal approach to pain relief and not as a stand-alone therapy. For a segment of the cancer pain population, pain control remains inadequate The failure to obtain acceptable pain or symptom relief prompted the inclusion.
It often has a significant neuropathic component due to infiltration of the coeliac plexus, described as pain radiating bilaterally and into the back. Tumour-related and post-surgical pain is classically neuropathic in nature. The most common acute oral side effect of radiotherapy is oral mucositis.
Topical local anaesthetic mouthwashes or opioid-based ones can be effective, albeit for a short duration. If needed, administering analgesics via alternative routes ie via feeding tube, transdermal or parenteral routes should be considered, with an emphasis on using neuropathic agents such as gabapentin, pregabalin or amitriptyline. General practitioners have an integral role in cancer pain management. With in-depth longitudinal knowledge and care of the patient, they are well placed to provide best holistic pain management.
Promotion of opioid use through the WHO pain ladder has been well embraced by general practice; however, dogmatically following guidelines and rapidly increasing opioid dosage can hinder best treatment and promote adverse effects. Instead, understanding analgesic pharmacology and the underlying mechanisms of pain will assist in determining drug selection.
Knowledge of the underlying cancer, its disease trajectory and common pain syndromes also fosters a more proactive rather than reactive approach to pain management, including use of concurrent analgesics, opioid rotation and timely consideration of appropriate interventional techniques. Regular pain assessment, monitoring and evaluation of interventions for efficacy and potential side effects are essential. Furthermore, there are many useful resources that are available to provide information and guidance, in print and online. Some examples are provided below.
Cancer pain Neoplasms Palliative care. Principles of cancer pain management: An overview and focus on pharmacological and interventional strategies.
Background Pain remains one of the most significant symptoms of cancer. Impeccable assessment and understanding of the cause and mechanism of pain, pragmatic prescribing including avoiding dogmatic opioid dose increments and consideration of all modalities of interventions are central to optimal treatment.
We discuss pharmacological and interventional treatment options and some cancer pain syndromes. Pain assessment Characteristics of the pain should be sought when taking a clinical history: quality, site, severity, radiation, temporal features, and factors that precipitate, exacerbate or relieve the pain. Mechanisms of cancer pain Consideration of the mechanism underlying the pain can assist in determining the analgesic treatment that should be used as first-line.
Table 1. Opioids Opioids bind to mu, kappa, and delta receptors present in the peripheral and central nervous system. Interventional techniques Interventional techniques may be appropriate adjuvants or alternatives to ongoing systemic pharmacological treatment.
Neuraxial infusion Neuraxial infusion involves continuous infusion of medication into either the epidural or intrathecal space by means of temporary or permanent catheters and implanted pumps. Bone metastases Pain may be due to direct invasion, secondary pathological fracture or damage to adjacent structures. Resources for general practitioners Expert Group for Palliative Care. Palliative care. In: eTG complete [internet]. Melbourne: Therapeutic Guidelines Limited, CareSearch, www. Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.
Update on prevalence of pain in patients with cancer: Systematic review and meta-analysis. J Pain Symptom Manage ;51 6 — Quality of cancer pain management: An update of a systematic review of undertreatment of patients with cancer. J Clin Oncol ;32 36 — Optimal pain management for patients with cancer in the modern era. CA Cancer J Clin ;68 3 — Cancer: WHO's cancer pain ladder for adults.
Geneva: WHO, Available at www.
Is the WHO analgesic ladder still valid? Twenty-four years of experience. Can Fam Physician ;56 6 —17, e Cancer: WHO definition of palliative care. Management of cancer pain: ESMO clinical practice guidelines. Ann Oncol ;23 Suppl 7:vii— An international survey of cancer pain characteristics and syndromes. International Association for the Study of Pain.
Pain ;82 3 — Description of a mechanistic approach to pain management in advanced cancer. Preliminary report. Clin J Pain. Ballantyne JC, Mao J.