Overview

Cancers are among the leading causes of morbidity and mortality worldwide, responsible for 18.1 million new cases and 9.6 million deaths in 2018. Pain is experienced by 55% of patients undergoing anti-cancer treatment and by 66% of patients who have advanced, metastatic, or terminal disease. This can be relieved in most cases through medicines and other treatments.

The World Health Organization (WHO) has developed Guidelines for the pharmacologic and radiotherapeutic management of cancer pain in adults and adolescents to provide evidence-based guidance to initiating and managing cancer pain. The aims of these guidelines are to provide guidance to health-care providers (i.e. the end-users of these guidelines: physicians, nurses, pharmacists and caregivers) on the adequate relief of pain associated with cancer. They also assist policy-makers, programme managers and public health personnel to create and facilitate appropriately balanced policies on opioids and prescribing regulations for effective and safe cancer pain management. Proper and effective stewardship of opioid analgesics in the cancer treatment setting is essential to ensure the safety of patients and to reduce the risk of diversion of medicine into society.

The goal of cancer pain management is to relieve pain to a level that allows for an acceptable quality of life. The last set of WHO guidelines focused on cancer pain management were issued in 1996.

The clinical guidelines and recommendations in this document are organized into three focal areas:

• Analgesia of cancer pain: This addresses the choice of analgesic medicine when initiating pain relief and the choice of opioid for maintenance of pain relief, including optimization of rescue medication, route of administration, and opioid rotation and cessation.

• Adjuvant medicines for cancer pain: This includes the use of steroids, antidepressants and anticonvulsants as adjuvant medicines.

• Management of pain related to bone metastases: This incorporates the use of bisphosphonates and radiotherapy to manage bone metastases.

Contents

• Abbreviations and Acronyms
• Executive Summary
• 1. Introduction
• 2. Objectives and Target Audience of these Guidelines
• 3. Scope of the Guidelines
• 4. Methods used in the Guidelines
• 5. Cancer Pain Management – Guiding Principles
  • 5.1. The Goal of Optimum Management of Pain is to Reduce Pain to Levels which Allow an Acceptable Quality of Life
  • 5.2. Global Assessment of the Person should Guide Treatment, Recognizing that Individuals Experience and Express Pain Differently
  • 5.3. Safety of Patients, Carers, Health-Care Providers, Communities and Society Must be Assured
  • 5.4. A Pain Management Plan Includes Pharmacological Treatments and May Include Psychosocial and Spiritual Care
  • 5.5. Analgesics, Including Opioids, must be Accessible: Both Available and Affordable
  • 5.6. Administration of Analgesic Medicine should be Given “By Mouth”, “By the Clock”, “For the Individual” and with “Attention to Detail”
  • 5.7. Cancer Pain Management should be Integrated as Part of Cancer Care
• 6. Recommendations for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents
  • 6.1. Initiation of Pain Relief
  • 6.2. Maintenance of Pain Relief
  • 6.3. Cessation of Opioid Use
  • 6.4. Adjuvant Medicines for Cancer Pain Management
  • 6.5. Management of Bone Pain
• 7. Research Agenda
  • Interests Declared by Persons Involved in Guideline Development
  • Funding Sources
• 8. Acknowledgements
• References
• Annexes
  • ANNEX 1. Evaluation of Pain
  • ANNEX 2. Systematic Review and Guideline Methods
  • ANNEX 3. Systematic Review Evidence Profiles and Evidence-to-Decision Tables
  • ANNEX 4. Background to the Development of the Guidelines and Details of Personnel
  • ANNEX 5. Opioid Analgesics and International Conventions
  • ANNEX 6. Pharmacological Profiles and Opioid Conversion Tables
  • ANNEX 7. Network Meta-Analysis of Evidence Comparing Analgesics for Cancer Pain Management Initiation & Maintenance and for Breakthrough Cancer Pain
  • ANNEX 8. Glossary

Suggested citation:

WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO.

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