From the Guidelines
For terminal cancer patients with abdominal pain on palliative care, a multimodal approach using strong opioids as the foundation is recommended, as stated in the NCCN guidelines 1. This approach is supported by the most recent and highest quality studies, including the 2019 NCCN clinical practice guidelines in oncology 1. The management of cancer pain is considerably more complex than the traditional 3-tiered “cancer pain ladder” suggests, and a comprehensive pain assessment must be performed, with reassessment of pain intensity at specified intervals to ensure that the therapy selected is having the desired effect 1. Some key points to consider in the management of cancer pain include:
- Starting with oral morphine (15-30mg every 4 hours) or oxycodone (5-15mg every 4 hours), with a rescue dose of 10-20% of the total daily dose available for breakthrough pain, as recommended by the ESMO clinical practice guidelines 1.
- Using long-acting formulations like MS Contin (30-60mg twice daily) or OxyContin (20-40mg twice daily) once pain is stabilized.
- Adding adjuvant medications, such as a stool softener (docusate sodium 100mg twice daily) and stimulant laxative (senna 8.6mg twice daily), to prevent opioid-induced constipation.
- Considering gabapentin (starting at 300mg daily, titrating up to 300mg three times daily) or pregabalin (75mg twice daily) for neuropathic pain components.
- Using dexamethasone (4-8mg daily) to reduce inflammation and improve appetite.
- Considering an antispasmodic like hyoscine butylbromide (10-20mg three times daily) for visceral pain. Pain management should be regularly reassessed every 24-48 hours, with doses titrated upward by 25-50% if pain persists, as recommended by the NCCN guidelines 1. This approach targets multiple pain pathways while minimizing side effects, providing effective relief for the complex pain associated with terminal abdominal cancer.
From the Research
Pain Management for Terminal Cancer Patients with Abdominal Pain
The management of pain in patients with terminal cancer is a critical aspect of palliative care. According to 2, opioids are the most effective analgesics for severe pain and are the mainstay of acute and terminal cancer pain treatments.
Recommended Pain Management Strategies
- For mild to moderate pain, non-opioid drugs such as paracetamol (acetaminophen) or nonsteroidal anti-inflammatory drugs (NSAIDs) can be used, either alone or in combination with opioids, as recommended by the WHO cancer pain treatment ladder 3.
- For severe pain, morphine is the drug of choice, and adjuvant drugs can be used to enhance the effect of narcotics and to treat specific side effects of the disease or of therapy 4.
- Antidepressants can also be used as adjunct analgesic agents to help manage cancer pain, especially when opioid analgesics are not enough to completely alleviate the patient's pain 5.
Considerations for Pain Management
- The use of opioids for chronic pain due to cancer requires careful consideration of the potential risks of tolerance, dependence, and addiction, and safeguards should be built into the treatment plan to minimize these risks 2.
- The WHO analgesic ladder provides a framework for the sequential use of analgesic drugs, starting with non-narcotics and progressing to weak narcotics and then narcotics, all in association with adjuvant drugs 3.
- A systematic approach to identifying the cause of pain and rational use of drug therapy are keys to providing pain relief to cancer patients 4.
Evidence for Paracetamol Use
- A Cochrane review found no high-quality evidence to support or refute the use of paracetamol alone or in combination with opioids for the first two steps of the three-step WHO cancer pain ladder 6.
- The review found that the available studies were at high risk of bias and provided no clear evidence of difference in pain reports, quality of life, use of rescue medication, or participant satisfaction or preference between paracetamol and placebo when added to another treatment 6.