From the Guidelines
Start analgesia immediately when initiating palliative radiation therapy (XRT), ideally before treatment begins, to ensure optimal pain control and minimize the risk of morbidity and mortality associated with uncontrolled pain. The management of cancer pain should follow the WHO analgesic ladder, which recommends a stepwise approach to pain management, starting with non-opioid analgesics for mild pain, followed by weak opioids for moderate pain, and strong opioids for severe pain 1.
For mild pain, begin with acetaminophen (500-1000mg every 6 hours) or NSAIDs like ibuprofen (400-600mg every 6-8 hours) 1. For moderate pain, add a weak opioid such as codeine (30-60mg every 4-6 hours) or tramadol (50-100mg every 4-6 hours), although some authors suggest replacing weak opioids with low doses of oral morphine 1. For severe pain, use strong opioids like morphine (starting at 5-10mg every 4 hours immediate-release, titrating as needed) or oxycodone (5-10mg every 4-6 hours) 1.
Some key points to consider when managing cancer pain include:
- Always prescribe a stimulant laxative (senna 15-30mg daily) and an osmotic laxative (lactulose 15-30ml daily) with opioids to prevent constipation 1.
- Consider adjuvant medications for neuropathic pain, such as gabapentin (starting at 300mg daily, increasing gradually) or pregabalin (starting at 75mg twice daily) 1.
- Pain management should be regularly reassessed every 24-48 hours during radiation treatment to ensure optimal pain control and minimize the risk of morbidity and mortality associated with uncontrolled pain 1.
- Early pain control is crucial because radiation-induced pain relief typically takes 1-2 weeks to manifest, and some patients may experience temporary pain flare during the first few days of treatment 1.
It is essential to prioritize the patient's quality of life and minimize the risk of morbidity and mortality associated with uncontrolled pain by starting analgesia immediately and following the WHO analgesic ladder 1.
From the Research
Initiation of Analgesia in Palliative Radiation Therapy
- There is no specific study that directly addresses when analgesia should be initiated in a patient starting palliative radiation therapy (XRT) 2, 3, 4, 5, 6.
- However, it is generally agreed that pain management is an essential component of palliative care, and opioids and adjuvant therapies are the mainstay of cancer pain management 4, 5.
- The provision of an on-demand opioid in addition to baseline opioid therapy is mandatory, especially for patients with breakthrough pain episodes 5.
- In localized bone pain, radiotherapy is the gold standard for pain reduction in addition to pharmacologic pain management 5.
- Interventional techniques, such as peripheral nerve blocks and neuraxial analgesia, may be used for refractory pain that does not respond to conventional analgesia 4, 6.
- Clinical guidelines agree that cancer pain management is best provided as part of a multiprofessional palliative care approach, addressing all domains of suffering, including psychosocial, spiritual, and existential aspects 5.