II. Management: Non-Pharmacologic Therapies (or non-systemic agents)

  1. Relaxation
  2. Support Groups
  3. Biofeedback
  4. Mental Imagery
  5. Physiotherapy
  6. Transcutaneous electrical nerve stimulation (TENS)
  7. Nerve Blocks
    1. Celiac plexus block (for Pancreatic Cancer pain)
  8. Vertebroplasty or Kyphoplasty
  9. Physical Activity
  10. Individual, Family and Group Psychotherapy

III. Management: Other Palliative Measures

  1. Palliative Radiotherapy
    1. Metastatic bone pain
    2. Neuropathic pain
      1. Lumbosacral plexopathy and brachial plexopathy
  2. Palliative surgery
  3. Palliative Chemotherapy

IV. Management: Guidelines and Pearls

  1. Oral route for Analgesics is preferred
  2. Do not assume the pain is part of the malignancy
    1. Make specific anatomic, and pathologic diagnoses
  3. Consider the patients feelings and listen to fears
    1. Pain threshold varies with mood and morale
    2. Less pain is experienced if patient can express fears
  4. Administer around the clock scheduled dosing
    1. Scheduled dosing requires less overall Analgesic need
    2. Avoid as needed medication dosing as much as possible
      1. As needed dosing results in breakthrough pain
  5. Prescribe adequate amounts of Analgesics
    1. Titrate dosing to the patient's pain
    2. Do not limit dosing to book values
  6. Start with non-Opioid medications if possible
    1. Acetaminophen and NSAIDs are the first steps on the WHO Cancer Pain Ladder
  7. Do not be afraid of Opioid use
    1. When non-Opioids fail, move to Opioids quickly
    2. Moderate to Severe pain will require Opioids
    3. Addiction is rare when Opioids are used for pain
  8. Make use of non-pharmacologic therapies
    1. See Cancer Pain Management
  9. Make use of consultants or colleagues
  10. Provide support for the entire family
    1. Treat anticipatory grief for family
    2. Prevent isolation and loneliness
    3. Intervene quickly for crises
  11. Maintain air of quiet confidence and cautious optimism
    1. Aim for small goals and graded relief
    2. Builds patient's trust and hope
    3. Exhibit determination to succeed
  12. Maintain clear sensorium
    1. Methylphenidate
      1. Overcomes Narcotic associated confusion, drowsiness

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