Cancer Pain



National and International Guidelines

Control of pain in adults with cancer - A national clinical guideline

Scottish Intercollegiate Guidelines Network. Nov 2008

Cancer Pain Management.

British Pain Society. 2010

WHO cancer pain guidelines


Opioids in palliative care

NICE Guideline CG140



Cochrane Reviews

Methadone for cancer pain.

Nicholson AB. Cochrane Database of Systematic Reviews 2007, Issue 4


Pain is a common and debilitating symptom of cancer. Methadone is an opioid drug used to treat cancer pain, and can be given by mouth as liquid, tablet or capsule, via the rectum as a suppository, or injected into the vein, muscle or under the skin. This updated review examines clinical trial evidence published up to September 2006 to determine how effectively methadone relieves cancer pain and how well tolerated this treatment is for these patients. The available evidence permits the following conclusions: methadone has a similar efficacy to morphine (an opioid drug commonly prescribed for cancer pain patients) in treating cancer pain; methadone is no more effective than morphine for cancer-related nerve related pain; and methadone has a similar side effect profile but these side effects may become more prominent with repeated dosing.

Oral morphine for cancer pain.

Wiffen PJ, McQuay HJ. Cochrane Database of Systematic Reviews 2007, Issue 4.


Morphine taken by mouth is an effective pain-killer for cancer pain. Pain is commonly experienced by people with cancer, and morphine is considered the gold standard for relieving pain when it becomes moderate to severe. This review aimed to assess the effectiveness of oral morphine, and 54 studies were found. However, the majority of these studies were designed to show that different formulations of morphine were effective, and this made it difficult to extract useful information on the effectiveness of morphine itself. Nevertheless, these trials show that morphine gives good relief for cancer pain but with some unwanted effects, mainly constipation and nausea and vomiting.

Ketamine as an adjuvant to opioids for cancer pain.

Bell RF, Eccleston C, Kalso EA. Cochrane Database of Systematic Reviews 2012, Issue 11.


The benefits and harms of adding ketamine to strong pain-killers such as morphine for the relief of cancer pain are not yet established. Morphine-like drugs (opioids) are frequently prescribed for moderate and severe cancer pain, but in some cases these drugs are not effective. Ketamine, an anaesthetic agent, is used to improve analgesia when opioids alone are ineffective. However, evidence for the effectiveness of this practice is limited. Two small studies suggest that when ketamine is given with morphine it may help to control cancer pain. However, these data are insufficient to assess the effectiveness of ketamine in this setting.

NSAIDS or paracetamol, alone or combined with opioids, for cancer pain.

McNicol ED, Strassels S, Goudas L, Lau J, Carr DB. Cochrane Database of Systematic Reviews 2005, Issue 2


NSAIDs are commonly used, often in combination with an opioid, for treatment of cancer pain. Short-term studies have shown that NSAIDs alone are effective in managing cancer pain, with side effects similar to placebo and in about 50% of studies, increasing the dose of NSAID can increase efficacy without increasing the incidence of side effects. Similar studies have not demonstrated a large clinical difference when combining an opioid with an NSAID versus either medication alone. Insufficient long-term studies have been conducted to provide information on chronic safety and effectiveness of NSAIDs alone or with opioids in treating cancer pain.

Calcitonin for metastatic bone pain.

Martinez-Zapata MJ, Roqué i Figuls M, Alonso-Coello P, Roman Y, Català E Cochrane Database of Systematic Reviews 2006, Issue 3.


The limited evidence currently available does not support the use of calcitonin to control pain arising from bone metastases. People who have cancer which has spread to their bones and the nerves adjacent to the bones often suffer severe pain. There are several treatments to help relieve this pain: radiotherapy, analgesic (pain-relieving) drugs such as opioids and bone-modulating drugs such as bisphosphonates and calcitonin. Calcitonin has the potential to relieve pain and maintain bone strength, thus reducing the risk of bone fractures. This review looked at the effectiveness of calcitonin for controlling pain from bone metastases. However, few studies were found and the evidence currently available does not support its use for patients suffering from bone pain. Until new studies provide additional information on this treatment, other therapeutic approaches should be considered.

Bisphosphonates for the relief of pain secondary to bone metastases.

Wong RKS, Wiffen PJCochrane Database of Systematic Reviews 2002, Issue 2.


Bisphosphonates give some relief from pain caused by cancer that has invaded bones. Patients with cancer that has spread to the bone frequently have pain. Pain control is an important part of cancer management. Bisphosphonates are medicines that affect the way bone develops, and are proving useful in treating patients with cancer that has invaded the bone (metastasis). This review looked at the effect of bisphosphonates on pain caused by bone metastases. Bisphosphonates do have some effect but are not as useful as either strong analgesics (such as morphine) or radiotherapy. However, where other methods of pain relief are inadequate, the addition of bisphosphonates can be beneficial. Bisphosphonates can cause nausea and vomiting.

Opioids for the management of breakthrough (episodic) pain in cancer patients.

Zeppetella G, Ribeiro MDC. Cochrane Database of Systematic Reviews 2006, Issue 1.


Oral transmucosal fentanyl citrate (OTFC) is an opioid and is effective in the management of breakthrough pain. Breakthrough pain is a common and debilitating component of pain in patients with cancer. Clinical trial evidence was sought to determine the effectiveness of opioids in relieving breakthrough pain and the incidence of side effects in these cancer patients. Four trials were identified and included 393 participants; the studies identified examined the use of OTFC in breakthrough pain in cancer patients taking regularly scheduled opioids. All four studies used similar outcome measures. Available data suggest that OTFC is safe and effective (compared to both placebo and morphine) in relieving breakthrough pain. The side effect profile of OTFC is similar to other opioids. Recommendations are made about future clinical trials.



Cochrane Reviews

Acupuncture for cancer pain in adults.

Paley CA, Johnson MI, Tashani OA, Bagnall AM Cochrane Database of Systematic Reviews 2011, Issue 1.


Up to 70% of patients with cancer-related pain do not receive adequate pain relief and this reduces their quality of life. Acupuncture may have a role to play in relieving cancer-related pain. This review evaluated evidence for the effectiveness of acupuncture in reducing pain associated with cancer or its treatment, or both. We found three studies (looking at a total of 204 participants) which met our inclusion criteria, but all had small sample sizes, leaving them prone to bias, and only one study was judged to be of high methodological quality. The high quality study found that auricular (ear) acupuncture reduced cancer-related pain when compared with auricular acupuncture at non acupuncture points, but the control group was not adequately blinded and this was likely to affect the outcomes. Of the low quality studies, one found that acupuncture was as effective as medication, and one study found that acupuncture was more effective than medication, but both studies were poorly designed and the study reports lacked detail. We concluded that there was insufficient evidence to judge whether acupuncture is effective in relieving cancer-related pain in adults.

Celiac plexus block for pancreatic cancer pain in adults.

Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni PA. Cochrane Database of Systematic Reviews 2011, Issue 3


Abdominal pain is a major symptom in patients with inoperable pancreatic cancer and is often difficult to treat. Celiac plexus block (CPB) is a safe and effective method for reducing this pain. It involves the chemical destruction of the nerve fibres that convey pain from the abdomen to the brain. We searched for studies comparing CPB with standard analgesic therapy in patients with inoperable pancreatic cancer. We were interested in the primary outcome of pain, measured on a visual analogue scale (VAS). We also looked at the amount of opioid (morphine-like drugs) patients took (opioid consumption) and adverse effects of the treatment. Six studies (358 participants) comparing CPB with standard therapy (painkillers) met our inclusion criteria. At four weeks pain scores were significantly lower in the CPB group. Opioid consumption was also significantly lower than in the control group. The main adverse effects were diarrhoea or constipation (this symptom was significantly more likely in the control group, where opioid consumption was higher). Endoscopic ultrasonography (EUS)-guided CPB is becoming popular as a minimally invasive technique that has fewer risks, but we were not able to find any RCTs assessing this method (current medical literature on this subject is limited to studies without control groups). Although the data on EUS-guided CPB and pain control are promising, we await rigorously designed RCTs that may validate these findings. We conclude that, although statistical evidence is minimal for the superiority of pain relief over analgesic therapy, the fact that CPB causes fewer adverse effects than opioids is important for patients.

Comparative efficacy of epidural, subarachnoid, and intracerebroventricular opioids in patients with pain due to cancer.

Ballantyne JC, Carwood C, Gupta A, Bennett MI, Simpson KH, Dhandapani K, Lynch L, Baranidharan G  Cochrane Database of Systematic Reviews 2005, Issue 2.


Cancer patients who do not obtain pain relief from treatment with opioids administered by mouth, rectally or by injection may do so if the drugs are administered in other ways. This review compared three alternative routes: intracerebroventricular (where opioids are injected through a small hole bored into the skull); epidural (where opioids are introduced into the epidural space in the spine using a catheter); and subarachnoid (where opioids are introduced into the subarachnoid space in the spine using a catheter). The evidence from uncontrolled studies showed that giving opioids intracerebroventricularly was more effective for pain relief than either epidural or subarachnoid administration. Adverse effects and complications were reported for all three procedures.



Cochrane Reviews

Spinal cord stimulation for cancer-related pain in adults.

Lihua P, Su M, Zejun Z, Ke W, Bennett MI. Cochrane Database of Systematic Reviews 2013, Issue 2.


Cancer-related pain is an emerging heavy burden on public health. Spinal cord stimulation (SCS) is a minimally invasive and potentially effective tool against chronic pain.This systematic review intended to evaluate the efficacy and effectiveness of SCS for cancer-related pain compared with standard care using conventional analgesic medication. No randomised controlled trials were identified. Four before-and-after case series studies (92 participants) were included in this systematic review. Current evidence is insufficient to establish the role of SCS in treating refractory cancer-related pain in comparison with other analgesic approaches. In addition, the studies reported significant side effects such as local infection.

Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults.

Hurlow A, Bennett MI, Robb KA, Johnson MI, Simpson KH, Oxberry SG Cochrane Database of Systematic Reviews 2012, Issue 3.


Cancer-related pain is complex and multidimensional but is mostly managed using drug therapy. There is increasing recognition of the need for non-drug approaches and TENS may have a significant role to play. Only one new study met eligibility criteria for this review update, making at total of three included studies. TENS was given to 15 participants in one study, 41 participants in the other and 24 participants in the most recently included study. The newly included study suggested TENS might improve cancer bone pain on movement, but as a pilot study it was not designed to determine the impact of TENS on pain. The two studies in the previous review did not show that TENS significantly improved cancer pain. One study did not have sufficient participants to determine whether or not TENS had an effect. TENS was well tolerated in all three studies. There were significant differences in participants, treatments, procedures and symptom measurement tools used in the studies. In two of the studies some participants were able to identify when they received active TENS and when they received placebo. Consequently, there is insufficient evidence to judge whether TENS should be used in adults with cancer-related pain. Further research using well designed clinical trials is needed to improve knowledge in this field.