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Manejo Del Dolor Oncologico
Manejo Del Dolor Oncologico
First draft submitted: 26 June 2017; Accepted for publication: 21 July 2017; Published online:
4 August 2017
Pain is a common symptom in cancer patients and although accurate prevalence estimates of pain
in cancer patients are not available, a systematic review of the literature showed that prevalence can
reach up to 70% in patients with advanced disease [1] , impacting directly their quality of life and
well-being. This high prevalence of pain in cancer patients compels all physicians who treat them
to also be trained in effective pain therapy.
The level of evidence and the grade of recommendation for cancer pain management are not
strong but the published guidelines recommend the use of opioids [2] . However, due to regulatory
barriers, among other reasons, in many countries, including the Latin-American region, the avail-
ability and use of opioids is suboptimal [3,4] leading to insufficient symptomatic relief of cancer pain.
1
Oncología Médica, Hospital General Universitario Gregorio Marañón, Madrid, Spain
2
Instituto Nacional de Cancerología/Universidad Militar Nueva Granada. Fondo Nacional de Estupefacientes en Políticas Públicas en
medicamentos de control especial. Asociación Colombiana de Cuidados Paliativos, Colombia
3
Oncología Médica, Hospital Clínico Universidad de Chile, Clínica Dávila, Chile
4
Oncología Médica, Hospital Clínico Universidad de Chile, Fundación Arturo López Pérez, Santiago, Chile
5
Instituto Nacional de Cancerología – Oncología Médica, Ciudad de México, México
6
Oncología Clínica, Hospital Solca-Núcleo Pichincha, Ecuador
7
Coordinator Supportive Therapy & Integrative Medicine, Hospital Alemão Oswaldo Cruz, Brazil
8
Jefe de la Unidad de Oncopaliativos del Programa ADAMO, Perú
9
Faculdade de Medicina do ABC, Setor de Oncologia Clínica do IBCC e do HCOR, Brazil
10
Unidad de Dolor del Hospital México/Unidad de Dolor Clínica Católica, Costa Rica
11
Centro Médico Nacional La Raza – Hospital de Ginecología, Ciudad de México, México
12
Oncología Clínica, Fundación Colombiana de Cancerología Clínica Vida, Colombia
13
Oncólogo Médico, Oncólogo Radioterapeuta, Hospital Base Valdivia, Clínica Alemana Valdivia, Chile
*Author for correspondence: yolandaesco@yahoo.es part of
10.2217/fon-2017-0288 © 2017 Future Medicine Ltd Future Oncol. (Epub ahead of print) ISSN 1479-6694
Special Report Escobar Alvarez, Agamez Insignares, Ahumada Olea et al.
600
Consumption (mg/capita)
400
200
There is currently no cancer patient registry in ●●Barriers & difficulties that impede a correct
the Latin-American countries, and opioid drug cancer pain management in Latin-America
consumption is variable and their average use & measures to overcome them according to
remains far below international levels, suggesting the participating experts
that pain management could be improved in the Despite some recent advances in opioid drugs use
Latin-American region. One of the challenges to for pain control in Latin-America, average con-
managing cancer pain in Latin-America is imple- sumption remains below average levels in other
menting effective opioid use. Opioids are needed regions, which translates into inadequate can-
to manage moderate and severe pain, and WHO cer pain management. Entities such as the Pain
has included them on the list of essential medi- and Policy Studies Group and the International
cines, but not all countries in the region have the Association of Hospices and Palliative Care have
same availability. Argentina and Brazil have the worked to identify barriers to adequate supply
highest medical use of opioids and there has been of opioids in different countries. Factors iden-
reported good availability of short-acting mor- tified include restrictive legislation, inadequate
phine and milder analgesics in Brazil, Argentina, health systems, poor knowledge and training
Mexico, Cuba and Peru. However, there is limited among health professionals regarding use of
availability of long-acting opioids and other step 3 these drugs, and fear of addiction and adverse
analgesics (according to the WHO pain ladder), drug events. The Pain and Policy Studies Group
which has a negative impact on the appropriate and International Association of Hospices and
management of pain in patients with advanced Palliative Care have organized workshops
cancer disease [5] (Figure 1 & Table 1) . in Colombia, Peru and Chile with doctors,
Box 1. The panel of experts has agreed on the following measures to help overcome barriers related
to patients.
●● On-going physical examination and anamnesis in every treatment follow-up appointment, asking
specifically about pain
●● Inform the patient about the pain therapy, side effects, and so on
●● Extensive communication with the patient and family to let them know they don’t need to suffer in
silence
●● Educate and involve nurses in pain management
●● Foster Patient Associations for correct pain management which help improve and spread general
knowledge through awareness campaigns to communicate that every patient is entitled to pain relief
ministers of health, insurance companies man- are functional differences between the different
agers and patients to find solutions applicable to oncology units throughout the country, with
each country and conclusions are that training different pharmacological options available
of health professionals in the administration of depending on the management of each unit and
opioid drugs and prescription management are their respective hospitals or insurance coverages.
important actions needed to achieve optimum Therefore, it is important that the oncologist,
use of these drugs [5] . according to his pharmacological experience,
Currently pain in cancer patients is managed makes the case to his or her respective authority
in different ways depending on the country [6] the need for a pharmacological arsenal for the
and a summary of each situation according to palliative care and oncology departments.
the expert panel in some of the region countries The oncologist takes care of the pain manage-
is showed. ment only during steps 1 and 2 of the WHO
analgesic ladder. If step 3 is needed, the patient
Chile is referred to the palliative care unit, as opioid
The registry of tumors started more than drugs can only be prescribed there. In addition,
30 years ago in the South of Chile (Valdivia), prescriptions from the oncologist have to be
in 1989 as a Population Registry of Cancer in the paid by the patient while the prescriptions from
Region of Los Ríos (Southern Chile, Valdivia) the palliative care unit physicians are provided
and in 2004 new population registries in some free. This is difficult to manage since pain can
other regions. be diagnosed in early stages and be heightened
Cancer pain management has improved by chemotherapy; therefore, the oncologist
enormously in the last years and palliative care should be entitled to prescribe analgesic drugs
is guaranteed for all patients. The National as appropriate.
Program of pain relief and palliative care pro-
moted by the Ministry of Health was created in Mexico
1995, and in 2006 a guaranteed health system The Mexican Society of Oncology is just start-
was established that benefits the patient, includ- ing to collect epidemiological data from some
ing quality care in defined times and financial of the tumors. Besides, the oncologists are not
support. trained in pain management, there is lack of
In the public healthcare system users do not pain management diffusion and its impact on
pay for services while in the private one there patients in quality of life, there is no global access
is a 20% co-payment of the total cost. There to all drugs recommended by international
Box 2. The panel of experts has agreed on the following measures to help overcome barriers related
to healthcare providers.
●● On-going education on pain management after graduation
●● Awareness of cancer pain therapy
●● Global management of the patient by the oncologist with continuous care
●● Time optimization of the medical appointment
●● Ask for support from other consultants in case that the oncologist is not well trained in pain
management
●● Promote projects and leadership to improve coordination between consultants
●● Pain management led by the oncologist
Box 3. The panel of experts has agreed on the following measures to help overcome barriers related
to the healthcare system.
●● Foster the patient’s continuous care between consultants and different levels of care
●● Guarantee pain treatment to all cancer patients
●● Oncologists should be able to prescribe opioid drugs, with public funding available in each country as
well as in palliative care units
●● Promote education in pain management at the public universities and ensure it is also included in the
private universities
●● Supervise the implementation of pain management protocols
●● Facilitate the approval of pain drugs and simplify the administrative prescription procedures
●● Implement a nationwide palliative care policy
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
Peor dolor
Sin (reverso)
dolor
Peor dolor
Sin
que haya
dolor
sentido
to a very small region of the country. Armed Box 4. The questions included in the patient
forces hospitals and the social security system assessment are.
are also developing similar domiciliary programs ●● How intense is your pain?
with interesting results. Oncologists and pallia- ●● How would you describe your pain?
tive care units, in some cases, work in complete ●● Where do you place your pain?
coordination and communication. ●● Does your pain transfer to other body regions?
●● When does the pain appear?
Brazil ●● What makes your pain improve or worsen?
Most of the pain management is still under the ●● How does this pain affect your daily life?
care of medical oncologists. The more difficult
●● What does your pain mean to you?
cases that need to be controlled with certain
medications are referred to pain specialists who ●● Opiophobia;
can sometimes execute some procedures such as
●● Lack of coordination between specialty
nerve blocks, epidural catheters, etc.
departments;
Opioid drugs are potentially available through
a restricted prescription policy to all physicians, ●● No continuity of care;
including those who care for cancer patients.
●● Lack of time.
Unfortunately, the number of pain special-
ists is small relative to our overall population. ●● Related to the healthcare system (Box 3) :
Furthermore, the private healthcare system still
●● Low economic resources;
lacks of many of the newer opioid formulations
and our public healthcare system may not be able ●● Lack of healthcare personnel;
to offer basic opioid medications to all patients
●● Cancer pain management not included in the
at all times.
cancer treatment protocols;
The main common barriers in the region for
the cancer pain treatment with opioid drugs are: ●● Lack of education programs on oncological
●● Related to patients (Box 1) : pain at all levels (undergraduate and post-
graduate);
●● Minimization of the symptoms;
●● Institutional barriers to the prescription of
●● Sociocultural factors and family environment; opioids and access limitations for some medi-
●● Opiophobia/fear of addiction; cal specialties;
well as the response to the treatment. Cancer of the WHO analgesic ladder we can classify the
pain is a chronic, destructive, useless, harmful pain according to its intensity:
and unlimited pain frequently accompanied ●● Mild pain: VAS from 0 to 3;
by depression and mood swings with an enor-
mous psychological, emotional and sociofamilial ●● Moderate pain: VAS from 4 to 6;
impact. ●● Severe pain: VAS from 7 to 10.
The most frequent pain is caused by the
tumor due to infiltration or compression by the According to the duration
tumor itself, adenopathy or metastasis in bones, ●● Acute: pain lasting less than 3–6 months with
nerves, viscera, soft tissues, vessels, etc., but it a well-defined onset and objective signs and
can also be related to the treatment aimed at symptoms;
eradicating the tumor (surgery, radiotherapy,
chemotherapy, hormone-therapy triggering ●● Chronic: pain lasting more than 6 months and
acute and delayed toxicity) or to other causes not usually accompanied with objective signs;
such as infections (e.g., postherpetic neuralgia) Persistent pain progressively impairs both
or muscle spasticity. the physical and the psychological state of the
Pain can be classified taking into account dif- patient. The level of tolerance to pain decreases
ferent criteria [10,11] (Table 2) . perhaps due to the depletion of endorphins
and loss of sleep and appetite may also occur,
According to the intensity resulting in a quality of life decrease.
Pain intensity can be measured through the ●● BTP has been established as transitory exac-
use of validated assessment tools: the Visual erbations of pain that occur on a background
Analogue Scale (VAS), the Verbal Rating Scale of stable pain otherwise adequately controlled
and the Numerical Rating Scale are the most by around-the-clock opioid therapy, although
simple and used in the clinical practice [12,13] . there is no widely accepted definition or well
VAS is a psychometric response scale which validated assessment tools. BTP is classified
can be used in questionnaires, consisting of a as:
horizontal 10 cm long line at the ends of which
lie the extreme pain expressions, with no pain on -- Incidental: triggered by known causes
the left side and worst possible pain on the right (movement, cough, defecation) and it can be
side. The patient is asked to indicate the pain predictable or unpredictable depending on
intensity he is suffering. Following the criteria the cause being voluntary or involuntary;
Fourth step
Third step Spinal
Second step Strong opioids Analgesia
First step Weak opioids Non-opioids and and other
Non-opioids and adjuvants techniques
Non-opioids and
adjuvants
adjuvants
to detecting new tumor lesions and improving commonly applied for initial and ongoing assess-
the follow-up of the patients. ment of pain and of patients with pain at any
The pan-European survey by Breivik in 2009 disease stage. These scales are equivalent in
indicated that many patients with moderate to terms of simplicity, clarity and ease of applica-
severe cancer pain received no analgesic medica- tion. Clinical trials have demonstrated that the
tion, and among patients reporting severe pain, Numerical Rating Scale is more reliable than
only 24% received strong opioid monotherapy. the VAS [15] . These scales have limited sensitiv-
The use of weak opioids was prevalent, suggest- ity owing to wide interindividual variability and
ing that several reasons may have accounted for different emotional, affective, cognitive, cultural
the poor care of cancer pain including inad- and behavioral responses [16] .
equate appreciation for or lack of knowledge The patient assessment should also include
by the physician of the intensity of the pain, questions about onset of pain, site affected, irra-
fear of the adverse effects of strong opioids and diation, quality (pressure, throbbing, muscle-
regulatory barriers to opioid prescription and cramps, colic, visceral pain, burning sensation,
dispensing [14] . electrical current and tingling), intensity in
The International Association for the Study the previous 24 h and week, both at rest and
of Pain describes pain as an unpleasant sensory in motion, attenuating and exacerbating fac-
and emotional experience that is associated with tors, duration, response to analgesics, as well as
actual or potential tissue injury. The pain experi- an evaluation of functional, psychological and
ence is always subjective and adequate measure social consequences [13] .
is difficult. Given that there is no international It is important to record previous analgesics
consensus on classification of cancer pain and and the treatment outcomes, additional informa-
that specific tools are lacking, the conventional tion that can modify perception of pain should
scales used for other forms of chronic pain are be taken into account (e.g., psychiatric history,
Breakthrough
Predictable: Unpredictable:
movement ischemia, cough,
bladder spasm
6
5 Basal
4 pain
3
2
1
0
Time
potential current or previous opioid addiction Once the underlying pathophysiology and the
and risk factors that may lead to inadequate pain intensity are defined, specific treatment should
management). be initiated.
Therefore, more complete multidimensional The pain can present with nociceptive or
scales may be more appropriate for use as they neuropathic components or both. In situations
measure three dimensions (sensory, affective and of nociceptive pain, the treatments used can
evaluative) as well as intensity of pain and patient include nonsteroidal anti-inflammatory agents
status, and have been validated for various cul- [NSAID] (diclofenac, ibuprofen, naproxen),
tures and languages, including Spanish [17–19] . adjuvants (corticoids and biphosphonates) and
Neuropathic pain should be identified using the associated with weak opioids (tramadol) or even
tools suggested by the International Association strong opioids (buprenorfine, hydromorphone,
for the Study of Pain (i.e., Lanss Pain Scale, methadone, morphine, oxycodone). For neuro-
DN4, Neuropathic Pain Questionnaire, pain- pathic pain, adjuvant treatments (such as anti-
DETECT) [20,21] (Boxes 4 & 5, Tables 3 & 4, Figures convulsants, antidepressants, antipsychotics and
2 & Figure 3) . anxiolytics) play a key role and are commonly
used; opioids should also be used.
●●Pain management
The WHO developed the first guidelines on can- Treatment of mild pain
cer pain management in 1986 based on the anal- Nonopioid analgesics, such as paracetamol or
gesic ladder concept, meaning that the choice of an NSAID, are indicated for the treatment of
the analgesic should be determined by the inten- mild pain (VAS 1–3) and are commonly used for
sity of the pain, including the use of opioids and the treatment of cancer pain as the first step, if
integrated in the overall control of the patient necessary to the maximum recommended dose,
diagnosis and treatment. The ladder is divided and if the nonopioid no longer relieves the pain,
into three steps depending on the intensity of an opioid drug should be prescribed in addition
the pain [2] . Therefore, the evaluation of the dif- to the nonopioid [2] .
ferent therapeutic options requires quantifying
the pain previously felt, and decision-making in Treatment of moderate pain
relation to pain must be adjusted to its intensity. In case of moderate pain (VAS 4–6), patients
The fourth step is not included in the WHO are usually treated with a combination of
guidelines that refers to invasive techniques and paracetamol, aspirin or NSAID plus a weak
other routes of administration (Figure 4) . opioid (codeine or tramadol) [2] . The level of
Box 7. Situations that can trigger incidental predictable breakthrough pain are:
●● Swallow in patients with oral mucositis
●● Diagnostic tests (PET, CT scan, bone scan)
●● Treatments that require posture or painful technique – radiotherapy
●● Mobilization maneuvers: get up, turn around
●● Wound healing of pressure ulcers
recommendation for the use of weak opioids is other routes (subcutaneous or intravenous)
not strong and low-dose third-step opioid substi- can be more useful. Additionally, transdermal
tution could be a better choice because weak opi- treatments (fentanyl, buprenorphine) are pre-
oids have analgesic ceiling and the adverse events ferred for patients whose opioid requirements
are common to opiates. The European Palliative are stable, are unable to swallow or have poor
Care Association also recommends the use of compliance [24] .
strong opioids in low dose [23] . Options to be
used could be morphine, buprenorphine, fenta- ●●Breakthrough pain
nyl, hydromorphone, tapentadol or oxycodone. A special mention must be referred to BTP
(Figure 5 & Box 6) , which is defined as an acute
Treatment of severe pain exacerbation of pain with sudden onset, short
Strong opioids (morphine, oxycodone, hydro- duration, and moderate-to-high intensity in
morphone, fentanyl, buprenorphine, tapent- patients who experience stabilized baseline
adol) are the cornerstone of treatment for severe pain controlled with opioids [25] . It should be
chronic oncologic pain (VAS 7–10), sometimes not confused with other types of pain in order
in combination with adjuvants and with no anal- to manage it correctly, because the diagnosis
gesic ceiling, the dose limit is marked by the and adequate management remain challeng-
appearance of side effects. ing [26–29] (Figure 6) . The average prevalence
Any of them can be used as opioid of first of the BTP in a 2012 multicenter trial was
choice in the third step because the analgesic 66% [30] , although the estimate of episodic
strength is very similar and the availability of or BTP depends strongly on the definition of
different drug options is an advantage in offer- the phenomenon and the methods applied to
ing the patient the pathway, interval and toxic- diagnose it [30] .
ity profile best suited to his or her situation and The main features of BTP are as follows [34] :
needs. The rotation of opioids (replacement of
●● Fast onset;
one opioid by another using the equivalent dose
in case of poor analgesic response or intolerable ●● Short duration;
toxicity) may be needed and the treatment pre-
●● Moderate-to-severe intensity.
scribed must be tailored to every patient (Table 4) .
Although the oral route of administration is Box 7 shows the situations that can trigger
commonly chosen, when urgent relief is needed incidental predictable BTP.
Box 9. The therapeutic strategy must include all -- Considering treatment start from WHO
the following steps: Step III using low doses of opioids in case
●● Select the appropriate drug; of intense pain;
●● Prescribe the adjusted dosage; -- When the etiology of pain is related to can-
●● Select the route of choice; cer and its intensity is moderate to severe,
●● Indicate the appropriate dose interval; there is consensus about the use of opiates
●● Prevent persistent and irruptive pain; as first-line therapy [38];
●● Titrate the dosage;
-- Adaptive use of the analgesic ladder helps
●● Prevent and treat adverse effects;
manage effective analgesia in 70–90% of
●● Use the right adjuvant drugs;
patients [37] .
●● Evaluate the response to treatment regularly.
●● BTP and basal pain usually have the same
causes and the location also usually coincides;
that can be put into practice and that helps to however, treatment and management are dif-
manage the cancer patient with chronic pain. ferent:
The main recommendations from the Expert
Panel about cancer pain treatment are: -- Basal pain is an acute pain which is stabi-
●● Cancer pain should be treated by the medical
lized and under control with appropriate
oncologist (who should meet a series of periodic treatment;
requirements) (Box 8) ; -- Pain at the end of the dose is no longer con-
sidered as BTP;
●● Cancer pain treatment must start early after
diagnose; -- Rescue treatment in the opioid titration
phase intended to correct the poor control
●● The three steps from the WHO guidelines of basal pain with the prescribed doses
should be managed by the oncologist; should not be confused with breakthrough;
●● Treatment should be specific and adapted to -- BTP is classified as incidental (caused by
patient characteristics: something) and can be volitional, (e.g., with
-- The treatment begins by giving the patient walking, chewing or involuntary – by def-
and their relatives clear and correct informa- ecation, by hypo) and idiopathic (cause and
tion about potential toxicities and the dos- trigger are unknown);
ing schedule because it may improve thera- -- The incidental volitional pain is predictable
peutic compliance. and therefore preventable with short-acting
●● Treatment must be adjusted to the intensity of
oral opioids because their intake can be
pain, taking into account the WHO analgesic adapted to the time that the maneuver or
ladder: test that will trigger the BTP;
-- For involuntary incidental and idiopathic
-- Use NSAIDs at any steps recalling their
BTP there is no prevention and the treat-
toxicity;
ment consists of a rapid relief adequate to its
-- The second step is indicated for moderate intensity with fast-acting, oral, sublingual
pain and the main drug used is tramadol; or nasal transmucosal opioids.
●● The best route of administration should be -- In case of renal impairment some opioids
selected in each patient: that do not require dose adjustment can be
used (buprenorphine, fentanyl, methadone);
-- The majority of patients on cancer treat-
ment will remain out-patients, so the ideal -- Pure agonist opioids do not have a ceiling
route to begin the opioid treatment with is effect and in the case of buprenorphine it is
oral or transdermal; higher than the commonly used analgesic
doses;
-- Parenteral opioids are usually used in hos-
pitalized patients with severe pain; -- For neuropathic pain the opioids with the
most evidence are oxycodone and buprenor-
-- Oral route allows the administration of
phine. Buprenorphine is often given by the
short-acting fixed doses (nonimmediate)
transdermal route in cancer patients who
every 4–6 h and introduce rescue therapy
have severe neuropathic pain. The analgesic
with the same drug as many times as neces-
efficacy of buprenorphine in neuropathic
sary throughout the day;
pain is probably due to its suggested antihy-
-- Long-acting opioids – oral or transdermal – peralgesic action [45];
are usually prescribed when basal pain is con-
-- Studies in patients with cancer with stable
trolled but they can also be used at the begin-
pain control support the use of a relative
ning of the treatment associated with the
analgesic power of 75:1 to interchange
appropriate rescue with short-acting opioids;
between oral morphine and transdermal
-- Transdermal opioids (buprenorphine, fen- buprenorphine [46];
tanyl) fit well in the WHO three-step ladder
-- Transmucosal fentanyl should always be
for pain relief, particularly in steps 2 and 3,
used in lower doses for breakthrough cancer
in its mean dosage range of morphine equiv-
pain to avoid toxicity although the opioid
alents, providing the stable plasma levels
already used for basal pain had been admin-
required by WHO guidelines and also com-
istered in high doses;
plying with recommendations that the anal-
gesics used to treat chronic pain should be -- Methadone is not frequently used (at least
easy to self-administer [42]; in the oncology services in Spain) because
its titration is complex, requires very close
-- Transdermal buprenorphine or fentanyl are
monitoring and it requires expertise;
usually the treatment of choice in patients
who cannot swallow, patients with poor tol- -- In case of economic or any other restric-
erance to morphine and patients with poor tions, it is important to optimize the use of
adherence to medication [39] . Besides, those treatments available and it is always
patients consider the use of buprenorphine better to use something well than to use
patches easy and convenient [43] and 81% of everything badly;
patients with cancer pain achieve good or
-- Corticosteroids as analgesics in oncology
very good pain relief with transdermal
have little evidence and although they seem
buprenorphine [44] .
to be useful in pain from spinal compression
●● The treatment drug options that should be and other nerve compressions and in symp-
considered for each patient: tomatic brain metastases, caution should be
taken due to its adverse effects in the short
-- The cornerstone of cancer pain treatment is
and long term;
the major opioids, especially pure agonists.
Morphine is the historical standard because -- Other drugs used for cancer pain treat-
of its wide use and low price but there are ment are muscular relaxants, bisphospho-
several other drugs, varying between coun- nates, radioactive isotopes or nonpharma-
tries: buprenorphine, tapentadol, fentanyl, cological treatments such as radiation
oxycodone, hydromorphone and methadone; therapy, surgery, rehabilitation and
psychotherapy;
-- Titration has been successfully done with
the lowest dose producing analgesia and no -- Neuropathic cancer pain is also treated with
or minimum adverse events; opioids but the cornerstone of the treatment
includes so-called adjuvant drugs (gabapen- -- The most serious opioid toxicity is neuro-
tin, pregabalin and antidepressants). toxicity in its manifold manifestations: from
fasciculations to delirium. It is always neces-
The drugs and treatments which the experts sary to monitor its appearance and the fac-
panel agreed to be recommended are in the fol- tors that can trigger it;
lowing table (Table 5, Table 6 & Box 9) . -- It should be remembered that opioids can
●● The pain control should be included in the be stopped in cancer patients if pain disap-
patient follow-up: pears by elimination of its cause but this
-- It is important to re-evaluate the patient
suspension must be gradual to avoid absti-
24–48 h after the first oral/transdermal opi- nence syndrome;
oid treatment; -- It is important not to confuse tolerance with
-- Once symptoms are managed and doses
dependence or addiction. In cancer patients
established, the patient is re-evaluated with addiction is very rare and is often related to
tumor treatment checks every 1, 2 or 3 weeks; previous substance abuse behaviors;
-- Buprenorphine, unlike morphine, has no
-- The adverse events that patients treated with
opioids develop (constipation, nausea, vom- immunosuppressive effect and may be con-
iting, urinary retention, drowsiness, confu- sidered as an option in patients with low
sion) may sometimes be reduced by lower- immune defenses, as is often the case of
ing the dose or switching to another opioid; patients with cancer [7,47] .
-- Throughout the treatment it may be neces- Table 7 shows the comparison of opioids
sary to change the route of administration adverse events.
or switch opioids, so we must know the con-
version doses between the different drugs. Future perspective
The most frequent reasons for the opioid Cancer pain has a strong impact on the patient’s
switch are no efficacy and toxicity; quality of life and thus the correct pain man-
agement should be as important as the tumor
-- Taking the time to explain potential toxicity treatment with an early diagnose of the pain in
is very important so that the patient can order to initiate the pain treatment at any stage.
cope with it and communicate it to the One of the challenges to better relieving cancer
oncologist at the next visit; pain in Latin-America is implementing effective
-- It should always be emphasized that consti- opioid use by improving its access by the country
pation will be a permanent side effect and authorities and through educating oncologists
will require prevention. Transdermal on its management.
buprenorphine and fentanyl has lower rates Pain is probably the main but not the only
of constipation and sedation than oral opi- symptom that a palliative patient faces. That
oids and offer a convenient dosing regimen is why the creation and development of pallia-
that improves patient compliance [46]; tive care as a new specialty in Latin-America is
almost a fact within the next 10 years, due to this
-- Other adverse effects such as nausea and increasing and unsatisfied demand for quality
vomiting will usually disappear within 48 and holistic palliative care services, including
h and prevention should be done consider- domiciliary attention. This is an urgent need
ing this fact. Therefore, the patient with that is being partially fulfilled by many special-
cancer pain with an opioid prescription ties but cannot be totally covered by any of them.
should also be prescribed an antiemetic and
a laxative treatment; Supplementary data
-- Respiratory depression is very uncommon To view the supplementary data that accompany this paper
in patients with cancer pain whose titration please visit the journal website at: www.futuremedicine.
is done correctly and with periodic reevalu- com/doi/full/10.2217/fon-2017-0288
ation but some factors such as dehydration
or renal insufficiency may facilitate the Financial & competing interests disclosure
occurrence; Expert’s meeting was supported by an educational grant
from Grünenthal. The authors have no other relevant
affiliations or financial involvement with any organization Writing and editorial assistance was provided by Irene
or entity with a financial interest in or financial conflict Perucho and Content Ed Net (Madrid, Spain) with fund-
with the subject matter or materials discussed in the manu- ing from Grünenthal Services, Inc.
script apart from those disclosed.
Executive summary
●● The oncologist should manage and be responsible for the cancer patient at all stages.
●● Cancer pain should be diagnosed and managed early.
●● Opioid drugs are approved and recommended for the cancer pain.
●● Barriers to opioid use should be eased.
●● There is no age limit for opioid treatment, only dose adjustment is required.
●● The oncologist is responsible for the integral management of the patient.
●● The Medical Oncology Societies of each country must lead the way.
●● Coordination between the multidisciplinary team taking care of cancer patients is crucial.
●● E ducation and training for the oncologists on pain management is essential and should be mandatory and guaranteed
by the National Education Authorities. This education should be on-going and included in the Medical degree
(undergraduate), Oncology studies (degree) and even postgraduate studies; it should also involve treatment options,
opioid treatment switch, breakthrough pain management and supportive care.
●● Palliative care, as a nationwide policy, should be included in every Latin-American government’s health agenda.
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Título y publicación originales: “Cancer pain management: recommendations from a Latin-American experts panel”
Yolanda Escobar Alvarez et al. - Future Oncology (2017) 1-18
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