VANCOUVER, BC-The US Agency for Health Care Policy and Research
(AHCPR) cancer pain practice guidelines, like the World Health
Organization (WHO) 3-step ladder, emphasize a hierarchical pain
management strategy, Richard Payne, MD, said at a symposium held
in conjunction with the 8th World Congress on Pain of the International
Association for the Study of Pain (IASP).
Dr. Payne, chief of the Section of Pain and Symptom Management,
The University of Texas M.D. Anderson Cancer Center, described
the AHCPR guidelines as a pyramid, with the base representing
use of oral, transdermal, and rectal drugs; circling the pyramid,
in his imagery, are ribbons representing important adjuvant therapies.
Determine the Cause of Pain
"Although systemic analgesics are the base and cornerstone
of therapy, and are effective in at least 75% to 85% of cancer
patients reporting moderate to severe pain, they should always
be used in the context of an appropriate assessment that tries
to determine the cause of the pain," he said.
The cause should be treated, if possible, with antineoplastic
therapies, palliative radiotherapy, adjuvant drugs, and physical
and psychosocial modalities.
The top of the pyramid includes more invasive approaches to pain
treatment such as the use of intravenous and subcutaneous opioids
and epidural or intrathecal subarachnoid analgesia, Dr. Payne
At the very top, for use in perhaps 1% to 5% of the total universe
of patients with severe cancer pain, are nerve blocks, palliative
surgery, and ablative neurosurgical approaches.