Mellar P. Davis, MD

FDA approval of palliative chemotherapy is largely based on disease-free and overall survival, quality of life, and symptom reduction; the latter should be routinely measured by the treating oncologist. Physician assessments of symptoms underreport symptom severity compared to patient-reported symptom assessments.

Approximately 60% of cancer patients experience pain, and 25% to 30% have severe pain. With some cancers, opioids will be needed before chemotherapy begins and may be more frequently prescribed than chemotherapy. Given the frequency with which pain management is necessary in cancer patients, all oncologists should be familiar with opioid prescribing principles. This article reviews the World Health Organization recommendations for analgesic therapy in this setting, as well as guidelines for opioid therapy in patients with renal failure or hepatic failure, assessment of pain, dosing strategies in both acute and chronic pain, management of opioid overdose, pain associated with dose-limiting side effects, and pain in the actively dying.

Dr. Khatcheressian and colleagueshave nicely reviewedboth barriers to palliative andsupportive care and remedies.

Opioid rotation involves changing from one opioid to another usingcorrect equianalgesic conversion techniques to achieve better analgesiaand/or fewer side effects. The strategy appears to work because ofsignificant interindividual variations in response to both analgesic activityand toxicity. Although there are many retrospective studies, fewprospective controlled trials of opioid rotation have been published.The practical and theoretical advantages of opioid rotation includeimproved analgesia, reduced side effects, cost reduction, and improvedcompliance. Disadvantages include problems related to inaccurate conversiontables, limited availability of certain opioid formulations, druginteractions, and the possibility of increased expense. Weighing theadvantages and disadvantages is essential prior to making a decisionabout opioid rotation selection.

Many individuals with advanced malignancy continue to sufferfrom pain and, consequently, impaired quality of life. The clinicalscenarios in advanced cancer pain are complex, and successful managementmay require a more sophisticated and individualized approachthan suggested by the World Health Organization guidelines.In patients referred to the Harry R. Horvitz Center for PalliativeMedicine in Cleveland, numerous commonly occurring errors inopioid use have been noted. This article describes these errors andoffers strategies with which to improve outcomes for patients sufferingwith cancer pain.