Sharon M. Weinstein, MD, FAAHPM

Most patients with advanced cancer, and up to 60% of patients with any stage of the disease, experience significant pain. The WHO estimates that 25% of all cancer patients die with unrelieved pain.

Cancer patients can expect to suffer pain, particularly in the advanced stages of the disease. Optimal pain control is an essential part of cancer management from the time of diagnosis, as pain can interfere with cancer therapy, limits patient function, and negatively impacts quality of life.

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.

The public fear that cancer is inevitably painful [1] is warranted: The majority of patients with advanced cancer and up to 60% of patients with any stage of disease will experience significant pain. The World Health Organization has estimated that 25% of all cancer patients die with unrelieved pain [2].

Cancer patients experience pain in multiple sites and from several pathophysiologies of the symptom complex. The fluctuating nature of cancer pain intensity is a relevant clinical feature and depends on disease patterns and pain mechanisms. Breakthrough pain is defined as episodes of pain that "break through" the control of an otherwise effective analgesic therapy.

Metastatic spinal disease is common in patients with prostate cancer. Spinal metastases may be asymptomatic (identified during staging) or cause pain and other neurologic signs and symptoms. In approximately 30% of prostate cancer patients,

In managing cancer pain, an alternative to the oral route of opioid administration may be considered under several circumstances. For example, the oral route may not be feasible due to impaired swallowing, gastrointestinal obstruction, poor

Among the most challenging problems in medicine is the management of patients with simultaneous cancer, pain, and psychological chemical dependency (substance abuse). It has been our experience at the UT