Pain relief is integral to the care of cancer patients at all stages of illness. Cancer pain can be due to direct effects (e.g., invasion of bone by tumor, nerve compression), complications of treatment (e.g., radiation fibrosis, chemotherapy-related neuropathy), or unrelated causes (migraines, arthritis). Pain may be somatic, visceral, or neuropathic in nature.

Several common cancer pain syndromes are worth highlighting: 1) Osseous pain due to bony metastases; 2) Thoracic pain due to local invasion of intercostal nerves; 3) Nerve root compression; 4) Peripheral nerve compression; 5) Herpes zoster; and 6) Phantom limb syndrome. Cancer pain management includes nonpharmacologic strategies, appropriate use of pharmacologic agents, including both analgesics agents and various adjuvants, and interventional approaches. The physician must always assess the patient carefully, as there may be multiple pains with multiple origins and mechanisms.

Non-opioid Analgesics: NSAIDs and acetaminophen are first-line and should be used around the clock prior to starting opioids. Acetaminophen should be used cautiously in chronic cancer patients because of the risk of hepatotoxicity (alcohol use and starvation predispose to toxicity at low doses).

Opioid Therapy: Opioids are invaluable because of their reliability, safety, multiple routes of administration, and ease of titration. Opioids can be used for somatic, visceral, and neuropathic pain (although neuropathic pain can be more difficult to treat with opioids alone).

Initial agents: The “weak” opioids (codeine, hydrocodone, oxycodone) can be combined with NSAIDs or acetaminophen and are effective for mild to moderate pain. Tramadol, a synthetic analog of codeine, may have a dual mechanism of action by binding to the mu-opioid receptor and inhibiting neuronal reuptake of serotonin and norepinephrine. Tramadol is useful for mild to moderate pain in patients who do not tolerate typical opioids but should be avoided in patients predisposed to seizures.

Use in renal failure: Avoid meperidine (Demerol; active metabolite, normeperidine, can cause CNS excitability), morphine (metabolite can lead to active narcosis), and codeine or tramadol (can accumulate and reduce seizure threshold). Methadone and fentanyl patch are considered best choices in those with renal failure (Dean, 2004).

Initiation of therapy:

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