samadhi db

depress, acute and cancer pain /EBM levels/pearls

MAJOR RECOMMENDATIONS Note from the National Guideline Clearinghouse (NGC): The following key points summarize the content of the guideline. Refer to the original guideline document for additional information. The levels of evidence [A-D] are defined at the end of the "Major Recommendations" field. Diagnosis Depressed patients frequently present with somatic complaints to their primary care doctor rather than complaining of depressed mood [C]. Treatment Mild depression can be effectively treated with either medication or psychotherapy. Moderate to severe depression may require an approach combining medication and psychotherapy [A]. Drug treatment. Fifty to sixty-five percent (50–65%) of patients respond to the first antidepressant [A]. No particular antidepressant agent is superior to another in efficacy or time to response. Choice can be guided by matching patients' symptoms to side effect profile, presence of medical and psychiatric comorbidity, and prior response [A]. Relative costs can also be considered (e.g., generics). University of Michigan Health System (UMHS) preferred agents are Fluoxetine (generic) and citalopram (Celexa®). Patients treated with antidepressants should be closely observed for possible worsening of depression or suicidality, especially at the beginning of therapy or when the dose increases or decreases [C]. Frequent initial visits. Patients require frequent visits early in treatment to assess response to intervention, suicidal ideation, side effects, and psychosocial support systems [D]. Continuation therapy. Continuation therapy (9–12 months after acute symptoms resolve) decreases the incidence of relapse of major depression [A]. Long term maintenance or life-time drug therapy should be considered for selected patients based on their history of relapse and other clinical features [B]. Education/support. Patient education and support are essential. Social stigma and patient resistance to the diagnosis of depression continue to be a problem [D]. Definitions: Levels of Evidence Randomized controlled trials Controlled trials, no randomization Observational trials Opinion of expert panel



Brief Summary
GUIDELINE TITLEAssessment and management of acute pain.
BIBLIOGRAPHIC SOURCE(S)Institute for Clinical Systems Improvement (ICSI). Assessment and management of acute pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2004 Mar. 66 p. [152 references]BRIEF SUMMARY CONTENT RECOMMENDATIONS EVIDENCE SUPPORTING THE RECOMMENDATIONS IDENTIFYING INFORMATION AND AVAILABILITY
Go to the Complete Summary
RECOMMENDATIONSMAJOR RECOMMENDATIONSThe recommendations for the assessment and management of acute pain are presented in the form of an algorithm with 19 components, accompanied by detailed annotations. Algorithms are provided for: Assessment of Acute Pain and Acute Pain Treatment; clinical highlights and selected annotations (numbered to correspond with the algorithm) follow.
Class of evidence (A-D, M, R, X) ratings and key conclusion grades (I-III, Not Assignable) are defined at the end of the "Major Recommendations" field.
Clinical Highlights and Recommendations
Determine the mechanism of pain (i.e. somatic, visceral, neuropathic) based on the physical examination and detailed history. (Annotation #6) Patients often experience more than one type of pain. (Annotation #6) Intensity of pain is assessed prior to initiation of appropriate treatment, and continually reassessed throughout duration of treatment. (Annotation #3) Somatic pain is well-localized and may be responsive to cold packs, tactile stimulation, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, opioids, and localized anesthetic (topical or infiltrate). ( Annotations #7, 8) Visceral pain is more generalized and is most responsive to opioid treatment. (Annotations #9, 10) Neuropathic pain may be resistant to opioid therapy and consideration should be given to adjuvant therapy such as tricyclic antidepressants and anticonvulsants. (Annotations #11, 12)Assessment of Acute Pain Algorithm Annotations
Patient Has Pain or Is Likely to Have Pain Pain is undertreated by many practitioners, which leads to serious clinical consequences. This guideline encourages aggressive assessment, treatment and reassessment of pain.
Evidence supporting this recommendation is of classes: B, D, R, X
Critical First Steps Acute pain is not a diagnosis, it is a symptom. Frequently its cause is obvious such as after surgery or an acute trauma. Many times, however, the exact underlying etiology is not clear and a diagnostic work-up is necessary. The guideline developer's work group believes that an interview with the patient or a responsible caregiver is essential. The interview and examination should cover the following:
General History
History of present illness (HPI) Current medications Medication allergies Past medical history Social historyPain History
Onset Duration Quality, character Ameliorating and provoking factors Patient rating if possible (see Annotation #3)Clinical Exam
Observation of response to pain (pre-verbal or cognitively impaired patients): e.g., rubbing a particular area, guarding, facial expression (Refer to "Observer/Caregiver Rating of Pain and Pain Relief" In Discussion #2 in the original guideline document) Evidence supporting this recommendation is of classes: C, D, R
Focused physical exam (part of body or region in pain), to include vital signs, especially pulse, respiratory rate, blood pressure Functional assessment (Refer to Annotation and Discussion #3, "Pain Assessment" in the original guideline document).Diagnostic Studies
Lab studies, x-rays or other diagnostic tests may be needed, depending on the results of the history and physical examination.
Specialty Consult
General surgical, orthopedic, anesthesiological or other consultation may be deemed necessary.
Key Patient Education Messages
The patient and/or caregiver play a critical role in the assessment and management of pain. Assessing the type and amount of pain is important to good pain control. This is done by describing and rating the pain. Educate the patient and/or caregiver in the selection and use of an appropriate pain scale. Parents can help assess pain in children by what their child says, what their child is doing, and how their child's body is reacting.Pain Assessment Based on the assumption that patient self-reporting is the "most reliable indicator of the existence and intensity of pain" (National Institutes of Health) the ideal tool for pain will identify the presence of pain and its evolution over time. In addition, tools should be applicable to any person regardless of age, race, creed, socioeconomic status, and psychological or emotional background.
The single dimensional scales measure only pain intensity and by their nature are self-report. The multidimensional scales measure not only the intensity but also the nature and location of the pain and in some cases the impact the pain is having on activity or mood. Refer to the original guideline document for Table 1, "Assessment Tools for Adults," and Table 2, "Assessment Tools for Children."
Evidence supporting this recommendation is of classes: A, B, C, D, R, X
Determine Mechanism of Pain (Somatic, Visceral, Neuropathic) and Arrange Diagnostic Work-Up and Treatment By identifying the type of pain, the provider can more efficiently treat pain by selecting the intervention most appropriate. The clinician should be aware the patient may experience a combination of pain types. See below for an assistive tool in determining mechanism of pain.
Evidence supporting this recommendation is of classes: D, R
Assistive Tool for Determining Type of Pain
Type of Pain Somatic Pain Visceral Pain Neuropathic Pain Location Localized Generalized Radiating or specific Patient Description Pin prick, or stabbing, or sharp Ache, or pressure, or sharp Burning, or prickling, or tingling, or electric shock-like, or lancinating Mechanism of Pain A-delta fiber activity. Located in the periphery* C Fiber activity. Involved deeper innervation* Dermatomal *** (peripheral), or non-dermatomal (central) Clinical Examples Superficial laceration Superficial burns Intramuscular injections, venous access Otitis media Stomatitis Extensive abrasion Periosteum, joints, muscles Colic and muscle spasm pain** Sickle cell Appendicitis Kidney stone Trigeminal Avulsion neuralgia Post-traumatic neuralgia Peripheral neuropathy (diabetes, human immunodeficiency virus) Limb amputation Herpetic neuralgia Most Responsive Treatments Cold packs Tactile stimulation Acetaminophen Non-steroidal anti-inflammatory drugs (NSAIDs) Opioids Local anesthetic (either topically or by infiltration) NSAIDs Opioid via any route Intraspinal local anesthetic agents Anticonvulsants Tricyclic antidepressants Neural blockade
*Most post-operative patients experience A-delta and C fiber pain and respond best to narcotic of any route and NSAIDs.
**Colic and muscle spasms may be less responsive to opioids. Respond best to antispasmodics, NSAIDs, benzodiazepines, baclofen.
***Segmental distribution follows a dermatome chart. This traces the pathway of sensation to its nerve root.
The algorithm acknowledges that in most clinical situations the initial treatment of pain and the diagnostic work-up occur concurrently. In other situations, e.g. central nervous system injury, it may be important to delay treating a patient's pain until the underlying diagnosis is established. These initial efforts to treat pain are based on the clinician's initial hypothesis of the etiology of the patient's pain. See the clinical pearls section in Annotation #13, "Prevention/Intervention."
Acute Pain Treatment Algorithm Annotations
Treatment Choices for Somatic Pain Treatment of somatic pain includes the use of topical therapies, non-steroidal anti-inflammatory drugs, acetaminophen, opioids, and local anesthetics.
Evidence supporting this recommendation is of class: R
Treatment Choices for Visceral Pain Treatment choices for visceral pain include nonsteroidal anti-inflammatory drugs, opioids (via any route), and intraspinal local anesthetic agents.
Evidence supporting this recommendation is of class: R
Treatment Choices for Neuropathic Pain Neuropathic pain may be resistant to standard opioid therapies or other nociceptive pain treatment strategies. Anticonvulsants and antidepressants are mainstays of therapy. Complaints of continuous burning may best respond to antidepressants, whereas lancinating complaints may best respond to anticonvulsants. The anticonvulsant Gabapentin however, can treat both continued burning and episodic neuropathic pain. Failure to adequately relieve neuropathic pain with one anticonvulsant does not imply that alternative therapies will not work. Please refer to the original guideline document Annotation Appendix D, "Pharmacologic Treatment of Neuropathic Pain" for more information.
Evidence supporting this recommendation is of class: R
Prevention/Intervention The ability to influence a patient's pain experience may be approached in multiple ways. Choices for intervention are varied and frequently involve multiple disciplines. Medications and interventions are selected based on symptomatology and mechanism of pain. Choosing the profile that is the most responsive to the pain complaint and has the least potential for side effects should be done initially. Visceral, somatic and neuropathic pain complaints respond most effectively to different treatments. (See Annotation Appendix A, "Determining Mechanism of Pain" in the original guideline document.) The route of administration often affects patient compliance and dosing requirements.
Preemptive analgesia may reduce the severity of postoperative pain. This consists of the application of local anesthetics or opioids near the spinal cord, usually by an anesthesiologist, in order to prevent sensitization of the central nervous system.
With proper education and training of patients (see "Key Patient Education Steps and Messages" below) prior to a painful experience, the ability to cope and the outcome of pain treatment may be enhanced.
See Table 3, "Acute Pain Interventions," in the original guideline document for summary of interventions.
Evidence supporting the use of preemptive analgesia is of class: A
Key Patient Education Steps and Messages
Describe the expected type of pain and how long it will last. (Preparatory Sensory Information - decrease uncertainty and fear of unknown. "Knowledge is power.") Individualize the information for the patient. Discuss goals of pain management and how these goals help the patient: comfort, quicker recovery, and avoid complications. Preventing pain is important to manage pain well. "Stay ahead of the pain." Many drug and non-drug treatments can be helpful in preventing and managing pain. Inform the patient of when and how to contact health care providers about his/her pain. Patients, parents of children with pain, and the health care providers will decide as a team which treatments are best to manage the pain. Discuss treatment choices and plan, including schedule of medications, which are most appropriate for the patient. Addiction to opioids used in the treatment of acute pain is rare. There are differences among physical addiction, tolerance, and psychological dependence.Pharmacological Therapy
The use of pharmacological agents is considered to be the mainstay of therapy for acute pain. There are three broad categories of medications to consider when treating the patient with acute pain: non-opioid analgesics (NSAIDs), opioid analgesics and analgesic adjuvants. They are used in this manner:
Non-opioid analgesics (NSAIDs): Should be considered initially. Often adequate for mild or moderate pain. NSAIDs have significant opioid dose-sparing properties and in turn reduce opioid-related side effects. Use with caution in patients with coagulopathies or thrombocytopenia and those who are at risk for bleeding. Watch for gastrointestinal effects, especially with these risk factors: age greater than 60 years, previous gastrointestinal events and concomitant corticosteroid use. Ketorolac, either parenteral or oral, should be used for no more than 5 days; dose reduction is indicated in the elderly and in those with renal impairment. [Conclusion Grade III: See discussion Appendix B, Conclusion Grading Worksheet -- Annotation #13 (Ketorolac) in the original guideline document]. See Annotations Appendix C, "Non-opioid Analgesics" the original guideline document.Evidence supporting these recommendations is of classes: A, B, C, D, M
Opioid Analgesics: If pain is not adequately controlled with an NSAID or is expected to be moderate to severe, an appropriate opioid should be added to the NSAID. In patients with absolute or strong relative contraindications to NSAIDs, an opioid for mild to moderate pain should be considered. Morphine is considered to be the standard opioid analgesic. Meperidine is a commonly used opioid. Due to the risk of adverse central nervous system effects, meperidine should be reserved for only very brief use in the treatment of acute pain. [Conclusion Grade III: See Discussion Appendix C, Conclusion Grading Worksheet -- Annotation #13 (Meperidine) in the original guideline document]. See the original guideline document, Annotation Appendix B, "Opioid Analgesics," also "Recognizing Substance Abuse" in Discussion #13.Evidence supporting these recommendations is of classes: C, D, R
Pharmacological analgesic adjuvants: Used to complement NSAIDs and opioids; not to be used alone in the treatment of acute pain. Gabapentin, however, can be used alone for treatment of neuropathic pain. Some have been shown to enhance the effect of a particular analgesic, such as caffeine when given with aspirin-like drugs; others have analgesic properties themselves, e.g., tricyclic antidepressants and hydroxyzine. See the section in Discussion and References #13, "Prevention/Intervention", Pharmacological Therapy - Pharmacological Analgesics Adjuvants in the original guideline document for further discussion of medications used for adjuvant pain management.Evidence supporting these recommendations is of classes: A, D, R
Further Diagnostic Work-up
Lab studies, x-rays, or other diagnostic tests may be needed, depending on the results of the history and physical examination.
Specialty Consult
General surgical, orthopedic, anesthesiological or other consultation may be deemed necessary.
Procedures
Procedures are used for both diagnostic and therapeutic effects and should be performed by experienced providers.
Policies and Procedures for Safe Medication Use
Policies and procedures regarding safe medication use should be in place.
Adjuvant Therapy
The addition of adjuvant therapies, procedures and pharmaceuticals are frequently helpful in reducing total drug dose requirements and in speeding recovery.
Behavioral/Cognitive Intervention
Behavior and cognitive interventions can be utilized independently or in conjunction with pharmacological pain therapy. Not all interventions are effective for all patients, and determining the best fit can be very difficult.
The extent of pain and anxiety in response to the same medical procedures or painful event varies widely as does the coping skills. Some patients do better with information about the painful procedure before and during, while others prefer not to be told but rather engage in distracting tasks.
In children, the cognitive stage will also influence the understanding and concept of pain. Behavioral and cognitive interventions (desensitization, positive reinforcement, relaxation, preparation, memory change, hypnosis, thought stopping and positive self-statements, distraction, modeling and rehearsal) are detailed in Table 5 of the original guideline document.
In addition to these, other approaches have included:
Verbal preparation and communication with nurses and doctors. Sensorimotor strategies: especially with infants the use of pacifiers, swaddling, rocking and holding. Imaginative involvement: using imaginative stories or "pain switches" or "anesthetic gloves."Physical strategies: application of heat or cold, massage, immobilization, rest, or exercise. Music, art, and play therapies.Evidence supporting this recommendation is of class: R
Pediatric Clinical Pearls
Circumcisions: The March 1999 Task Force Report from the American Academy of Pediatrics states, "If a decision for circumcision is made, procedural analgesia should be provided. Dorsal Penile Nerve Block (DPNB), EMLA (Eutectic Mixture of Local Anesthetics), topical lidocaine, and ringblock have all been shown to be efficacious and safe but none completely eliminate the pain of circumcision." Infantile colic: Colic is characterized by excessive crying in otherwise healthy infants. Uncertainty regarding its etiology has led to multiple treatments. Oral sucrose in high concentrations has been shown to stimulate the opioid pathways in preterm and term infants, and has been demonstrated to have a significant ameliorating effect on the pain of colic. To obtain a 24-25 percent sucrose solution, dilute 1 teaspoon of table sugar (one packet of restaurant sugar) with 10 cc of water. Percutaneous procedures: Eutectic mixture of local anesthetics (EMLA): Mixture of lidocaine and prilocaine applied under occlusive dressing with onset of action of 60-90 minutes. Has been shown to be useful in venipuncture, intravenous access, circumcision and meatotomy. There have been concerns about methemoglobinemia which thus limits its use in neonates or infants. Recent studies in small populations demonstrate little toxicity. Intramuscular injections should be avoided if possible; children would rather experience pain. Otalgia: The ear pain associated with acute middle ear infections has traditionally been ignored or treated with non-opioid analgesics. When compared to olive oil, topical analgesics such as Auralgan Otic Solution (antipyrine, benzocaine, and glycerin) have been shown to provide excellent ear pain reduction. This therapy should never be prescribed if there is a perforation, pressure equalizing tube or otorrhea. Tonsillitis/pharyngitis: In a study of 231 children ages 6-12 years with tonsillitis/pharyngitis, ibuprofen was shown to be more effective in relieving the sore throat pain in the first 48 hours than acetaminophen or placebo.Evidence supporting this recommendation is of classes: A, R



Adult Clinical Pearls
Acute ureteral colic: Parenteral non-opioid analgesics are more effective than meperidine. "As needed" basis: For optimal treatment of acute pain, avoid the use of intramuscular injections ordered on an "as needed" basis. Acute pain medications should initially be titrated to effect and then given on a scheduled basis. Suturing non-end-artery sites: Use TAC (Tetracaine, Adrenaline, and Cocaine solution), or LET (Lidocaine, Epinephrine, and Tetracaine solution). See supporting references in the original guideline document for solution concentrations. Head injury and stroke: Avoid strong opioids to allow adequate patient assessment. Strong opioids may also decrease respiration rate, which may adversely affect (increase) intracranial pressure. Medication interaction: Oxycodone, Hydrocodone, Codeine and Tramadol may not be effective analgesics when given with other agents that strongly inhibit the Cytochrome P4502D6 liver enzymes. Common agents with this characteristic include the selective serotonin reuptake inhibitors Zoloft (doses greater than 150 mg), Paxil, and Prozac. Loading doses should be utilized for the management of acute pain once the underlying causes are known. See Discussion and References #13, "Prevention/Intervention" in the original guideline document for more information on use of loading doses. Meperidine: In the treatment of acute pain, meperidine should be used only briefly and via a parenteral route. Propoxyphene is no more effective than acetaminophen in acute pain. "Road rash": NSAIDs (any route) or local anesthetic can be used.Evidence supporting these recommendations is of classes: A, C, D, M, R
Intolerable Symptoms Secondary to Analgesia? Reassessment should be performed at regular intervals.
Inpatients: Completed after each pain management intervention, once a sufficient time has elapsed for the treatment to reach peak effect.
General guideline:
Parenteral medication -- 30 minutes Oral medication -- 60 minutes Non-pharmacologic intervention -- 30-60 minutesOutpatients: Instruct patient on when and how to contact care provider regarding efficacy of pain therapy.
Intolerable symptoms that could be related to either the pain medication (particularly the opioid) or other causes include:
Decrease in mental status Confusion or delirium Nausea and vomiting Constipation or prolonged ileus Pruritus Urinary retentionThe identification of pain through patient self report, or when that's not possible through a behavioral rating scale, will dictate the reduction of the opioid dosage or frequency. However, it should not be assumed that the opioid is always the cause.
The differential for decrease in mental status, confusion, or delirium is vast (see the original guideline document, Annotation Appendix E, "Side Effects"). Nausea and vomiting may be related to physiologic causes and other medication side effects, as well as pain medications. The cause should be determined. Annotation Appendix E, "Side Effects," in the original guideline document presents side effects of pain medications and their management.
Accurate documentation of bowel function should be done by the nurses in the postoperative setting. Constipation could be caused by immobility, all types of medications, metabolism dysfunction, etc. and is best treated from a prevention standpoint rather than after the patient complains. It is usually the belief that prolonged ileus is caused by postoperative opioids. Slowing of bowel function may be due to pain itself. The tendency in the surgical setting is to decrease or stop the opioid if an individual has prolonged ileus. If this is a strong opinion, then efforts need to be continued to control the individual's pain through other means, e.g., local anesthetics, or NSAIDs.
Patient should be given information about possible side effects and other symptoms that should be reported to nurse or provider.
Side Effect Management See the original guideline document, Annotation Appendix E, "Side Effects."
Key patient education messages:
Medications can cause side effects which can be managed or decreased. Side effects pertinent to medications and how to manage.Follow-Up Instructions Reassessment should be continued at regular intervals.
Inpatients: Completed after each pain management intervention, once a sufficient time has elapsed for the treatment to reach peak effect.
General guideline:
Parenteral medication -- 30 minutes Oral medication -- 60 minutes Non-pharmacologic intervention -- 30-60 minutesOutpatients:
Upon discharge, the discharge plan identifies the patient's continuing needs The discharge plan should be communicated to the patient with regards to appropriate follow-upDefinitions:
Classes of Research Reports:
Primary Reports of New Data Collection: Class A:
Randomized, controlled trialClass B:
Cohort studyClass C:
Non-randomized trial with concurrent or historical controls Case-control study Study of sensitivity and specificity of a diagnostic test Population-based descriptive studyClass D:
Cross-sectional study Case series Case reportReports that Synthesize or Reflect upon Collections of Primary Reports: Class M:
Meta-analysis Systematic review Decision analysis Cost-effectiveness analysisClass R:
Consensus statement Consensus report Narrative reviewClass X:
Medical opinionConclusion Grades:
Grade I: The evidence consists of results from studies of strong design for answering the question addressed. The results are both clinically important and consistent with minor exceptions at most. The results are free of any significant doubts about generalizability, bias, and flaws in research design. Studies with negative results have sufficiently large samples to have adequate statistical power.
Grade II: The evidence consists of results from studies of strong design for answering the question addressed, but there is some uncertainty attached to the conclusion because of inconsistencies among the results from the studies or because of minor doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from weaker designs for the question addressed, but the results have been confirmed in separate studies and are consistent with minor exceptions at most.
Grade III: The evidence consists of results from studies of strong design for answering the question addressed, but there is substantial uncertainty attached to the conclusion because of inconsistencies among the results of different studies or because of serious doubts about generalizability, bias, design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from a limited number of studies of weak design for answering the question addressed.
Grade Not Assignable: There is no evidence available that directly supports or refutes the conclusion.
CLINICAL ALGORITHM(S)A detailed and annotated clinical algorithm is provided for:
Assessment of Acute Pain Acute Pain TreatmentTop^EVIDENCE SUPPORTING THE RECOMMENDATIONSTYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONSThe guideline contains an annotated bibliography and discussion of the evidence supporting each recommendation. The type of supporting evidence is classified for selected recommendations (see "Major Recommendations").
In addition, key conclusions contained in the Work Group's algorithm are supported by a grading worksheet that summarizes the important studies pertaining to the conclusion. The type and quality of the evidence supporting these key recommendations (i.e., choice among alternative therapeutic approaches) is graded for each study.
Top^IDENTIFYING INFORMATION AND AVAILABILITYBIBLIOGRAPHIC SOURCE(S)Institute for Clinical Systems Improvement (ICSI). Assessment and management of acute pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2004 Mar. 66 p. [152 references]ADAPTATIONNot applicable: The guideline was not adapted from another source.
DATE RELEASED2000 Oct (revised 2004 Mar)
GUIDELINE DEVELOPER(S)Institute for Clinical Systems Improvement - Private Nonprofit Organization
GUIDELINE DEVELOPER COMMENTOrganizations participating in the Institute for Clinical Systems Improvement (ICSI): Affiliated Community Medical Centers, Allina Medical Clinic, Altru Health System, Aspen Medical Group, Avera Health, CentraCare, Columbia Park Medical Group, Community-University Health Care Center, Dakota Clinic, ENT SpecialtyCare, Fairview Health Services, Family HealthServices Minnesota, Family Practice Medical Center, Gateway Family Health Clinic, Gillette Children's Specialty Healthcare, Grand Itasca Clinic and Hospital, Hamm Clinic, HealthEast Care System, HealthPartners Central Minnesota Clinics, HealthPartners Medical Group and Clinics, Hennepin Faculty Associates, Hutchinson Area Health Care, Hutchinson Medical Center, Lakeview Clinic, Mayo Clinic, Mercy Hospital and Health Care Center, MeritCare, Minnesota Gastroenterology, Montevideo Clinic, North Clinic, North Memorial Health Care, North Suburban Family Physicians, NorthPoint Health &: Wellness Center, Northwest Family Physicians, Olmsted Medical Center, Park Nicollet Health Services, Quello Clinic, Ridgeview Medical Center, River Falls Medical Clinic, St. Mary's/Duluth Clinic Health System, St. Paul Heart Clinic, Sioux Valley Hospitals and Health System, Southside Community Health Services, Stillwater Medical Group, SuperiorHealth Medical Group, University of Minnesota Physicians, Winona Clinic, Winona Health
ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; e-mail: icsi.info@icsi.org; Web site: www.icsi.org.
SOURCE(S) OF FUNDINGThe following Minnesota health plans provide direct financial support: Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, Metropolitan Health Plan, PreferredOne, and UCare Minnesota. In-kind support is provided by the Institute for Clinical Systems Improvement's (ICSI) members.
GUIDELINE COMMITTEECommittee on Evidence-Based Practice
COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINEWork Group Members: Paul Carns, MD (Work Group Leader) (Mayo Clinic) (Anesthesiology); Howard Stang, MD (HealthPartners Medical Group) (Pediatrics); Christopher Kaye, PA-C (Stillwater Medical Group) (Physician Assistant); Kay Greenlee, MSN, RN (CentraCare) (Clinical Nurse Specialist); Dianne Brundage, PharmD (Park Nicollet Health Services) (Pharmacy); Kathy Chick, CNS (Mayo Clinic) (Health Education); Beth Green, MBA, RRT (Institute for Clinical Systems Improvement) (Measurement/Implementation Advisor); Nancy Greer, PhD (Institute for Clinical Systems Improvement) (Evidence Analyst); Pam Peitruszewski, MA (Institute for Clinical Systems Improvement) (Facilitator)
FINANCIAL DISCLOSURES/CONFLICTS OF INTERESTIn the interest of full disclosure, ICSI has adopted a policy of revealing relationships work group members have with companies that sell products or services that are relevant to this guideline topic. The reader should not assume that these financial interests will have an adverse impact on the content of the guideline. Readers of the guideline may assume that only work group members listed below have potential conflict of interest to disclose.
Diane Brundage, PharmD has significant financial interest in GlaxoSmith Kline.
Chris Kaye, PA-C has not returned disclosure information.
No other work group members have potential conflicts of interest to disclose.
ICSI's conflict of interest policy and procedures are available for review on ICSI's website at www.icsi.org.
GUIDELINE STATUSThis is the current release of the guideline.
This guideline updates a previously released version: Assessment and management of acute pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2002 Aug. 74 p.
GUIDELINE AVAILABILITYElectronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site.
Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org; e-mail: icsi.info@icsi.org.
AVAILABILITY OF COMPANION DOCUMENTSThe following is available:
Assessment and management of acute pain. In: ICSI pocket guidelines. April 2004 edition. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI), 2004 Mar.Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org; e-mail: icsi.info@icsi.org.
PATIENT RESOURCESNone available
NGC STATUSThis NGC summary was completed by ECRI on August 26, 2002. The information was verified by the guideline developer on September 23, 2002. This summary was updated by ECRI on March 14, 2003. The updated information was verified by the guideline developer on May 15, 2003. This summary was updated again by ECRI on July 28, 2004.
COPYRIGHT STATEMENTThis NGC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Guideline) is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
The abstracted ICSI Guidelines contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Guidelines are downloaded by an individual, the individual may not distribute copies to third parties.
If the abstracted ICSI Guidelines are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.
All other copyright rights in the abstracted ICSI Guidelines are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Guidelines.ef Summary





GUIDELINE TITLECancer pain.
BIBLIOGRAPHIC SOURCE(S)Singapore Ministry of Health. Cancer pain. Singapore: Singapore Ministry of Health; 2003 Mar. 88 p. [146 references]BRIEF SUMMARY CONTENT RECOMMENDATIONS EVIDENCE SUPPORTING THE RECOMMENDATIONS IDENTIFYING INFORMATION AND AVAILABILITY
Go to the Complete Summary
RECOMMENDATIONSMAJOR RECOMMENDATIONSThe recommendations that follow are those from the guideline's executive summary; detailed recommendations can be found in the original guideline document. Each recommendation is rated based on the level of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, Good Practice Points) and level of the evidence (Level I-Level IV) are presented at the end of the Major Recommendations field.
General
A - Patients and their families should be reassured that most cancer pain can be relieved safely and effectively. (Grade A, Level Ib)
A - Involvement of a multidisciplinary team of specialists is associated with effective analgesia and better health outcomes. (Grade A, Level Ib)
GPP - Clinicians should assess patients for pain and provide optimal relief throughout the course of illness. (GPP)
Evaluation of Cancer Pain
A - Cancer pain should be comprehensively evaluated because this results in improved analgesia. (Grade A, Level Ib)
B - Health professionals should routinely ask about pain in cancer patients, and the patient's self-report should be the primary source of assessment. (Grade B, Level III)
B - An accurate assessment should be performed to determine the type and severity of pain and its effect on the patient prior to treatment. (Grade B, Level III)
B - A simple formal assessment tool should be used in the ongoing assessment of pain. (Grade B, Level III)
B - Clinicians should be aware of common pain syndromes, because prompt recognition allows early therapy and minimizes the morbidity of unrelieved pain. (Grade B, Level III)
B - A thorough assessment of the patient's psychosocial state should be carried out. The clinician should look for anxiety and depression and ascertain the patient's beliefs about his or her pain. (Grade B, Level III)
B - Attention should be given to cultural and ethnic factors which may have a bearing on the patient's response to pain and pain control. (Grade B, Level III)
C - Sudden severe pain in patients with cancer should be recognized as a medical emergency and patients should be promptly assessed and treated. (Grade C, Level IV)
GPP - Clinicians should document the efficacy of pain relief at regular intervals after starting or changing treatment. Documentation forms should be readily accessible to all clinicians involved in the patient's care. (GPP)
Principles of Cancer Pain Management
B - The principles of treatment outlined in the World Health Organization (WHO) Cancer Pain Relief Programme should be followed when treating pain in patients with cancer. (Grade B, Level III)
B - Medications for persistent cancer-related pain should be administered on a round-the-clock basis with additional "as needed" doses, because regularly scheduled dosing maintains a constant level of drug in the body and helps to prevent a recurrence of pain. (Grade B, Level III)
GPP - The simplest dosage schedules and least invasive pain management modalities should be used first. (GPP)
GPP - Placebos should not be used in the management of cancer pain. (GPP)
Choice of Analgesic Therapy
B - A patient's treatment should start at the step of the WHO analgesic ladder appropriate for the severity of the pain. (Grade B, Level III)
B - If pain severity increases, the next step of the analgesic ladder should be taken. Another analgesic of the same potency should not be used. (Grade B, Level III)
A - Pharmacologic management of mild pain should include a nonsteroidal anti-inflammatory drug (NSAID) or paracetamol at recommended doses, unless there is a contraindication. (Grade A, Level Ia)
A - Patients receiving an NSAID who are at risk of gastrointestinal side effects should be prescribed famotidine 40 mg twice a day, misoprostol 200 micrograms four times a day, or omeprazole 20 mg once a day. (Grade A, Level Ib)
A - When pain persists or increases, an opioid should be added to the analgesic regimen. (Grade A, Level Ia)
B - All patients with moderate to severe pain should receive a trial of an opioid analgesic, regardless of the aetiology of the pain. (Grade B, Level IIa and IIb)
B - If the effect of an opioid for mild to moderate pain at optimum dose is not adequate, move to step 3 of the analgesic ladder. (Grade B, Level III)
Use of Opioids in the Treatment of Moderate to Severe Pain
B - The opioid of first choice for moderate to severe pain is morphine. (Grade B, Level III)
B - The optimal route of administration is by mouth. There should ideally be two types of oral formulations: immediate-release for dose titration and controlled-release for maintenance treatment. (Grade B, Level III)
B - The opioid dose for each patient should be individually titrated to achieve maximum analgesia and minimum side effects. (Grade B, Level III)
C - Where possible, opioid dose titration should be carried out with an immediate-release morphine preparation given every four hours to maintain constant levels of analgesia. (Grade C, Level IV)
A - Once suitable pain control is achieved by use of immediate-release morphine, conversion to the same total daily dose of controlled-release morphine should be considered. (Grade A, Level Ib)
C - Every patient on opioids for moderate to severe pain should have access to breakthrough analgesia, usually in the form of immediate-release morphine. The breakthrough dose should approximate one-sixth of the total daily dose of oral morphine. (Grade C, Level IV)
C - If patients are unable to take opioids orally, the rectal, transdermal, or subcutaneous route may be used. There is no indication for use of the intramuscular route for chronic cancer pain because the subcutaneous route is associated with less risk and less pain. (Grade C, Level IV)
C - The average relative potency ratio of oral to parenteral morphine is 1:3. (Grade C, Level IV)
B - A small proportion of patients develop intolerable side effects with oral morphine. In such patients a change to an alternative opioid or a change in the route of administration should be considered. (Grade B, Level III)
A - Transdermal fentanyl is an effective alternative to oral morphine but is best reserved for patients with stable opioid requirements. (Grade A, Level Ib)
C - Methadone is an effective alternative drug but is more difficult to use than other opioids because of pronounced inter- and intra-individual differences in its duration of action and relative analgesic potency. Its use by non-specialist practitioners is not recommended. (Grade C, Level IV)
B - Patients receiving opioid agonists should not be given a mixed agonist-antagonist because of the risk of precipitating a withdrawal syndrome and exacerbation of pain. (Grade B, Level IIb)
B - Pethidine should not be used if continued opioid use is anticipated. (Grade B, Level IIa)
B - Spinal (epidural or intrathecal) administration of opioid analgesics in combination with local anaesthetics or clonidine should be considered in patients who derive inadequate analgesia or suffer intolerable side effects despite the optimal use of systemic opioids and non-opioids. (Grade B, Level III)
Specific Issues Regarding Opioid Use
A - Specific interventions to treat the adverse effects of opioid therapy are efficacious. (Grade A, Level Ib)
B - Constipation is a common problem associated with long-term opioid administration and should be treated prophylactically. (Grade B, Level III)
B - When naloxone is given to reverse opioid-induced respiratory depression, it should be titrated to improve respiratory function, but with preservation of analgesia. (Grade B, Level IIb)
C - Mental clouding or confusion due to opioid toxicity should be managed by reducing the dose of opioid, ensuring adequate hydration, and treating the agitation/confusion with a neuroleptic, such as haloperidol. (Grade C, Level IV)
B - Initiation of opioids should not be delayed due to unfounded fears concerning psychological dependence or addiction. (Grade B, Level III)
B - Patients prescribed opioids for pain should be reassured that they will not become psychologically dependent on or addicted to their opioid analgesia. (Grade B, Level III)
Adjuvant Drugs
A - Patients with neuropathic pain should have a trial of a tricyclic antidepressant and/or an anticonvulsant. (Grade A, Level Ia and Ib)
C - A trial of steroids should be considered for raised intracranial pressure, severe bone pain, nerve infiltration or compression, pressure due to soft tissue swelling or infiltration, and spinal cord compression. (Grade C, Level IV)
Bisphosphonates
A - Bisphosphonate treatment should be considered in addition to conventional analgesic techniques for all patients with multiple myeloma and for breast cancer patients who have pain due to metastatic bone disease. (Grade A, Level Ia and Ib)
Anti-tumour Therapy
C - Systemic chemotherapy should be considered for cancers which are highly chemosensitive. (Grade C, Level IV)
C - Hormonal manipulation may contribute to pain relief in hormone sensitive cancers. (Grade C, Level IV)
C - Radiotherapy is effective in relieving pain due to tumour infiltration. (Grade C, Level IV)
C - When using anti-tumour therapy, concomitant use of effective analgesics must not be neglected. (Grade C, Level IV)
Interventional Techniques
C - Professionals who manage patients with cancer pain should be aware of the range of interventional techniques available for the relief of pain and have access to a specialist pain clinic providing a range of interventional techniques. (Grade C, Level IV)
GPP- Non-invasive therapies should precede invasive treatments, except in rare instances. (GPP)
A - Coeliac plexus block should be considered in patients with upper abdominal pain, especially when secondary to pancreatic cancer. (Grade A, Level Ia and Ib)
A - Epidural, intrathecal, and intraventricular opioids should be considered in treatment of cancer pain not controlled with opioids by other routes. (Grade A, Level Ia and Ib)
Non-pharmacologic Management: Physical and Psychosocial Modalities
C - Cutaneous stimulation techniques, such as application of superficial heat and cold, massage, pressure, and vibration, may provide pain relief when the source of pain is associated with muscle tension or spasm. (Grade C, Level IV)
A - Patients should remain active and participate in self-care when possible. (Grade A, Level Ib)
B - Prolonged bed-rest for cancer patients should be avoided because prolonged immobilization may lead to joint contractures, muscle atrophy, cardiovascular deconditioning, and other undesirable effects. (Grade B, Level III)
A - Psychosocial interventions should be used concurrently with pharmacological treatment for pain as part of a multidisciplinary approach to pain management and not as substitutes for analgesics. (Grade A, Level Ib)
B - Education on effective pain control modalities and correction of misconceptions relating to the use of opioids should be a routine part of patient management. (Grade B, Level III)
GPP - Pastoral care team members should participate in health care team meetings that discuss the needs and treatment of patients. They should be conversant with community resources that provide spiritual care and support for patients and their families. (GPP)
Pain in Special Populations
B - Clinicians should give special attention to the assessment and treatment of pain in special populations, including the very young, the very old, the cognitively impaired, and known or suspected substance abusers. Aggressive pain assessment and management are as necessary for them as for the general population. (Grade B, Level III)
B - Behavioural observation should be the primary assessment method for preverbal and nonverbal children and should be used as an adjunct for assessment of verbal children. (Grade B, Level III)
B - In older children, assessment includes self-report using age-appropriate scales, such as the Faces Pain Scale and the Numeric Rating Scale. Observation should be used as an adjunct to self-report. (Grade B, Level IIb)
C - Oral medication in children with cancer pain should follow the WHO analgesic ladder, with dosage adjustments. The basic principles of opioid use are similar to those in adults. (Grade C, Level IV)
GPP - Assessment in the cognitively intact elderly patient with cancer pain should be done in ways similar to that of the general adult population. (GPP)
B - Behavioural observation should be an adjunct to cancer pain assessment in cognitively impaired adults. (Grade B, Level III)
C - Non-opioid analgesic modalities should not be substituted for opioid analgesics to treat severe pain in the suspected or known substance abuser. (Grade C, Level IV)
Definitions:
Grades of Recommendations
Grade A (evidence levels Ia, Ib): Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation.
Grade B (evidence levels IIa, IIb, III): Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation.
Grade C (evidence level IV): Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality.
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group.
Levels of Evidence
Level Ia: Evidence obtained from meta-analysis of randomised controlled trials.
Level Ib: Evidence obtained from at least one randomised controlled trial.
Level IIa: Evidence obtained from at least one well-designed controlled study without randomisation.
Level IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study.
Level III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies.
Level IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.
CLINICAL ALGORITHM(S)None provided
Top^EVIDENCE SUPPORTING THE RECOMMENDATIONSTYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONSThe type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").
Top^IDENTIFYING INFORMATION AND AVAILABILITYBIBLIOGRAPHIC SOURCE(S)Singapore Ministry of Health. Cancer pain. Singapore: Singapore Ministry of Health; 2003 Mar. 88 p. [146 references]ADAPTATIONNot applicable: The guideline was not adapted from another source.
DATE RELEASED2003 Mar
GUIDELINE DEVELOPER(S)Singapore Ministry of Health - National Government Agency [Non-U.S.]
GUIDELINE DEVELOPER COMMENTThese guidelines were developed by a multidisciplinary workgroup brought together by the Council of the Pain Association of Singapore, the local chapter of the International Association for the Study of Pain (IASP).
SOURCE(S) OF FUNDINGSingapore Ministry of Health
GUIDELINE COMMITTEEWorkgroup on Cancer Pain
COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINEWorkgroup Members: Dr Cynthia Goh, Head, Department of Palliative Medicine, National Cancer Centre (Chairperson); Dr Ho King Hee, Consultant Neurologist and Physician, K H Ho Neurology & Medical Centre, Gleneagles Medical Centre (Chairperson); Dr Noreen Chan, Associate Consultant, Department of Palliative Medicine, National Cancer Centre; Dr Koh Nien Yue, Palliative Care Service, Associate Consultant, Department of General Medicine, Tan Tock Seng Hospital; Dr Koo Wen Hsin, Deputy Head, Department of Medical Oncology, National Cancer Centre; Dr Angel Lee Onn Kei, Consultant, Palliative Care Service, Department of Geriatric Medicine, Tan Tock Seng Hospital; Dr Yoong Chee Seng, Consultant, Department of Anaesthesia, Changi General Hospital; Advisors: Ms Lita Chew, Pharmacy Manager, National Cancer Centre; Dr Daphne Koh, Director of Pain Service, Department of Anaesthesia and Surgical Intensive Care, Singapore General Hospital; Prof Lee Tat Leang, Senior Consultant, Department of Anaesthesia, National University Hospital; Dr Pang Weng Sun, Head, Department of Geriatric Medicine, Alexandra Hospital; Dr Ting Pui Leong, Consultant Anaesthetist & Specialist in Pain Medicine, Mount Elizabeth Medical Centre; Dr Yeo Sow Nam, Associate Consultant, Department of Anaesthesia and Surgical Intensive Care, Singapore General Hospital; Dr Yeo Tseng Tsai, Unit Head, Department of Neurosurgery, National Neuroscience Institute; Ms Clara Yip, Department of Palliative Medicine, National Cancer Centre (Secretariat)
FINANCIAL DISCLOSURES/CONFLICTS OF INTERESTNot stated
GUIDELINE STATUSThis is the current release of the guideline.
GUIDELINE AVAILABILITYElectronic copies: Available in Portable Document Format (PDF) from the Singapore Ministry of Health Web site.
AVAILABILITY OF COMPANION DOCUMENTSNone available
PATIENT RESOURCESThe following is available:
Patient education brochure on cancer pain. Singapore: Singapore Ministry of Health; 2003. 41 p.Electronic copies: Available in Portable Document Format (PDF) from the Singapore Ministry of Health Web site.
Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.
NGC STATUSThis summary was completed by ECRI on November 28, 2003.
COPYRIGHT STATEMENTThis NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Ministry of Health, Singapore by e-mail at MOH_INFO@MOH.GOV.SG.Good Morning Donna,

posted by PainNP @ 5:46 PM