Page 31 - CPG - Clinical Practice Guidelines - Management of Cancer Pain

Management of Cancer Pain (Second Edition)

STRONG OPIOID
• Morphine
• Oxycodone
• Fentanyl
± non-opioid ± adjuvant
WEAK OPIOID
• Tramadol Step 3
• Codeine Pain Score 7 - 10
• Dihydrocodeine Severe
± non-opioid ± adjuvant
NON-OPIOID
Step 2
• Paracetamol Pain Score 4 - 6
• NSAIDs (including COX-
2 inhibitors) ± adjuvant Moderate
Step 1
Pain Score 1 - 3
Mild
*Strong opioids can be considered to treat moderate cancer pain. 23, level I
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MoH; 2010.

A multi-centre RCT showed that low doses of morphine were more
effective than standard doses of weak opioids for moderate cancer pain
in opioid-naive patients as shown below: 23, level I
• 88.2% of patients on morphine and 54.7% of patients on weak
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95% CI 3.12 to 12.24)
• the effectiveness of morphine over weak opioids was evident in the
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and remained constant over four weeks
Both drug treatments were well tolerated with no differences observed
in the intensity and frequency of opioid-related side-effects between
them.
In a recent pragmatic clinical trial, there was some evidence that a
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than a 3-step approach in cancer pain management. However, the
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XVH RI WKH RULJLQDO ODGGHU DQG VKRXOG EH UHJDUGHG DV H[SORUDWLYH DV WKLV
study was underpowered. 24, level I

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• The treatment of cancer pain should be based on the World Health
Organization (WHO) analgesic ladder.

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