Page 34 - CPG - Clinical Practice Guidelines - Management of Cancer Pain

Management of Cancer Pain (Second Edition)
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2.42 to 7.54). 30, level I

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dry mouth. There is also an increased risk of convulsion with its use.
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with strong opioids. 29, level III
A Cochrane systematic review comparing codeine ± paracetamol
with placebo found limited evidence to indicate that codeine is more
effective in cancer pain. However, it had an increased risk of nausea,
vomiting and constipation. 31, level I In clinical practice, oral codeine and
dihydrocodeine appear to be equipotent. 9
Weak opioids are generally more accessible compared with strong
opioids. In situations where access to morphine or other strong opioids
may be limited or not immediate, tramadol or dihydrocodeine may be
an option in cancer pain management.

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• Weak opioids may be used for moderate pain (step 2 of the WHO
analgesic ladder) in cancer pain.

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the appropriate dose is the dose which provides pain relief without
causing major or intolerable AEs. In most settings, morphine remains
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32
listed in the WHO essential medicines list.
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A large Cochrane systematic review of 62 studies compared the
effectiveness and safety of oral morphine with various controls in
relieving cancer pain. The range of oral morphine doses used varied
from 25 mg/day to 300 mg/day and titrated to effect. Mean daily doses
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{ morphine was an effective analgesic for moderate to severe
cancer pain and >90% of participants had ‘no worse than mild
pain’
{ adverse events (AEs) were common and predictable but only
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morphine because of intolerable AEs

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