Page 52 - CPG - Clinical Practice Guidelines - Management of Cancer Pain

Management of Cancer Pain (Second Edition)
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Tools for recognising and predicting opioid misuse are available for
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the Opioid Risk Tool (ORT) for patients considered for long-term opioid
therapy in predicting opioid misuse. For patients already on opioids, the
guidelines suggest the Current Opioid Misuse Measure (COMM) tool to
detect aberrant behaviour associated with opioid misuse. 61

• It is important to identify patients at risk of opioid misuse so that they
can be closely monitored.
• Fear of opioid misuse or tolerance should not preclude the start of
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Adjuvant analgesics are medications with primary indications other than
pain. However, they are useful in managing certain painful conditions,
particularly neuropathic pain. The most common classes of adjuvant
analgesics used in cancer pain management are anticonvulsants,
antidepressants and corticosteroids. Evidence for the use of these
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• Anticonvulsants
A large meta-analysis on patients with neuropathic pain including
cancer-related neuropathic pain reported the following NNT to achieve
50% pain relief and NNH for the following anticonvulsants: 62, level I
{ gabapentin (900 - 3600 mg/day): NNT 6.3 (95% CI 5.0 to 8.3) and
NNH 25.6 (95% CI 15.3 to 78.6)
{ pregabalin (150 - 600 mg/day): NNT 7.7 (95 % CI 6.5 to 9.4) and NNH
13.9 (95% CI 11.6 to 17.4)
There was no evidence on a dose-response effect for gabapentin, while
pregabalin showed a better response at higher doses. Combination
therapy of gabapentin with morphine was superior to monotherapy.
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In a Cochrane systematic review, a small RCT on cancer-related
neuropathic pain showed that gabapentin 1800 mg daily and pregabalin
600 mg decreased pain scores, had a morphine-sparing effect and
improved functional capacity. The quality of the evidence was very
low. 63, level I

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