The management of chronic pain in patients with breast cancer. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Canadian Society of Palliative Care Physicians. Canadian Association of Radiation Oncologists.

OBJECTIVE: To help health professionals develop optimal strategies for controlling the chronic pain caused by breast cancer.

OUTCOMES: Pain control, absence of adverse effects.

EVIDENCE: Systematic review of the literature up to Dec. 30, 1996, with nonsystematic coverage to July 1997. Where experimental evidence is lacking, recommendations are based on expert opinion. The evidence was evaluated and graded in "levels" (page S2).

RECOMMENDATIONS: The nature and severity of pain should be carefully evaluated using the history and physical examination. Psychosocial and emotional factors must also be identified. Adequacy of pain control should be evaluated regularly. The first objective in the management of pain due to cancer is to identify the cause and treat it whenever feasible. The first priority of treatment is to control pain rapidly and completely, as judged by the patient. The second priority is to prevent recurrence of pain. The administration of analgesic medication should be based on a regular schedule, around the clock, with additional doses for breakthrough pain when necessary. When drug therapy is necessary, the World Health Organization (WHO) 3-step approach to the use of analgesics is recommended. The oral route should be the first choice for opioid administration. If the oral route fails, transdermal or rectal administration should be considered. When parenteral administration is necessary, the intravenous or subcutaneous routes can be used according to circumstances. Intramuscular administration of opioids is not recommended. Careful observation and titration are required when switching from 1 opioid to another, particularly when the patient is already receiving a high dosage. When converting a patient from long-term oral use of morphine or hydromorphone to parenteral use, a ratio of 3:1 should usually be employed. (This ratio increases to 6:1 for opioid-naive patients.) After initiating morphine or making any change of dose or route of administration, the dosage should be evaluated after approximately 24 hours. Tolerance to opioids must not be confused with physical dependence or psychological, dependence (so-called "addiction"). Patients should be made aware of possible side effects of medications and should be encouraged to maintain a diary for recording medications taken, dosages and adverse events. Adjuvant analgesics should be administered, when necessary, with an opioid or nonopioid analgesic. Noninvasive measures such as psychosocial interventions and physical modalities may bring significant relief. Neuroinvasive procedures are rarely required and should only be considered when other interventions have failed.

VALIDATION: The guidelines were reviewed and revised by a writing committee, expert primary reviewers, secondary reviewers selected from all regions of Canada and by the Steering Committee. The present guidelines reflect a consensus of all of these contributors. They have been reviewed and endorsed by the Canadian Society of Palliative Care Physicians and the Canadian Association of Radiation Oncologists.