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Pharmacological options for the management of refractory cancer pain—what is the evidence?

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Abstract

Refractory cancer pain that does not respond to standard opioid and/or co-analgesic therapy occurs in 10–20 % of patients. Risk factors include young age, neuropathic pain type, incident pain, psychological distress, previous opioid use, high tolerance, a history of addiction and impaired cognition. The management of patients with refractory pain remains a challenge. Treatment options include opioid manipulation (parenteral delivery, rotation, combination, methadone and buprenorphine), non-opioids and co-analgesics (paracetamol, non-steroidal anti-inflammatory agents, antidepressants and anticonvulsants), NMDA receptor antagonists, cannabinoids, lignocaine and corticosteroids. The evidence of benefit for any of these agents is weak, and each additional agent increases the risk of adverse events. Evidence-based guidelines cannot, therefore, be developed at present. New approaches are recommended including targeted opioid therapy, multimodal analgesia, a goal-oriented approach to pain management and increasing use of the multidisciplinary team and support services.

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Acknowledgment

The authors wish to thank A/Prof John Hooper and Prof CR Pinkerton for their advice and help in this project.

Funding

BA was supported from a grant from the Mater Research Institute.

Disclosures

JH sits on the medical advisory boards of Mundipharma Pty Ltd and Menarini Australia Pty Ltd. She has contributed to the opioid educational modules of Mundipharma Pty Ltd.

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Authors and Affiliations

  1. Department of Palliative and Supportive Care , Mater Health Services, and Mater Research Institute, University of Queensland, Brisbane, Australia

    B. Afsharimani, K. Kindl, P. Good & J. Hardy

  2. St Vincent’s Private Hospital, Brisbane, Australia

    P. Good

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  1. B. Afsharimani
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  2. K. Kindl
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Correspondence to J. Hardy.

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Afsharimani, B., Kindl, K., Good, P. et al. Pharmacological options for the management of refractory cancer pain—what is the evidence?. Support Care Cancer 23, 1473–1481 (2015). https://doi.org/10.1007/s00520-015-2678-9

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