Key messages
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The assessment and management of pain in populations with cancer is best considered as an essential component of the broad therapeutic approach known as palliative care
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Pain assessment should characterise the pain complaint; take into account the status of the underlying disease; clarify the pain in terms of its cause, syndrome, and pathophysiology; and obtain details about other factors that contribute to illness burden
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Pain can be addressed with primary disease-modifying treatment, most often radiotherapy, if this approach is available, feasible, and consistent with the goals of care
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The mainstay symptomatic treatment for cancer pain is opioid-based pharmacotherapy, and all clinicians who provide care to patients with cancer should aim to optimise the positive outcomes from these drugs and minimise the risks associated with both side-effects and outcomes related to chemical dependency (misuse, addiction, and diversion)
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Effective opioid treatment depends on appropriate selection of a drug and route, individualisation of the dose, consideration of so-called rescue dosing for breakthrough pain, and treatment of common opioid side-effects
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The addition of a non-steroidal anti-inflammatory drug to opioid treatment can be helpful, especially in some painful conditions, but the gastrointestinal, cardiovascular, and renal risks of these drugs should be weighed against their benefits on a case-by-case basis
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Adjuvant analgesic drugs, such as glucocorticoids, antidepressants, and anticonvulsants, have many uses as adjuvant analgesics when opioid treatment is not sufficient; clinicians should familiarise themselves with the common indications and agents
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Many non-pharmacological treatments can be used to improve pain control, coping, adaptation, and self-efficacy; mind–body strategies have established benefit and can be used in a restricted but potentially useful manner by non-specialists
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Interventions, including neural blockade and implanted therapies, play a small but important part in the management of refractory pain