We did a systematic search for English-language randomised and non-randomised trials and meta-analyses that involved human adults with chronic cancer pain and contained data on efficacy, side-effects, or both, of the treatment considered and described relevant outcomes associated with each topic. We electronically searched Medline, Embase, and the Cochrane Central Register of Controlled Trials from the inception of each database to July 31, 2009. The search terms were text words and MeSH/EMTREE
ReviewUse of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC
Introduction
Moderate to severe pain in cancer is common and affects 70–80% of patients with advanced disease. We have the means and the knowledge to relieve most pain in cancer for most patients,1 but evidence from surveys and observational studies shows that many patients have troublesome or severe pain and do not get adequate relief.2
The skilled use of opioid analgesics is crucial to the relief of cancer pain, but there is a shocking lack of evidence to support clinical practice. The so-called analgesic ladder is the central idea of the WHO 1996 guidelines on cancer pain relief,3 in which the choice of analgesic is determined by the severity of the pain. The WHO method has been adopted worldwide but the lack of up-to-date evidence, knowledge, and opioid availability have obstructed the path to effective relief of cancer pain.2, 4
Randomised controlled trials (RCTs) in patients with cancer pain are beset by difficulties.5 In the absence of hard evidence from RCTs, expert consensus and clinical guidelines might be helpful, because cancer pain relief is a specialist area but most care is delivered by non-specialist practitioners. The European Association for Palliative Care (EAPC) research network published its first guidelines on the use of morphine and alternative opioids in cancer pain in 1996,6 and published an update in 2001.7 In this Review we present further work done to strengthen the scope of the EAPC recommendations by the application of rigorous, evidence-based methodology.
Section snippets
Development of recommendations
A comprehensive list of relevant topics on opioid use for cancer pain was derived from a comparison of the previous EAPC recommendations with other available guidelines on cancer pain relief. This list was submitted to a formalised expert consensus process that led to 30 practical clinical questions being summarised in 22 topics.8, 9 The subsequent guidelines development process followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.10, 11, 12, 13
Each of
Findings
Step II opioids (table 1) have been traditionally used for moderate cancer pain. The systematic review showed that codeine and tramadol are effective compared with placebo.15 The analgesic effect of paracetamol in conjunction with codeine was shown in an RCT34 that compared 150 mg codeine alone with 60 mg codeine plus 600 mg paracetamol, and showed that the combination four times per day was as effective and safe as codeine alone twice daily.
Only one RCT provided direct comparative data for the
Discussion
The guidelines we present are the product of an international European Palliative Care Research Collaborative project aimed at revising previous EAPC recommendations for use of opioids to treat cancer pain.7 We used a stepwise process8, 9 combined with a systematic literature review strategy. In view of the long-standing experience with opioid analgesics, the overall poverty of the evidence underlying many features of their use is surprising.
The quality and the content of the most recent
Search strategy and selection criteria
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Cited by (0)
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These authors contributed equally