ANESTHETIC MANAGEMENT OF THE PATIENT WITH CANCER PAIN

Abstract

Because of a legacy of undertreatment, cancer pain has only been recently recognized as a disease state. Thus, a paucity of data exist relating to the perioperative management of patients withchronic pain syndromes, most of whom are prescribed multiple analgesics and related agents for the control of a myriad of symptoms. Patients are prescribed traditional analgesics (i.e., nonsteroidal anti-inflammatory drugs [NSAIDS] and opioids), often in doses far in excess of those used for the management of acute pain, but patients may also be taking a variety of so-called ”adjuvant” analgesics, drugs developed for alternate purposes and only serendipitously observed to promote analgesia in specific settings (e.g., antidepressants, anticonvulsants, and antiarrhythmics, usually for neuropathic pain). Although a modicum of information exists on potential drug interactions and the perioperative management of patients prescribed adj~vants,’~ there is a dearth of literature on the perioperative management of patients using high-dose opioids. With the recent release of guidelines that endorse more aggressive cancer pain management, the use of opioid analgesics is likely to increase further.l0 In addition, although the chronic use of opioids has traditionally been reserved for oncologic pain management, there is a growing trend toward the use of these agents in patients with chronic nonmalignant pain.’, 47 15, l9 Thus, patients in whom chronic opioid and adjuvant analgesic therapy is an important anesthetic consideration includes not only cancer patients presenting for tumor reduction and other surgery, but also individuals coming for orthopedic, neurologic, and routine surgery. Without careful planning based on a sound knowledge of the pharmacology of chronically administered opioids and an appreciation for basic pain management principles, these patients pose significant perioperative problems to the anesthesiologist and surgeon.