Guidelines For Cancer Pain Management Research Articles

Development of a nurse navigation program for cancer pain

ObjectiveCancer pain significantly impacts the overall quality of life of cancer patients, necessitating proactive management. The manifestations of cancer pain vary individually and require tailored interventions to address each patient's unique characteristics. Therefore, this study aims to develop a nurse navigation program for cancer pain (NNP-CP) tailored to the needs of cancer patients requiring pain control, aiming to establish evidence-based clinical nursing practices and promote effective cancer pain management. MethodsThis study is a methodological research into developing a pain management program led by nurses for cancer patients requiring pain control, based on a professional navigation framework. The development of the program relied on three out of the five stages of the ADDIE (Analysis, Design, Development, Implementation, Evaluation) model. ResultsA literature review was conducted to select the content and rationale to be included in the intervention program. Publications within the last 10 years in English or Korean were identified and screened based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 literature selection flow, 17 articles were included. Standardized information regarding cancer pain control was based on the 7th edition of 'Cancer Pain Management Guidelines'. The initial draft of the pain management intervention program was developed by organizing and structuring the derived content based on the professional navigation framework. Subsequently, the final intervention program was confirmed through the review by six clinical experts specializing in cancer pain. ConclusionsCancer pain is a significant factor that profoundly influences the quality of life and survival duration of cancer patients. While appropriate management methods offer the prospect of control, insufficient intervention is the current reality. Through the pain management intervention program based on the expert navigation framework that promotes continuity of care and empowers the recipients, this study anticipates not only pain reduction in cancer patients but also an enhancement in their quality of life.

Managing Cancer Pain in Patients With Opioid Use Disorder

Practice guidelines for cancer pain management recommend optimizing treatments to improve function and meet the patient’s goals of care. Analgesic regimens often include an opioid in addition to adjuvant treatments. Cancer patients who use opioids in a dose or manner other than medically prescribed may develop opioid use disorder (OUD). Some patients may have OUD before their diagnosis of cancer and others may develop OUD during or after cancer treatment. Cancer patients with OUD may experience long-term, devastating consequences such as suboptimal management of their cancer or increased morbidity and mortality. Nurse practitioners caring for patients before, during, or after a diagnosis of cancer should understand the risks of opioid use and treatment options for cancer patients at risk for developing OUD or diagnosed with OUD. Four case presentations discuss how a multidisciplinary team approached the management of pain in patients with cancer and OUD.

Factors associated with adherence to guidelines in cancer pain management among adult patients evaluated at oncology unit, in the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

IntroductionCancer pain is one of the most important deleterious and distressing symptoms suffered by patients with cancer which disturb their quality of life, especially in the last part of their life. Alleviating pain is a primary goal of prognosis of cancer pain management and pain symptoms must be prevented, treated as a priority, and considered an independent part of cancer management. Despite the presence of guidelines for cancer pain management, many patients with cancer are still undertreated. Therefore, this study aimed to assess factors associated with adherence to guidelines in cancer pain management among adult patients evaluated at the oncology unit, in the University of Gondar Comprehensive Specialized Hospital (UoGCSH), Northwest Ethiopia.MethodsAn institution-based cross-sectional study was conducted from January to March 2021. All patients who were in cancer treatment were our population of interest. A systematic random sampling technique was used to select a total of 384 participants. The dependent variable of the study was adherence to guidelines in cancer pain management. It was determined using the pain management index (PMI) which was calculated by subtracting the pain level from the analgesics level. A negative range was considered an indicator of poor adherence to guidelines in cancer pain management. Bivariable and multivariable binary logistic regression analyses were performed. Adjusted odds ratio (AOR) with a 95% CI was used as a measure of association. Variables having P < 0.05 from the multivariable analysis were considered to have a significant association with the outcome.ResultsThe prevalence of poor adherence to guidelines in cancer pain management among 384 adult patients in this study was 21.35% (95%CI: 17.53, 25.76). Patients who were not married [AOR = 2.2; 95%CI: 1.15, 4.19], who know their diagnosis before 4 months ago [AOR = 0.53; 95%CI: 0.26, 0.96], who have metastasis cancer [AOR = 3.76; 95%CI: 1.83, 7.72], and being stage III patients [AOR = 3.21; 95%CI: 1.64, 7.93] and stage IV patients [AOR = 1.63; 95%CI: 1.09, 5.81], respectively, had a significant association with poor adherence to guidelines in cancer pain management.ConclusionThe prevalence of poor adherence to guidelines in cancer pain management among adult patients with cancer in UoGCSH Northwest Ethiopia is relatively low as compared with other studies. Factors such as patients who were not married and who have metastasis cancer, and being patients with stage III and stage IV cancer had a significant positive association with poor adherence to guidelines in cancer pain management, on the other hand, patients who know their diagnosis 4 months ago had a positive association with having adherence to guidelines in cancer pain management. Patients with high stage and metastasis need care from pain specialists early on in the diagnosis of pain. The hospital should reassure the diagnosis of cancer for the patient before they started the treatment.

Impact of expanded strong opioid availability on opioid prescription patterns in patients with cancer: A population-wide cohort study in Taiwan.

Background One of the major barriers to adequate cancer pain management in Taiwan is the limited prescription options regarding strong opioids. Internationally recommended strong opioids, including oxycodone and hydromorphone, were not introduced in Taiwan until late 2014. We analysed the patterns in opioid prescription for cancer pain management, after the introduction of new opioid options.Methods All inpatient and outpatient clinical visits from January 1, 2012, to December 31, 2017, with the diagnosis of cancer and the analgesic prescriptions were collected from the database of National Health Insurance, Taiwan, and analysed. Opioids were grouped into strong opioids, weak opioids, and guideline non-recommended opioids.Findings A total of 1, 292, 905 patients with cancers were included. Approximately 50% of patients used analgesics, 50% of which were opioids; the proportions were stable during the study period. The annual cumulative opioid use per patient (defined daily dose, DDD) significantly decreased from 36•41±102•59 (Mean±SD) in 2012 to 32•42±100•99 in 2017 (p < •001). The annual cumulative strong opioid use per patient increased significantly from 17•54±89•23 in 2012 to 19•28±94•97 in 2017 (+9•90%, p < •001). In parallel, the annual cumulative weak opioids use per patient decreased from 18•64±40•81 in 2012 to 13•04±26•79 in 2017 (−30•04%, p < •001). Among extended-release strong opioids, the use of transdermal fentanyl significantly decreased after oxycodone and hydromorphone were introduced (p < •001).Interpretation Increased therapeutic options in strong opioid prescriptions led opioid prescription patterns to evolve towards international cancer pain management guidelines. In addition, increased accessibility to a wider range of different strong opioids may facilitate more efficient opioid titration and rotation - and thus decrease, not increase, the opioid usage.Funding This study was supported by Ministry of Science and Technology, Taiwan (MOST-106-2314-B-002-213 and MOST-108-2314-B-002-072-MY3), Ministry of Health and Welfare, Taiwan (MOHW109-TDU-B-211-114002), National Taiwan University Hospital, Taipei, Taiwan (NTUH-103-002314 and NTUH. 105‐S2954), and National Center of Excellence for Clinical Trial & Research, National Taiwan University Hospital, Taipei, Taiwan (NCTRC201208 and NCTRC201603).

P36-8 Achievements and challenges in developing the in-house certified nurses for cancer pain management

We developed and implemented an educational program to develop in-house certified nurses for cancer pain management (hereinafter referred to as “in-house CNs”) at our hospital, which has two Board-Certified Nurses in Cancer Pain Management Nursing. We used this educational program as an opportunity for mid-level and experienced nurses who play a key role in the organization to attend training in a specialized field and to utilize their individual strengths. To train in-house CNs to acquire expertise and provide high quality pain management nursing, and to provide pain screening to patients as the department's link nurse. Eligible candidates were recommended by directors of their department or were at the Clinical Ladder Level III. Between June 2018 and February 2020, five 90-minute lectures (instructors: nurses, pharmacists, psychologists, psychiatrists, and orthopedic surgeons) and a written exam; and three case studies based on the Clinical Guidelines for Cancer Pain Management were conducted. All participants passed the exam and nine in-house CNs were developed. Participants were highly satisfied with the content of the training, with comments such as “I learned the importance of conducting assessments from multiple perspectives” and “I began to think about nursing care in pain management.” On the other hand, there was a comment such as “The role required was too large.” The nurses felt burdened by the role of in-house CNs because they had to refer patients with pain to the specialist palliative care team in addition to pain screening. It is hoped that the role of bridging from the department to the palliative care team and resource nurses will be activated in the future. The challenge is to train CNs in departments where CNs are not available, and to create an environment in which CNs can play an active role working with the link nurse of the Palliative Care Directors Meeting, which was established this year.

Use and patient affordability of opioid analgesics for cancer pain management in different regions of China: a retrospective analysis of data from 2006 to 2016

BackgroundLittle information is available on the need for opioid analgesics based on demographic, economic and disease spectrum data, or on patient affordability of opioid analgesics, in different regions of China. This study analysed the level of, and trends in, opioid analgesic use in different regions of China from 2006 to 2016, calculated the need for opioid analgesics based on demographic, economic and disease spectrum data from the different regions, and analysed the gap between need and actual consumption. Patient affordability of opioid analgesics for cancer pain management was also measured. MethodsOpioid analgesic consumption data were obtained from the China Hospital Pharmaceutical Audit (CHPA) database of IQVIA (formerly Quintiles and IMS Health). We assessed the clinical need for opioid analgesics by calculating the morphine use density (MUD, daily defined doses of morphine per 100 000 population) and its growth rate from 2006 to 2016 in China and its seven regions. Regional need for opioid analgesics (in morphine equivalents) was estimated based on regional cancer registration data and standard treatment doses of opioids, as defined by international guidelines for cancer pain management. The study adopts WHO and Health Action International (HAI) methods to evaluate patient affordability of opioid analgesics for cancer pain management using standardized costs in daily defined doses (DDD). FindingsThe national MUD increased from 1·45 DDD/100 000/day in 2006 to 6·93 DDD/100 000/day in 2016. Southern China had the highest MUD (9·67 DDD/100 000/day), and northwest China had the lowest MUD (3·28 DDD/100 000/day) in 2016. The actual use of morphine equivalents accounted for only 21·5% of the morphine required for cancer pain management at the national level; 26% in east, 36% in south, 11% in southwest, and 12% in northwest China. The DDD costs of all studied opioid analgesics ranged from CNY ¥10·80 to ¥848·88. Except for morphine injections, the out-of-pocket payments for a standard full course of treatment with opioid analgesics were more than the daily disposable income in all regions. Patient affordability of opioid analgesics is low according to the WHO and HAI method. InterpretationOpioid analgesic use for the management of cancer pain was insufficient relative to needs in China, and varied markedly across regions with different levels of economic development. Long-term use may pose a heavy economic burden to patients. The findings call for actions to strengthen cancer pain management, and to improve the affordability of drugs. FundingThe Peking Union Medical College Education Fund.

Something Must Be Wrong with the Implementation of Cancer-pain Treatment Guidelines. A Lesson from Referrals to a Pain Clinic.

ObjectiveThe World Health Organization’s (WHO) guidelines for cancer pain management were intentionally made simple in order to be widely implemented by all physicians treating cancer patients. Referrals to pain specialists are advised if pain does not improve within a short time. The present study examined whether or not a reasonable use of the WHO guideline was made by non-pain specialists prior to referral of patients with cancer-related pain to a pain clinic.MethodsCancer patients referred to a pain specialist completed several questionnaires including demographics, medical history, and cancer-related pain; the short-form McGill Pain Questionnaire (SF-MPQ); and the Short Form Health Survey SF-12. Data from referral letters and medical records were obtained. Treatments recommended by pain specialists were recorded and categorized as “unjustified” if they were within the WHO ladder framework, or “justified” if they included additional treatments.ResultsSeventy-three patients (44 women, 29 men) aged 55 years (range, 25–85) participated in the study. Their pain lasted for a mean of 6 (1–192) months. Mean pain intensity scores on a 0–10 numerical rating scale were 7 (2–10) at rest and 8 (3–10) upon movement. Most patients complied with their referring physician’s recommendations and consumed opioids. Adverse events were frequent. No significant correlation was found between the WHO analgesic medication step used and mean pain levels reported. There were 63 patient referrals (85%) categorized as “unjustified,” whereas only 11 patients (15%) required “justified” interventions.ConclusionsThese findings imply that analgesic treatment within the WHO framework was not reasonably utilized by non-pain specialists before referring patients to pain clinics.

Framing of the opioid problem in cancer pain management in Canada.

Two guidelines about opioid use in chronic pain management were published in 2017: the Canadian Guideline for Opioids for Chronic Non-Cancer Pain and the European Pain Federation position paper on appropriate opioid use in chronic pain management. Though the target populations for the guidelines are the same, their recommendations differ depending on their purpose. The intent of the Canadian guideline is to reduce the incidence of serious adverse effects. Its goal was therefore to set limits on the use of opioids. In contrast, the European Pain Federation position paper is meant to promote safe and appropriate opioid use for chronic pain. The content of the two guidelines could have unintentional consequences on other populations that receive opioid therapy for symptom management, such as patients with cancer. In this article, we present expert opinion about those chronic pain management guidelines and their impact on patients with cancer diagnoses, especially those with histories of substance use disorder and psychiatric conditions. Though some principles of chronic pain management can be extrapolated, we recommend that guidelines for cancer pain management should be developed using empirical data primarily from patients with cancer who are receiving opioid therapy.

Appraisal of International Guidelines for Cancer Pain Management

Appraisal of International Guidelines for Cancer Pain Management

Minimally Invasive Cordotomy for Refractory Cancer Pain: A Randomized Controlled Trial.

Up to 30% of patients with cancer continue to suffer from pain despite aggressive supportive care. The present study aimed to determine whether cordotomy can improve cancer pain refractory to interdisciplinary palliative care. In this randomized controlled trial, we recruited patients with refractory unilateral somatic pain, defined as a pain intensity (PI) ≥4, after more than three palliative care evaluations. Patients were randomized to percutaneous computed tomography-guided cordotomy or continued interdisciplinary palliative care. The primary outcome was 33% improvement in PI at 1 week after cordotomy or study enrollment as measured by the Edmonton Symptom Assessment Scale. Sixteen patients were enrolled (nine female, median age 58 years). Six of seven patients (85.7%) randomized to cordotomy experienced >33% reduction in PI (median preprocedure PI = 7, range 6-10; 1 week after cordotomy median PI = 1, range 0-6; p = .022). Zero of nine patients randomized to palliative care achieved a 33% reduction in PI. Seven patients (77.8%) randomized to palliative care elected to undergo cordotomy after 1 week. All of these patients experienced >33% reduction in PI (median preprocedure PI = 8, range 4-10; 1 week after cordotomy median PI = 0, range 0-1; p = .022). No patients were withdrawn from the study because of adverse effects of the intervention. These data support the use of cordotomy for pain refractory to optimal palliative care. The findings of this study justify a large-scale randomized controlled trial of percutaneous cordotomy. This prospective clinical trial was designed to determine the improvement in pain intensity in patients randomized to either undergo cordotomy or comprehensive palliative care for medically refractory cancer pain. This study shows that cordotomy is effective in reducing pain for medically refractory cancer pain, and these results can be used to design a large-scale comparative randomized controlled trial that could provide the evidence needed to include cordotomy as a treatment modality in the guidelines for cancer pain management.

A phase III wait-listed randomised controlled trial of novel targeted inter-professional clinical education intervention to improve cancer patients\u2019 reported pain outcomes (The Cancer Pain Assessment (CPAS) Trial): study protocol

BackgroundVariations in care models contribute to cancer pain being under-recognised and under-treated in half of all patients with cancer. International and national cancer pain management guidelines are achievable with minimal investment but require practice changes. While much of the cancer pain research over the preceding decades has focused on management interventions, little attention has been given to achieving better adherence to recommended cancer pain guideline screening and assessment practices. This trial aims to reduce unrelieved cancer pain by improving cancer and palliative doctors’ and nurses’ (‘clinicians’) pain assessment capabilities through a targeted inter-professional clinical education intervention delivered to participants’ mobile devices (‘mHealth’).MethodsA wait-listed, randomised control trial design. Cancer and/or palliative care physicians and nurses employed at one of the six participating sites across Australia will be eligible to participate in this trial and, on enrolment, will be allocated to the active or wait-listed arm. Participants allocated to the active arm will be invited to complete the mHealth cancer pain assessment intervention. In this trial, mHealth is defined as medical or public health practice supported by mobile devices (i.e. phones, patient monitoring devices, personal digital assistants and other wireless devices). This mHealth intervention integrates three evidence-based elements, namely: the COM-B theoretical framework; spaced learning pedagogy; and audit and feedback. This intervention will be delivered via the QStream online platform to participants’ mobile devices over four weeks. The trial will determine if a tailored mHealth intervention, targeting clinicians’ cancer pain assessment capabilities, is effective in reducing self-reported cancer pain scores, as measured by a Numerical Rating Scale (NRS).DiscussionIf this mHealth intervention is found to be effective, in addition to improving cancer pain assessment practices, it will provide a readily transferable evidence-based framework that could readily be applied to other evidence practice gaps and a scalable intervention that could be administered simultaneously to multiple clinicians across diverse geographical locations. Moreover, if found to be cost-effective, it will help transform clinical continuing professional development. In summary, this mHealth intervention will provide health services with an opportunity to offer an evidence-based, pedagogically robust, cost-effective, scalable training alternative.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12618001103257. Registered on 3 July 2018.

Screening and Audit as Service-Level Strategies to Support Implementation of Australian Guidelines for Cancer Pain Management in Adults: A Feasibility Study

Background: Pain in people with cancer is common but often under-recognized and under-treated. Guidelines can improve the quality of pain care, but need targeted strategies to support implementation. Aim: To test the feasibility of two service-level strategies for supporting guideline implementation: a screening system and medical record audit. Design: Multimethods. Setting: One oncology outpatient service, and one palliative care outpatient and inpatient service. Participants: Patients with advanced cancer. Methods: Patients were screened in the waiting room with a modified version of the Edmonton Symptom Assessment System-revised either electronically or in paper-based format. Feasibility indicated the percentage of patients successfully screened from the total number attending the services. An audit assessed adherence to key indicators of pain assessment and management. Feasibility thresholds were set at 75% incidence for screening and a median of 30 minutes per patient for audit. Results: Of 452 patient visits, 95% (n = 429) were successfully screened, 34% (n = 155) electronically and 61% (n = 274) paper-based. Electronic pain screening was technically challenging and time-intensive for nurses. Thirty-one patients consented to have their records audited. The median audit time was 37.5 minutes (range 10-120 minutes). Variability arose from the number and type of record (outpatient or inpatient). Adherence to indicators varied from 63% (pain assessment at first presentation) to 94% (regular pain assessment and medication prescribed at regular intervals). Conclusions: This study confirmed the need to implement evidence-based guidelines for cancer pain and generated useful insights into the feasibility of pain screening and audit.

Knowledge and Attitudes Toward Cancer Pain Management Among Nurses at Oncology Units.

Nurses have major responsibilities to treat cancer pain in an optimal way. Their knowledge and attitudes are the key to success cancer pain management (CPM) process and impact the outcomes of pain treatment. This study aimed to evaluate the knowledge and attitudes toward CPM among Jordanian nurses working at oncology units. A cross-sectional descriptive design was used to collect data from 135 nurses who were working at four oncology units using Knowledge and Attitudes Survey Regarding Pain. The percentage of correct answers was 51.5% indicating that participants had fair knowledge and attitudes toward CPM. Nurses appeared knowledgeable about CPM guidelines but were unfamiliar regarding pharmacological management and had negative attitudes toward opioids addiction and pain assessment. Significantly, knowledge and attitudes were higher among nurses who had previous education programs (P<.001) and worked in a pain team (P<.001). Therefore, including CPM topics in nursing curricula and postgraduate educational programs is needed. Additionally, initiating pain management teams and using CPM guidelines will contribute to effective treatment of cancer pain.

Latin-American guidelines for cancer pain management.

Cancer is a major public health issue. Poor pain management has devastating consequences that seriously affect quality of life, diminish functionality and place a huge emotional burden on patients and their relatives. A group of Latin American opinion leaders were invited to participate in a meeting to discuss areas associated with cancer pain. The expert panel reviewed the latest literature to draft region-specific guidelines for effective pain management. The guidelines make recommendations on tailoring treatment to the specific type of pain and provide local physicians with the state-of-the art findings in the field. Management should be with pharmacological approaches (nonopioid, adjuvant and opioid analgesics, as well as oncologic therapies and interventional procedures) and nonpharmacological approaches.

How Do Hospital Palliative Care Teams Use the WHO Guidelines to Manage Unrelieved Cancer Pain? A 1-Year, Multicenter Audit in Japan.

It has been reported that pain relief for patients with cancer is suboptimal in Japan. This has been mainly attributed to inadequate dissemination of the World Health Organization (WHO) guidelines for cancer pain management. To better understand this problem, we reviewed how 6 hospital palliative care teams (HPCTs) used the WHO guidelines for unrelieved pain in a 1-year audit that included 534 patients. The HPCT interventions were classified according to the contents of the WHO guidelines. In our study, HPCT interventions involved opioid prescriptions in >80% of referred patients, and "For the Individual" and "Attention to Detail" were the 2 most important principles. Our study indicates which parts of the WHO guidelines should be most heavily emphasized, when disseminating them in Japan.

Reply to commentary on "a nationwide survey of knowledge of and compliance with cancer pain management guidelines by korean physicians".

See the letter "Commentary on “A Nationwide Survey of Knowledge of and Compliance with Cancer Pain Management Guidelines by Korean Physicians”" on page 425.

Commentary on "a nationwide survey of knowledge of and compliance with cancer pain management guidelines by korean physicians".

Kim et al. [1] have presented the results of a fascinating study that seems to show that “better knowledge of cancer pain management resulted in greater reduction of patient pain severity.”

A Nationwide Survey of Knowledge of and Compliance with Cancer Pain Management Guidelines by Korean Physicians

PurposeAlthough cancer pain is prevalent, under-treatment still remains a problem. Knowledge of and compliance with guidelines for management of cancer pain were analyzed for exploration of physician-related barriers to cancer pain management. In addition, physicians' knowledge and its correlation with cancer pain control were audited.Materials and MethodsFrom July 8 to December 2, 2010, a nationwide survey of house staff enquired about their knowledge of cancer pain control guidelines, and the medical records of patients under their care were analyzed.ResultsIn total, 180 physicians participated in the study. Their average score for knowledge was 14.6 (range, 7 to 19; maximum possible, 20). When the knowledge score was divided into low, medium, and high scores, patients receiving care from physicians with high levels of knowledge tended to have better cancer pain control (p<0.001). Of the total patients with severe pain, 19.5% were not prescribed strong opioids, and 40% were not prescribed any medication for breakthrough pain.ConclusionPhysicians' knowledge of guidelines for control of cancer pain showed an association with improvement of pain management. Overall adherence to the guidelines was lacking. Continuous interventions such as education and audits regarding cancer pain control guidelines for physician are needed.

Evidence‐based practice for pain management for cancer patients in an acute care setting

The purpose of this study is to implement an evidence utilization project using an audit and feedback approach to improve cancer pain management. A three-phased audit and feedback approach was used. A 46-bed oncology nursing unit in the university's cancer centre was selected as a research site. Nursing records extracted from 137 patients (65 for the baseline assessment and 72 for the follow-up audit) were used to examine nurse compliance with four audit criteria derived from best practice guidelines related to the assessment and management of pain. We observed a significant improvement in compliance from baseline to follow-up for the following criteria: documenting the side effects of opioids (2-83%), use of a formalized pain assessment tool (22-75%), and providing education for pain assessment and management to patients and caregivers (0-47%). The audit and feedback method was applicable to the implementation of clinical practice guidelines for cancer pain management. Leadership from both administrative personnel and staff nurses working together contributes to the spread of an evidence-based practice culture in clinical settings. As it was conducted in a single oncology nursing unit and was implemented over a short period of time, the results should be carefully interpreted.

EL9 - Palliative Care 2: Palliative Care Based on EBM

ABSTRACT (1) Palliative care: Providing palliative care from the early stage of cancer is indicated to be effective. (2) Pain management according to the ‘Clinical Guidelines for Cancer Pain Management’: (i) assessment: pain is a subjective symptom. Pain should be evaluated by patient's expression in its intensity, quality and the level of impairment on quality of life. (ii) Classification: pain is classified into visceral pain, somatic pain and neuropathic pain. Appropriate assessment leads to proper management of pain. (iii) The WHO method for cancer pain relief: analgesics should be chosen according to the severity of the pain, complications and possible route of administration. (iv) Opioid rotation: switching opioid enhances the analgesic effect and avoids side-effects. Understanding the characteristics of each opioid is important to make appropriate choice of opioid. (v) Neuropathic pain (NP): NP is characterized as burning pain, lancinating pain, paresthesia, hyperalgesia and/or allodynia. Using opioids, NSAIDs, analgesics adjuvants (antidepressants, anticonvulsants, antiarrhythmic drugs, antagonists NMDA (N-methyl- d -aspartate receptor)) in combination is recommended for the management of NP. (3) Dyspnea management according to the ‘Clinical Guidelines for Respiratory Symptoms in Cancer Patients': (i) definition: dyspnea is defined as ‘an uncomfortable sensation of breathing’. It is not always correlated with respiratory failure (=hypoxemia). (ii) Symptomatic treatment: systematic reviews showed morphine alleviate dyspnea in cancer patients. The effectiveness of oxicodone and fentanil has not yet been reported. Anti-anxiety drug and corticosteroids may be suggested. (4) Sedation according to the ‘Clinical Guideline for Palliative Sedation Therapy’: Sedation may be recommended in case of refractory sufferings in terminal stage. Palliative prognostic index is widely used as a screening tool to predict death within 3 weeks.