Treating Adult Cancer Pain in Primary Care

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Figure 1.
Mild cancer pain treatment algorithm.
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Figure 2.
Moderate and severe cancer pain treatment algorithm.

Table 1.

Selected Agents for Managing Side Effects of Opioids

Nausea/Vomiting	Pruritus	Sedation
Metoclopramide^* 10 mg po/IV q 4 hours prn	Diphenhydramine^* 25–50 mg po/IV q 12 hours	Caffeine
Prochlorperazine^* 10 mg po/IV q 4hours, or 25 mg PR q 8 hours	Hydrocortisone 1% cream to affected area q 6 hours	Dextroamphetamine 2.5–10 mg po
Add meclizine if motion exacerbates symptoms	Dexamethasone 1 mg po q day	Methylphenidate 2.5–10 mg po q day to TID
If severe: Transdermal scopolamine or 5HT3 antagonist^†		(Modafinil 100 to 400 mg q day is almost 5× as expensive as methylphenidate)

* Available in liquid form.
q, every; prn, as needed; po, by mouth; IV, intravenous; TID, 3 times per day.
† Ondansetron is available in both liquid and oral transdermal forms.

Table 2.

Oncologic Emergencies

Brain metastases
Red flag	Increased frequency of headaches
	New or qualitatively different headache
	Localized headache brought on by a specific motion of the head
Action	Check MRI to rule out brain metastases
Visceral pain emergencies
Red flag	Anuria/oliguria
Action	Sonogram to rule out obstruction
Red flag	Continuous/colicky abdominal pain may indicate intestinal obstruction
Action	Digital rectal exam to rule out fecal impaction (caution if friable mucosa)
	Dexamethasone for partial obstruction in advanced disease
Spinal cord compression
Red flag	Progressive central or radicular back pain, increased with movement, weight-bearing,
	OR
	Bilateral lower extremity weakness or sensory deficit
Action	Magnetic resonance imaging, radiation oncology and neurology consults