Cancer pain – not only the pain of the dying

Marie Fallon is the St Columba’s Hospice Chair of Palliative Medicine at the University of Edinburgh and an Honorary Consultant in Palliative Care at the Western General Hospital in Edinburgh, Scotland. She leads a large portfolio of multicentre clinical trials in Palliative Care of which three are CRUK-funded.

There is an increasing pharmacological armamentarium to manage cancer pain and this gives us an opportunity to optimize analgesia while minimizing adverse effects.  While this has always been an important aim, this is of increasing importance on the background of patients living with cancer for longer periods of time.  Improved oncological therapies, particularly palliative chemotherapy, have meant that in some cases cancer has almost become a chronic illness.

Opioids remain key in cancer pain management and avoiding and managing opioids-related side-effects has been an ongoing challenge.  The common side-effects of chronic opioid use are sedation and nausea/vomiting which, if they occur, usually resolve within days of either starting treatment or increasing opioid dose. However dry mouth and constipation, the other two major side-effects, are usually ongoing problems.  Constipation secondary to opioid medication is usually associated with abdominal bloating and sometimes nausea.  Management of these symptoms is not always easily achieved with currently available laxatives, with some patients finding the laxatives also have side-effects.  Cases describing patients with difficult to manage constipation secondary to opioids will be presented along with descriptions of effects of switching to prolonged release oxycodone in combination with prolonged released naloxone.  Oral prolonged release naloxone will clearly bind with higher affinity to peripheral gut opioid receptors than oxycodone, while oxycodone will be unchanged by first pass metabolism, naloxone will be broken down by the liver and will not have any systemic effects on opioid efficacy.

There will be an opportunity for discussion on the appropriate use of prolonged release oxycodone/naloxone in patients with chronic cancer pain.