**9.6 Analgesics**

Both opioid and non-opioid analgesics are recommended for the symptomatic treatment of pain. Clinical trials show that bisphosphonate therapy improves pain control and allows most patients to use lower opioid doses; however, bisphosphonates should be viewed as adjunctive for pain control because nearly all patients will require analgesics.

In patients with mild pain, non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are acceptable agents to use. Acetaminophen is preferred in patients with thrombocytopenia, renal dysfunction, those receiving nephrotoxic agents, or at risk for gastrointestinal bleeds. In patients with liver dysfunction, NSAIDs are preferred for mild pain (Wadhwa VK, et al., 2008).

Since most patients experience moderate to severe pain, opioid analgesics often are used. Patients naïve to opioid therapy should begin with low doses of immediate release agents (typically 5-15 mg orally morphine or 2-4 mg intravenous morphine) and reassessed every 1 to 2 hours for effect. After 24 hours of pain control on a short-acting regimen, patients should be converted to a long-acting agent such as sustained release morphine, oxycodone, fentanyl, or methadone for basal control. Patients who are opioid tolerant should begin with higher doses of short-acting agents; if they are on a long-acting product, this should be continued, increasing the dose as needed to account for short-acting opioid use. A similar approach should be taken in patients initiating opioid therapy as an outpatient, with a shortacting opioid available every 3 to 4 hours and close follow-up. A bowel regimen with a stimulant plus stool softener should be initiated to prevent constipation from opioid use. The National Comprehensive Cancer Network (NCCN) provides a useful guideline for pain management in cancer patients (Coleman RE, 2004).

Adjunct agents such as anticonvulsants (gabapentin, lamotrigine, topiramate), tricyclic antidepressants (amitriptyline, imipramine, desipramine, nortriptyline), venlafaxine, duloxetine, or topical analgesics (lidocaine or capsaicin) may also help to reduce neuropathic pain caused by nerve compression (Cole J, et al., 2008).
