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Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®): Supportive care - Health Professional Information [NCI] - Orofacial Pain in Cancer Patients

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Topical benzydamine (not available in the United States), an anti-inflammatory and analgesic/anesthetic agent, has been shown in randomized controlled studies to reduce pain in oral mucositis and reduce the need for systemic analgesics.[2] Other topical approaches include the following:

  • A single application of topical doxepin, a tricyclic antidepressant, in cancer patients produces analgesia for 4 hours or longer.[1] Besides producing an extended period of pain relief, application of topical doxepin to damaged mucosa is not accompanied by burning.
  • Topical morphine has been shown to be effective for relieving pain,[1] but there is concern about dispensing large volumes of the medication.
  • Topical fentanyl prepared as lozenges administered in a randomized placebo-controlled study showed relief of oral mucositis pain.
  • Topical capsaicin has been studied for the control of oral mucositis pain [3] but is poorly tolerated by patients. Pretreatment initiation of capsaicin may represent an approach to desensitize patients before the onset of mucositis.

Topical coating agents may reduce pain in mucositis. Coating agents such as sucralfate may have a role to play in mucosal pain management but not in reducing tissue damage.

Systemic medications

Pain management strategies directed at diagnoses and pain mechanisms include the following:

  • Topical anesthetics/analgesics.
    • Topical before systemic therapies; if topicals are effective, continue while adding systemic analgesics.
  • Systemic analgesics.
  • Adjuvant medications (muscle relaxants, anti-inflammatories, antianxiety medications, antidepressants, anticonvulsants).
  • Adjuvant therapies (physiotherapy, relaxation, cognitive-behavioral therapies, counseling).
  • Palliative radiation therapy.

Additional and nonpharmacologic pain management techniques in oncology include the following:

  • Transcutaneous electrical nerve stimulation.
  • Cold/moist heat applications.
  • Hypnosis.
  • Acupuncture.
  • Psychological approaches:
    • Distraction.
    • Relaxation/imagery.
    • Cognitive/behavioral therapy.
    • Music therapy, drama therapy.
    • Counseling.

Suggestions for the use of opioids in cancer pain include the following:

  • Use the lowest effective dose.
  • Base time-contingent prescription on drug characteristics.
  • Provide analgesics for breakthrough pain.
  • Combine with nonopioid analgesics.
  • Provide prophylaxis/treatment for constipation.
  • Conduct regular pain assessment and modify management, depending on pain control.
  • Follow steps in World Health Organization (WHO) analgesic ladder.

The WHO analgesic ladder is a three-step strategy for managing pain in cancer patients.[4] Pain management must be directed at the severity of pain; the lowest dose of strong opioids (step 3 in the WHO ladder) may be chosen instead of weak opioids for better pain control.[5,6]

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