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. 2012 Apr 27;7(2):113–120. doi: 10.1159/000338579

Table 3.

Eleven basic rules for management of pain due to bone metastases

  • 1.

    Rule out non-cancer related causes of pain! (E.g.: gastritis, urinary tract infection, pathologic fractures, myocardial infarction)

  • 2.

    Consider radiotherapy in local bone (somatic nociceptive-) pain. Gold standard in combination with pharmacologic pain management

  • 3.

    Consider radionuclids (e.g. samarium) in diffuse or multilocal bone pain.

  • 4.

    Opioid therapy:

    • 4.1.

      If pain is moderate to severe: initiate opioid therapy according to WHO step III

    • 4.2.

      Start with potent pure μ agonist (e.g. morphine, hydromorphone, fentanyl, oxycodone)

    • 4.3.

      Provide both a baseline (‘regular’ or ‘scheduled’) opioid (e.g. SR morphine or SR hydromorphone) and on demand (rescue) opioid medication (e.g. immediate release morphine or rapid onset fentanyl)

    • –

      Dosing of immediate release opioids: 1/6th or less than the daily dose of the baseline opioid

    • –

      Beware of strict dose ‘calculation’ in case of high doses of baseline opioid and if baseline opioid is provided as transdermal opioid

    • –

      Dosing of rapid onset fentanyl: start with lowest available dose, be prepared for rapid dose increase

    • 4.4.

      Adjust baseline opioids according to temporal pattern of pain; e.g.: If pain is higher during day, provide double morning dose of SR opioid

    • 4.5.

      Identify breakthrough pain (pain episodes, pain attacks)

    • –

      Identify triggers (e.g. physical activity)

    • –

      Educate patient to take on demand opioid in advance (e.g. 30 min before taking physical activity)

    • –

      If pain episodes need fast onset of analgesia: rapid onset fentanyl (nasal/buccal)

    • 4.6.

      In case of dose escalation (>240 mg morphine/day) without suffient pain relief: consider opioid rotation

    • –

      Calculate carefully, start with low doses but provide enough on-demand opioid medication

  • 5.

    Identify concomitant neuropathic pain

    • Initiate and titrate coanalgetic (e.g. pregabalin with anxiolytic effect)

  • 6.

    Identify other factors that contribute to ‘total pain’

    • –

      Other symptoms (e.g. dyspnoea, anxiety, depression)

    • –

      Psychosocial domain (feeling of left alone, no communication about disease, feeling urged to ‘fight’)

    • –

      Spiritual burden (e.g. feeling of guilt)

    • –

      Existential suffering (hopelessness, wish for hastening death, meaninglessness of life)

  • 7.

    Advanced cancer: consider indication for glucocorticoids (e.g. dexamethasone 4 mg/d)

  • 8.

    Provide non-opioid in a fixed, regular basis; e.g. dipyrone (metamizole, novaminsulfone) 2.5–5 g/d, ibuprofen 1,200–1,800 mg/d

  • 9.

    Always check bisphosphonate therapy even if patient is ‘pain free’ or in early stage of the disease

  • 10.

    Advanced disease: consider support of palliative care service

  • 11.

    Invasive procedures (e.g. neuroaxial ananaesthesia): rarely necessary but important option

SR: Sustained-release.