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Palliative cancer care - oral problems - Management
When should systemic pain relief be used?

  • Treat the underlying cause of oral pain where possible. If this is not possible or not fully effective, treat pain symptomatically.
  • Use systemic analgesia if the person prefers this option or as an alternative/addition to topical analgesia in cases where oral pain is extensive and not controlled by topical analgesia.
  • The choice of systemic analgesia depends on the severity of pain and the benefits compared with risks for the individual person.
    • Mild pain: nonsteroidal anti-inflammatory drug (NSAID) or paracetamol.
    • Mild to moderate pain: full-dose weak opioid plus paracetamol or NSAID.
    • Moderate to severe pain: strong opioid (e.g. morphine) plus paracetamol or NSAID.
  • Seek specialist advice if pain is difficult to manage.
  • See the CKS topic on Palliative cancer care - pain for more information.
Clarification / Additional information
  • Topical treatment is preferred to systemic treatment because of the lower incidence of significant adverse effects. Some drugs have both topical and systemic actions (e.g. dispersible diclofenac).
  • Systemic analgesics are used when topical therapies are inadequate at controlling pain.
  • Oral analgesia is preferred where possible, but if the person cannot eat or drink (e.g. mucositis), consider using a 24-hour continuous subcutaneous infusion of an opioid (e.g. diamorphine). See the CKS topic on Palliative cancer care - pain for further information on starting and titrating oral morphine.
Basis for recommendation
  • The basis of these recommendations is the World Health Organization (WHO) stepped guide to pain management [WHO, 1996; WHO, 2003].

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