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Cancer Pain

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

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  • Cancer pain affects 60–70% of patients during treatment and up to 90% with advanced disease; it is multifactorial — arising from the tumour itself, anticancer treatment, or comorbid illness.
  • Assess using a validated tool (e.g., Edmonton Symptom Assessment System–revised, Brief Pain Inventory) and document pain character, intensity, mechanism (nociceptive, neuropathic, mixed), functional impact, and psychosocial contributors.
  • The WHO analgesic ladder (non-opioids → weak opioids → strong opioids ± adjuvants) remains a useful framework, but modern practice favours individualised multimodal analgesia from the outset.
  • First-line strong opioids for moderate-to-severe cancer pain include oral morphine (immediate- and modified-release), oxycodone, and hydromorphone — titrate to effect and prescribe regular laxatives concurrently.
  • Fentanyl transdermal patches are appropriate only when opioid requirements are stable; they are NOT suitable for opioid-naïve patients or rapidly escalating pain.
  • Chemotherapy-induced peripheral neuropathy (CIPN) is a dose-limiting toxicity of platinum agents, taxanes, vinca alkaloids, bortezomib, and thalidomide; duloxetine is the only agent with level-one evidence for treatment.
  • Bone metastases causing pain respond well to radiotherapy (single 8 Gy fraction equally effective), bisphosphonates (zoledronic acid) or denosumab, and corticosteroids for acute flare.
  • Breakthrough (incident) pain requires short-onset opioid rescue doses of 10–20% of the total 24-hour opioid dose, given every 30–60 minutes as needed.
  • Opioid rotation (switching) may improve efficacy or reduce adverse effects — convert at 50–75% of the equianalgesic dose and re-titrate.
  • Adjuvant analgesics — corticosteroids (dexamethasone), gabapentinoids, antidepressants, and nerve blocks — are essential components of a multimodal regimen, especially for neuropathic and bone pain.
  • Specialist palliative care referral should be considered early; timely referral improves pain control, quality of life, and survival in advanced cancer.
  • Aboriginal and Torres Strait Islander Australians experience higher cancer mortality and later presentation, compounded by barriers to culturally safe pain management and palliative care access in remote communities.

Introduction & Australian Epidemiology

Cancer pain is one of the most feared and prevalent symptoms experienced by people living with cancer. It may arise from direct tumour invasion, anticancer treatments (surgery, chemotherapy, radiotherapy, immunotherapy), or concurrent comorbid conditions. Effective pain management is a core component of cancer care and a right of every patient.

In Australia, over 160,000 new cancer diagnoses are made annually (Australian Institute of Health and Welfare [AIHW], 2023). Approximately 60–70% of patients undergoing active treatment report clinically significant pain, rising to 80–90% in advanced or metastatic disease (Currow et al., 2020). Despite guideline-recommended approaches, undertreatment remains common — a 2021 Australian survey found that nearly one-third of patients with cancer-related pain rated their pain as inadequately controlled (Luckett et al., 2021).

Australia's opioid regulatory framework (including real-time prescription monitoring via SafeScript systems) has improved safety but may inadvertently create barriers to timely opioid access for patients with genuine cancer pain. Clinicians must balance responsible prescribing with the imperative to treat suffering.

This article covers the assessment and management of cancer-related pain, treatment-related pain, the rational use of opioids, and chemotherapy-induced peripheral neuropathy, with emphasis on Australian guidelines, PBS-listed therapies, and equitable access for underserved populations.

Opioids in Cancer Pain

Opioids are the mainstay of moderate-to-severe cancer pain management. They are effective, titratable, and appropriate at all stages of disease when used according to evidence-based principles. Concerns about addiction should not prevent adequate pain treatment in the cancer setting.

Initiation and Titration

1
Assess pain
Confirm moderate-to-severe pain (NRS ≥ 4/10) inadequately controlled by non-opioids and adjuvants. Document mechanism and functional impact.
2
Choose first-line opioid
Oral morphine immediate-release (IR) is the standard starting opioid in Australia. Start at 5–10 mg PO every 4 hours (opioid-naïve adults). Use 2.5 mg in elderly or frail patients.
3
Prescribe breakthrough rescue dose
10–20% of the total 24-hour morphine dose, given every 30–60 minutes PRN. If breakthrough doses are needed ≥ 3 times/day, increase the regular dose.
4
Titrate to effect
Increase by 30–50% every 24–48 hours until pain is controlled or dose-limiting adverse effects occur. There is no maximum dose — titrate to analgesic effect.
5
Convert to modified-release
Once 24-hour requirements are stable, convert to modified-release (MR) opioid (e.g., Kapanol®, MS Contin®) with IR for breakthrough.

Opioid Drug Cards

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Morphine (Immediate-Release)
Sevredol® · Oramorph® · Oral solution · Strong opioid
Adult dose 5–10 mg PO every 4 hours; titrate by 30–50% every 24–48 h
Paediatric dose 0.2–0.4 mg/kg PO every 4 hours (palliative care guidance)
Renal adjustment eGFR <30: reduce dose by 50%, extend interval to every 6–8 h; active metabolites (M6G) accumulate — consider hydromorphone
Hepatic adjustment Reduce dose by 50% in severe hepatic impairment
PBS status ✔ PBS General Benefit for cancer pain
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Morphine (Modified-Release)
Kapanol® · MS Contin® · Strong opioid
Adult dose 10–30 mg PO every 12 hours (or equivalent daily dose converted from IR); titrate every 48–72 h
Renal adjustment Avoid MR formulations in eGFR <30 — use IR morphine at reduced dose or switch to hydromorphone
PBS status ✔ PBS General Benefit (Authority Required for some strengths ≥60 mg)
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Oxycodone (Immediate-Release)
OxyNorm® · Endone® · Strong opioid
Adult dose 5–10 mg PO every 4–6 hours; titrate by 30–50% every 24–48 h
Renal adjustment Reduce starting dose by 50% in eGFR <30; titrate cautiously
PBS status ✔ PBS General Benefit
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Oxycodone/Naloxone (MR)
Targin® · Strong opioid + peripherally-acting opioid antagonist
Adult dose 10/5 mg PO every 12 hours (starting); titrate oxycodone component. Maximum naloxone 80/40 mg/12 h
Key advantage Reduced opioid-induced constipation; may avoid need for laxatives in some patients
PBS status ⚠ PBS Authority Required
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Hydromorphone
Jurnista® (MR) · Dilaudid® (IR) · Strong opioid
Adult dose (IR) 1–2 mg PO every 4 hours (opioid-naïve); 1.3 mg hydromorphone ≈ 10 mg oral morphine
Renal adjustment Preferred opioid in severe renal impairment (eGFR <15) — no active metabolites; start at low dose and titrate
PBS status ⚠ PBS Authority Required
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Fentanyl Transdermal Patch
Durogesic® · DTrans® · Strong opioid
Adult dose 12 mcg/h patch every 72 hours (minimum starting dose); convert from stable oral opioid dose using equianalgesic tables. NOT for opioid-naïve patients.
Key considerations Delayed onset (12–24 h to peak effect); avoid in unstable or rapidly escalating pain; risk of toxicity with fever or heat application (↑ absorption). Breakthrough analgesia must be provided with oral IR opioid.
PBS status ⚠ PBS Authority Required (cancer pain indication)
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Methadone
Physeptone® · Strong opioid with NMDA antagonist activity
Adult dose 2.5–5 mg PO every 8–12 hours (opioid-naïve); complex pharmacokinetics — long and variable half-life (15–60 h); specialist initiation recommended
Key considerations Useful for neuropathic cancer pain (NMDA antagonism), opioid rotation, renal failure. Risk of QTc prolongation — baseline ECG required. Complex equianalgesic ratios — do not use standard conversion tables.
PBS status 🔒 S8 — State/Territory authority
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Tapentadol (MR)
Palexia® · Dual mechanism (μ-opioid agonist + NRI)
Adult dose 50 mg PO every 12 hours (initial); titrate by 50 mg every 3–7 days; maximum 500 mg/day
Key considerations May be useful in mixed nociceptive-neuropathic pain; lower incidence of constipation and nausea compared with traditional opioids; limited evidence in severe cancer pain
PBS status ⚠ PBS Authority Required

Opioid Adverse Effects and Management

Adverse Effect Incidence Management
Constipation ~100% (no tolerance develops) Start regular laxative at opioid initiation — senna + docusate (Senokot D®) or macrogol (Movicol®); add naloxegol (Moventig®) if refractory
Nausea / vomiting ~30–40% (tolerance develops in 5–7 days) Metoclopramide 10 mg TDS or haloperidol 0.5–1 mg nocte; reassess at 1 week
Drowsiness / sedation ~20–30% (tolerance develops in 3–5 days) Reduce dose, consider opioid rotation, rule out delirium; avoid routine use of psychostimulants
Respiratory depression Rare at titrated doses Naloxone 0.04–0.4 mg IV/IM/SC; titrate to respiratory improvement (not full reversal to avoid precipitated pain crisis)
Pruritus ~5–15% Low-dose nalbuphine 2.5 mg IV or antihistamine; consider opioid rotation
Myoclonus ~5–10% (dose-related) Clonazepam 0.5–1 mg or midazolam 2.5–5 mg SC; reduce dose or rotate opioid
Hyperalgesia Uncommon (dose-related) Reduce opioid dose, rotate opioid, add ketamine infusion (specialist setting) or methadone

Opioid Rotation (Switching)

Opioid rotation involves switching from one opioid to another to improve the therapeutic ratio (better analgesia or fewer adverse effects). In cancer pain, opioid rotation is required in approximately 20–30% of patients.

  • Calculate the total 24-hour opioid dose of the current opioid.
  • Use an equianalgesic dose table (e.g., Palliative Care Australia or eTG) to determine the equivalent dose of the new opioid.
  • Reduce the calculated equianalgesic dose by 25–50% to account for incomplete cross-tolerance.
  • Initiate the new opioid and titrate to effect over 24–48 hours.
  • Provide IR rescue opioid (of the NEW opioid) for breakthrough pain.
  • Specialist advice is recommended when rotating to or from methadone due to complex pharmacokinetics.
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Fentanyl patches — NOT for opioid-naïve patients. Fentanyl transdermal patches must only be used when opioid requirements are stable and known. Applying a patch to an opioid-naïve patient carries a risk of fatal respiratory depression. Always use oral morphine or oxycodone to establish requirements first.

Chemotherapy-Induced Peripheral Neuropathy (CIPN)

Chemotherapy-induced peripheral neuropathy (CIPN) is a dose-limiting, often persistent adverse effect affecting 30–70% of patients receiving neurotoxic chemotherapy. It is a major cause of treatment dose reductions, delays, and discontinuation, and can significantly impair quality of life for months to years after treatment completion.

Causative Agents

Drug Class Examples Pattern of Neuropathy Typical Onset
Platinum agents Cisplatin, oxaliplatin, carboplatin (high dose) Sensory > motor; length-dependent; "stocking-glove"; oxaliplatin: acute cold-triggered paraesthesia (within hours of infusion) Cumulative; cisplatin typically after 300+ mg/m² total dose
Taxanes Paclitaxel, docetaxel Sensory predominant; painful paraesthesias in feet/hands; may include myalgia/arthralgia Often after first cycle; cumulative dose-related
Vinca alkaloids Vincristine Mixed sensorimotor; autonomic (constipation, ileus); foot/wrist drop Cumulative; usually after 4+ cycles
Proteasome inhibitors Bortezomib, carfilzomib, ixazomib Small-fibre predominant; severe burning pain; may be debilitating Early — often within first 2–4 cycles
Immunomodulatory drugs Thalidomide Sensory; may be irreversible at high cumulative doses Cumulative; dose-dependent
Epothilones Ixabepilone Sensory; similar to taxanes Cumulative

Clinical Features and Assessment

  • Symmetrical, length-dependent sensory neuropathy: paraesthesias, numbness, burning pain, allodynia, loss of proprioception and vibration sense.
  • Motor involvement (less common): distal weakness, foot drop (vincristine), fine motor impairment.
  • Autonomic neuropathy: constipation, orthostatic hypotension, urinary retention (vincristine, thalidomide).
  • Assessment: Total Neuropathy Score (TNS) or NCI-CTCAE grading; patient-reported outcomes (FACT/GOG-Ntx); nerve conduction studies for diagnostic confirmation.

Treatment of CIPN

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Evidence summary: Prevention of CIPN remains elusive — no agent has shown reliable efficacy for primary prophylaxis in high-quality RCTs. Treatment is focused on symptom management and dose modification of the causative agent.
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Duloxetine
Cymbalta® · SNRI antidepressant
Adult dose 30 mg PO daily for 1 week, then 60 mg PO daily. First-line for CIPN — only agent with level-1 evidence (RCT)
Renal adjustment Use with caution in eGFR <30; no specific dose adjustment in product information
PBS status ⚠ PBS Authority Required (depression indication); CIPN indication is off-label
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Gabapentin
Neurontin® · Gabapentin Sandoz® · Gabapentinoid
Adult dose 300 mg PO nocte day 1, then 300 mg BD day 2, then 300 mg TDS day 3; titrate to 600 mg TDS (max 3600 mg/day)
Renal adjustment eGFR 30–59: max 600 mg BD; eGFR 15–29: max 300 mg daily; eGFR <15: 300 mg alternate days
PBS status ⚠ PBS Authority Required
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Pregabalin
Lyrica® · Gabapentinoid
Adult dose 75 mg PO BD, titrate to 150–300 mg BD over 1–2 weeks; max 600 mg/day
Renal adjustment eGFR 30–59: max 300 mg/day in divided doses; eGFR 15–29: max 150 mg/day; eGFR <15: 75 mg/day
PBS status ⚠ PBS Authority Required
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Amitriptyline
Endep® · TCA antidepressant
Adult dose 10 mg PO nocte, titrate by 10 mg weekly to 25–75 mg nocte (lower doses often effective for neuropathic pain)
Key caution Anticholinergic effects; avoid in elderly where possible; ECG if cardiac history (QTc prolongation risk)
PBS status ✔ PBS General Benefit
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Lidocaine 5% Medicated Plaster
Versatis® · Topical anaesthetic
Adult dose Apply up to 3 plasters to affected area for 12 hours on / 12 hours off. Useful for localised CIPN or post-surgical neuropathic pain
PBS status ⚠ PBS Authority Required

Non-Pharmacological Approaches

  • Exercise: Supervised aerobic and resistance exercise programmes reduce CIPN severity and improve function (2023 ASCO guideline update).
  • Cryotherapy/compression therapy: Cryotherapy gloves/socks during taxane and oxaliplatin infusions may reduce CIPN incidence (emerging evidence from RCTs).
  • Scrambler therapy: Transcutaneous electrical nerve stimulation that "scrambles" pain signalling — small studies show benefit in refractory CIPN.
  • Physiotherapy and occupational therapy: Balance training, assistive devices for fine motor impairment, and fall prevention strategies.
  • Acupuncture: Some evidence for symptom reduction; generally well-tolerated; available through integrative oncology services in Australian cancer centres.

Dose Modification and Prevention

  • Grade 2 CIPN (moderate symptoms, limiting instrumental ADLs): consider dose reduction of causative agent (e.g., cisplatin 50% dose reduction; vincristine hold).
  • Grade 3–4 CIPN (severe, limiting self-care ADLs, life-threatening): discontinue causative agent and consider alternative regimen if available.
  • Prevention: calcium/magnesium infusions were previously used for oxaliplatin CIPN prophylaxis but are no longer recommended after the CONcePT trial showed reduced efficacy of chemotherapy; no other agent has proven efficacy for CIPN prevention (ASCO 2020 guideline).

Multimodal Analgesia & Adjuvant Therapies

Optimal cancer pain management employs a multimodal approach, combining analgesic classes with different mechanisms to achieve synergistic pain relief while minimising opioid-related adverse effects.

Non-Opioid Analgesics

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Paracetamol
Panadol® · Panadol Osteo® · Non-opioid analgesic
Adult dose 1 g PO every 4–6 hours (max 4 g/day; 2 g/day if ≤50 kg or hepatic impairment)
PBS status ✔ PBS General Benefit
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Ibuprofen
Nurofen® · Brufen® · NSAID
Adult dose 200–400 mg PO TDS-QID with food; useful for bone pain, soft-tissue inflammation, and bone metastases
Key considerations Gastroprotection with PPI required; caution in renal impairment, heart failure, anticoagulation. Shortest effective duration.
PBS status ✔ PBS General Benefit
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Dexamethasone
Decadron® · Corticosteroid
Adult dose 4–8 mg PO/IV daily for acute cancer pain syndromes (bone pain, nerve compression, raised ICP, lymphoedema, bowel obstruction); taper when stable
Key considerations Rapid onset (6–24 h); reduces oedema around tumour; use lowest effective dose; monitor glucose, GI prophylaxis with PPI
PBS status ✔ PBS General Benefit

Bone-Targeted Therapies for Bone Metastases

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Zoledronic Acid
Zometa® · Bisphosphonate
Adult dose 4 mg IV over ≥15 minutes every 3–4 weeks. Requires dental review prior to initiation (risk of osteonecrosis of the jaw).
Renal adjustment SCr <1.4 mg/dL: 4 mg; SCr 1.4–2.4: reduce dose; SCr >2.4: avoid. eGFR <30: generally avoid or specialist decision.
PBS status ⚠ PBS Authority Required
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Denosumab
Xgeva® · RANKL monoclonal antibody
Adult dose 120 mg SC every 4 weeks. No renal dose adjustment required (advantage over bisphosphonates). Supplement with calcium and vitamin D.
Key considerations Risk of rebound hypercalcaemia on discontinuation — transition to zoledronic acid. ONJ risk equivalent to bisphosphonates. Dental review required.
PBS status ⚠ PBS Authority Required

Interventional Pain Management

When systemic analgesia is inadequate or causes intolerable adverse effects, interventional techniques may be considered:

  • Nerve blocks: Coeliac plexus block (pancreatic and upper GI cancer pain — reduces opioid requirements by 50–70%); superior hypogastric plexus block (pelvic cancer pain); ganglion impar block (perineal pain).
  • Neuraxial analgesia: Intrathecal or epidural morphine via implanted pump for refractory cancer pain; enables lower doses with fewer systemic effects.
  • Vertebroplasty/kyphoplasty: For painful vertebral compression fractures due to metastases; rapid pain relief in 70–90% of patients.
  • Palliative radiotherapy: Single-fraction (8 Gy) or multi-fraction radiotherapy for painful bone metastases — 60–80% response rate; single fraction is equally effective for uncomplicated bone metastases (TROG 03.04 / Trans-Tasman trial data).
  • Radium-223 (Xofigo®): For castration-resistant prostate cancer with symptomatic bone metastases — alpha-emitting radiopharmaceutical; improves overall survival and reduces skeletal events. PBS Authority Required.

Non-Pharmacological Interventions

  • Psychological therapies: cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), mindfulness-based stress reduction — all shown to reduce pain intensity and distress in cancer pain.
  • Transcutaneous electrical nerve stimulation (TENS): adjunct for localised somatic pain; non-invasive and patient-controlled.
  • Physiotherapy and exercise: maintains function, reduces pain-related disability; particularly important for bone metastases — supervised exercise with fracture-risk assessment.
  • Complementary therapies: massage, relaxation therapy, music therapy — available through Australian cancer support services; evidence for moderate benefit in symptom relief.

Monitoring & Follow-Up

  • Reassess pain intensity, functional status, and adverse effects at every consultation (minimum weekly during active titration, then every 2–4 weeks when stable).
  • Use standardised pain assessment tools (ESAS-r, BPI) for serial monitoring — enables objective tracking of treatment response.
  • Monitor for opioid adverse effects systematically: constipation (ask at every visit), sedation, cognitive effects, nausea, and pruritus.
  • Reassess renal function (eGFR) regularly when using morphine, gabapentinoids, or NSAIDs — at least monthly in advanced cancer with declining function.
  • Monitor for opioid misuse or aberrant behaviour using clinical observation; routine urine drug screening is not standard in cancer pain management but may be considered in complex cases.
  • Patients on long-term opioids: annual review of ongoing need, efficacy, dose stability, and quality of life; consider trial of dose reduction if pain aetiology has changed.
  • For CIPN: serial assessment using FACT/GOG-Ntx or NCI-CTCAE grading; reassess need for ongoing chemotherapy modification.
  • Patients on bisphosphonates/denosumab: monitor serum calcium, phosphate, renal function (creatinine) before each infusion; dental review every 6 months.
  • Psychosocial screen: depression (PHQ-9), anxiety (GAD-7), and spiritual distress at diagnosis and periodically throughout treatment — refer to psycho-oncology or counselling if identified.
⚠️
SafeScript / Real-Time Prescription Monitoring: Australian states and territories have implemented real-time prescription monitoring (RTPM) systems (e.g., SafeScript in Victoria, ScriptCheck in NSW). These systems flag high-risk Schedule 8 prescribing. Clinicians treating cancer pain should document clinical indication clearly and communicate with community pharmacies to prevent unnecessary barriers to legitimate opioid prescribing. Cancer patients are exempt from some dose thresholds in some jurisdictions — check your state regulations.

Special Populations

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Pregnancy & Breastfeeding

Opioids: Codeine is contraindicated in breastfeeding (risk of infant respiratory depression via CYP2D6 ultra-rapid metaboliser genotype). Morphine is the preferred opioid in pregnancy and breastfeeding — low transfer into breast milk. Oxycodone also acceptable short-term.
NSAIDs: Contraindicated in the third trimester (premature ductus arteriosus closure, oligohydramnios). Avoid ibuprofen after 28 weeks; paracetamol is the preferred non-opioid.
Gabapentinoids: Not recommended in pregnancy (limited safety data; teratogenicity concerns). Pregabalin is category B3 in Australian classification.
Duloxetine: Avoid in pregnancy (limited data; neonatal withdrawal risk). Citalapram or sertraline preferred antidepressants if needed.
Cancer in pregnancy requires multidisciplinary input from obstetric, oncology, and palliative care teams. Pain management must balance maternal wellbeing with fetal safety.
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Paediatrics

Morphine: First-line strong opioid for children. Starting dose: 0.2–0.4 mg/kg PO every 4 hours; titrate to effect. IV/SC: 0.05–0.1 mg/kg every 4 hours. Modified-release formulations available from 6 years.
Fentanyl: Transdermal patches may be used in children ≥2 years with stable opioid requirements. IV fentanyl for procedural pain: 1–2 mcg/kg.
Ketamine: Low-dose sub-anaesthetic ketamine (0.1–0.25 mg/kg/h SC) may be useful for refractory neuropathic pain in children under specialist supervision.
Paediatric cancer pain management should involve a paediatric palliative care team. Age-appropriate pain assessment tools are essential (e.g., Wong-Baker FACES, FLACC scale for pre-verbal children).
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Elderly

Opioids: Start at 50% of standard adult dose (e.g., morphine 2.5 mg IR every 4 hours). Increased sensitivity to CNS effects (sedation, confusion, falls). Polypharmacy increases drug interaction risk.
Amitriptyline: Avoid if possible due to anticholinergic burden (delirium, urinary retention, falls). Use nortriptyline or duloxetine as alternatives.
NSAIDs: Increased risk of GI bleeding, renal impairment, and cardiovascular events. Use lowest dose for shortest duration; co-prescribe PPI.
Gabapentin: Increased sensitivity; start at low dose (100 mg daily) and titrate slowly to avoid dizziness and sedation.
Regular medication review is essential. Use the STOPP/START criteria to identify potentially inappropriate medications. Falls risk assessment should accompany any opioid initiation in elderly cancer patients.
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Renal Impairment

Morphine: Active metabolites (M6G, M3G) accumulate in renal failure → risk of excessive sedation, respiratory depression, myoclonus. AVOID in eGFR <15 mL/min. Reduce dose by 50% in eGFR 15–30.
Hydromorphone: PREFERRED opioid in severe renal impairment — no active metabolites. Start at 50% dose reduction and titrate cautiously.
Fentanyl: Acceptable in renal impairment (hepatic metabolism); transdermal patches may be used if requirements are stable. No active renally-excreted metabolites.
Methadone: Acceptable in renal failure (hepatic elimination); specialist initiation recommended.
Gabapentinoids: Mandatory dose reduction. Pregabalin: eGFR 15–29 → 75–150 mg/day; eGFR <15 → 25–75 mg/day. Dose after dialysis if on haemodialysis.
NSAIDs: Avoid if eGFR <30. Risk of acute kidney injury, fluid retention, and hyperkalaemia.
Denosumab (Xgeva®) does not require renal dose adjustment and is preferred over zoledronic acid when eGFR <30.
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Hepatic Impairment

All opioids: Hepatic metabolism means prolonged half-life and increased bioavailability. Reduce doses by 50% in severe hepatic impairment (Child-Pugh C). Morphine: oral bioavailability increases significantly in cirrhosis — start low.
Paracetamol: Maximum 2 g/day in chronic liver disease.
NSAIDs: Avoid if possible — increased risk of GI bleeding, hepatorenal syndrome, and fluid retention in cirrhosis.
Duloxetine: Contraindicated in severe hepatic impairment.
Patients with liver metastases may have normal hepatic function initially but require regular monitoring as disease progresses.
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Immunocompromised

Infection-related pain: Consider occult infection as a cause of new/worsening pain — particularly herpes zoster, oral candidiasis, and Clostridioides difficile colitis. Screen with relevant investigations.
Corticosteroids: Dexamethasone is commonly used but increases infection risk — monitor for opportunistic infections (PJP, fungal) in patients on concurrent chemotherapy or with lymphopenia.
Neutropenic precautions: Avoid rectal suppositories and NSAIDs in severe neutropenia (ANC <0.5 × 10⁹/L) due to mucosal bleeding and infection risk.
Patients receiving immunotherapy who develop pain should be assessed for immune-related adverse events (irAEs) — inflammatory arthritis, myositis, colitis — as these require specific management with corticosteroids.
Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience a 1.4-fold higher overall cancer incidence and 1.5-fold higher cancer mortality compared with non-Indigenous Australians (AIHW, 2023). Presentation at more advanced stages is more common, contributing to higher symptom burden including pain. Culturally safe, equitable access to cancer pain management and palliative care is a national priority.

Geographic access
Many Aboriginal and Torres Strait Islander people live in remote and very remote areas with limited access to oncology, pain medicine, and palliative care specialists. Telehealth consultations (MBS items 99200, 99210) and Royal Flying Doctor Service (RFDS) retrieval are essential components of equitable cancer care.
Cultural safety
Pain expression and pain concepts may differ from Western biomedical models. Concept of "worry" and holistic understanding of illness must be respected. Aboriginal Health Workers and Aboriginal Liaison Officers are vital in pain assessment and treatment communication. Family-centred models of care align with cultural values.
Palliative care access
Aboriginal and Torres Strait Islander people are significantly under-referred to specialist palliative care. Many prefer to "return to country" for end-of-life care. Community-controlled health organisations (ACCHOs) should be supported with palliative care training, opioid availability, and specialist outreach. The Palliative Care Australia framework for Aboriginal and Torres Strait Islander communities emphasises cultural, spiritual, and family needs.
Opioid access & stigma
Opioid availability may be limited in remote communities due to pharmacy access and regulatory concerns. Opioid stigma (fear of addiction, association with substance use) may prevent patients from accepting appropriate analgesia. Clear, respectful communication about the role of opioids in cancer pain — distinct from non-medical use — is essential.
Comorbidities
Higher prevalence of chronic kidney disease, diabetes, and cardiovascular disease impacts analgesic choice (opioid and NSAID use, renal dose adjustment). Rheumatic heart disease may affect sedation tolerance. Integration of cancer pain management with existing chronic disease management plans is important.
Health literacy & communication
English may be a second or third language for some community members. Interpreter services (Aboriginal Interpreter Service, TIS National) should be used. Written pain management plans should use plain language and visual aids. Radio and community health promotion are effective in remote settings.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Cancer in Australia 2023. AIHW, Canberra; 2023.
  2. 2. Currow DC, Phillips J, Clark K. Using opioids in general practice for chronic non-cancer pain: an overview of current evidence. Med J Aust. 2016;204(8):305–309.
  3. 3. Luckett T, Phillips J, Agar M, et al. Elements of effective palliative care models: a rapid review. BMC Health Serv Res. 2021;21(1):1–15.
  4. 4. Swarm RA, Paice JA, Anghelescu DL, et al. Adult cancer pain, version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2019;17(8):977–1007.
  5. 5. Fallon M, Giusti R, Aielli F, et al. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2018;29(Suppl 4):iv166–iv191.
  6. 6. Hershman DL, Lacchetti C, Dworkin RH, et al. Prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2014;32(18):1941–1967.
  7. 7. Loprinzi CL, Lacchetti C, Bleeker J, et al. Prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers: ASCO guideline update. J Clin Oncol. 2020;38(28):3325–3348.
  8. 8. Smith EM, Pang H, Cirrincione C, et al. Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial. JAMA. 2013;309(13):1359–1367.
  9. 9. Chow E, Zeng L, Salvo N, et al. Update on the systematic review of palliative radiotherapy trials for bone metastases. Clin Oncol (R Coll Radiol). 2012;24(2):112–124.
  10. 10. Portenoy RK, Ahmed E. Cancer pain syndromes: clinical features and diagnosis. In: UpToDate. Wolters Kluwer; 2024.
  11. 11. RACGP. Prescribing drugs of dependence in general practice: Part C2 — The role of opioids in pain management. 3rd edn. Melbourne: RACGP; 2023.
  12. 12. Palliative Care Australia. National Palliative Care Strategy 2018. Canberra: Department of Health; 2018.
  13. 13. Aboriginal and Torres Strait Islander Cancer Framework. Cancer Council Australia / Menzies School of Health Research; 2020.
  14. 14. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd edn. Sydney: ACSQHC; 2021.
  15. 15. Mercadante S, Portenoy RK. Opioid poorly-responsive cancer pain. Part 1: Clinical considerations. J Pain Symptom Manage. 2001;21(2):144–150.
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction
Paracetamol ± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ± calcitonin; DXA + osteoporosis Rx
6–12 weeks healing
Elderly; osteoporosis; acute onset
ACS (posterior MI)
Aspirin 300 mg, GTN, heparin; urgent PCI
Time-critical
ECG, troponin; CV risk factors
Aortic dissection
IV labetalol; urgent CT aortogram; surgery (Type A)
Time-critical
Tearing pain; BP differential >20 mmHg
Vertebral osteomyelitis
IV antibiotics (vancomycin + ceftriaxone initially); ID consult
6 weeks IV antibiotics
Fever, elevated CRP, IV drug use
Biliary colic / cholecystitis
Paracetamol ± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

📚 References

  1. 1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
  5. 5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
  6. 6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).