How to Manage Cancer Pain When Patients Misuse Opioids

Megan Brooks

July 06, 2022

Opioids remain a staple in pain management for cancer, but there is little guidance around how to treat patients who have a history of opioid misuse.

Recently, a group of palliative and addiction medicine specialists developed strategies to help frontline clinicians manage patients with advanced cancer-related pain and opioid use disorder.

"There is a tendency to ignore treatment of opioid use disorder in advanced cancer patients because people think, 'Oh, this person has bigger fish to fry,' but that’s not a very patient-centric way of looking at things," senior author Jessica Merlin, MD, PhD, with University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, said in a news release.

"We know that opioid use disorder is a really important factor in quality of life, so addressing opioid addiction and prescription opioid misuse in people with advanced cancer is really critical," Merlin added.

The study was published online June 30 in JAMA Oncology.

To improve care for people with advanced cancer and cancer-related pain, the researchers first assessed how clinicians currently treat patients with opioid complexity.

Using an online Delphi platform, the team invited 120 clinicians with expertise in palliative care, pain management, and addiction medicine to weigh in on three common clinical scenarios — a patient with a recent history of untreated opioid use disorder, a patient taking more opioids than prescribed, and a patient using nonprescribed benzodiazepines.

For a patient with cancer and a recent history of untreated opioid use disorder, regardless of prognosis, the panel deemed it appropriate to begin treatment with buprenorphine/naloxone for pain but inappropriate to refer the patient to a methadone clinic. The panel felt that going to a methadone clinic would be too burdensome for a patient with advanced cancer and not possible for those with limited prognoses.

"This underscores the importance of access to [opioid use disorder] treatment in cancer treatment settings, including non-addiction specialists waivered to prescribe buprenorphine/naloxone and addiction specialists for more complex cases," the authors write.

For a patient with untreated opioid use disorder, the panel deemed split-dose methadone (two to three times daily) appropriate in those with limited prognosis of weeks to months but was uncertain about the suitability of this approach for patients with longer prognoses of a year or longer.

The appropriateness of initiating treatment with a full-agonist opioid was considered uncertain for a patient with limited prognosis and inappropriate for a patient with longer prognosis.

For a patient with cancer pain and no medical history of opioid use disorder but taking more opioids than prescribed, regardless of prognosis, the panel felt it was appropriate to increase monitoring and inappropriate to taper opioids. The panel was not certain about whether to increase opioids based on the patient's account of what they need or transition to buprenorphine/naloxone.

For a patient with no history of opioid use disorder who was prescribed traditional opioids for pain and had a positive urine drug test for nonprescribed benzodiazepines, regardless of prognosis, the panel felt it was appropriate to continue opioids with close monitoring and inappropriate to taper opioids or transition to buprenorphine/naloxone.

The researchers say that improving education around buprenorphine and cancer pain management in the context of opioid use disorder or misuse is needed.

In a related editorial, two experts note that the patients considered in this "important article" require considerable time and expertise from an interdisciplinary team.

"It is important that cancer centers establish and fund such teams mainly as a safety measure for these patients and also as a major contribution to the care of all patients with cancer," write Joseph Arthur, MD, and Eduardo Bruera, MD, with The University of Texas MD Anderson Cancer Center in Houston.

In the wider context, Arthur and Bruera highlight how treatments for patients with advanced cancer have evolved over the past three decades, yet patients have continued to be given opioids to address cancer-related pain. Developing more sophisticated drugs that relieve pain without significant side effects or addictive properties is imperative.

Arthur and Bruera say the study authors "appropriately emphasize the value of delivering compassionate and expert care for these particularly complex cases and the importance of conducting research on the best ways to alleviate the suffering in this rapidly growing patient population."

This research was supported by Cambia Health Foundation and the National Institute of Nursing Research. Merlin, Arthur, and Bruera report no relevant disclosures.

JAMA Oncol. Published online June 30, 2022. Abstract.

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