A new ASCO guideline on opioids in managing pain from cancer or cancer treatment in adults provides recommendations on administering them in the midst of interventions to address the public health crisis from their misuse and related deaths across the country.1
Eduardo Bruera, MD
“ASCO took wonderful leadership in saying that this is part of cancer medicine. Opioids are as much part and parcel of cancer treatment [as] immunotherapy or chemotherapy,” said Eduardo Bruera, MD, of The University of Texas MD Anderson Cancer Center, and Co-Chair of the Guideline Expert Panel.
Opioids and Cancer Pain
Opioids are a mainstay for many patients with cancer because pain from both the disease and treatment is common. Overall, approximately 55% of patients receiving active treatment experience pain, with that number rising to about 66% in individuals with advanced disease.2
“Pain can be associated with the tumor or with cancer treatment, and given that cancer is generally a disease of older ages, pain can often be related to arthritis or other painful syndromes associated with the aging process,” said Judith A. Paice, PhD, RN, of the Northwestern University Feinberg School of Medicine, and Co-Chair of the Guideline Expert Panel.
Much of the national attention on opioids has focused on the crisis of addiction and death, which the U.S. Department of Health & Human Services (HHS) declared to be a public health emergency in 2017. According to HHS, 10.1 million Americans misused prescription opioids in 2019, and 1.6 million had a use disorder.3
Judith A. Paice, PhD, RN
This has led to concerns among patients about being stigmatized for taking opioids or becoming addicted. Interventions to address this epidemic also have made it more difficult for patients with cancer to receive opioids, with access issues occurring even after the opioid is prescribed.4,5
“Opiates are very old drugs that normally should be inexpensive, but the manufacturers have charged extremely high amounts, and the insurance companies don’t want to pay for that. So, the patients are stuck somehow in the middle,” Dr. Bruera said.
The panel researched published scientific literature from 2010 to 2022 that included 31 systematic reviews and 16 randomized controlled trials on the efficacy and safety of opioids in cancer, along with treatment, prevention, and management. As they conducted their review, the guideline panel asked seven questions to formulate their recommendations.
“The very first recommendation answers the question, ‘when should opioids be used?’ Clearly, opioids are indicated in individuals with moderate-to-severe pain related to cancer or its treatment. Even in some people with mild pain, but who are unable to take nonopioid analgesics, low-dose opioids may be warranted,” Dr. Paice said.
In addition to recommending that opioids approved by the U.S. Food and Drug Administration be offered to patients with moderate to severe pain related to cancer unless contraindicated, the guideline also calls for clinicians, patients, and caregivers to discuss expectations and concerns. This should include education and strategies related to adverse effects, along with how the care team will monitor and manage these effects if they occur.
“Making patients aware that there might be some constipation and occasional nausea, and how they will treat those, are a wonderfully simple way oncology teams can address pain while also reassuring patients that what they’re doing is the right thing to do,” Dr. Bruera said.
The guideline recommends that opioids begin at the lowest possible dose to achieve acceptable analgesia and meet patient goals. The opioids should be immediate-release, fast-acting, short-lasting, and administered on an as-needed basis, followed by early assessment. For patients with a substance use disorder, clinicians should work with a palliative care, pain, and/or substance use disorder specialist.
“The topline message to me is that clinicians should start appropriate patients on an opioid as needed for the first week or 10 days to see if they need it regularly,” Dr. Bruera said. “If they do, they can then move on to a regular medication around the clock to prevent the pain and receive an immediate release dose for breakthrough pain when needed.”
Looking to the Future
The guideline also notes where evidence was limited and where the panel had to rely on consensus for these recommendations or could not yet make a recommendation. Dr. Paice said that citing these gaps in the literature and science “will serve as a road map for future investigators and potentially for future guidelines.”
“There are a lot of questions about health disparities and how we treat cancer survivors and older adults who have noncancer-related pain but are undergoing cancer treatment,” she added. “There are even some more fundamental questions, such as the differences between each opioid.”
1. Paice JA, Bohlke K, Barton D, et al: Use of opioids for adults with pain from cancer or cancer treatment: ASCO guideline. J Clin Oncol. December 5, 2022 (early release online).
2. van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, et al: Update on prevalence of pain in patients with cancer. J Pain Symptom Manage 51:1070-1090.e9, 2016.
3. Substance Abuse and Mental Health Services Administration: 2019 National Survey of Drug Use and Health Releases. Available at https://www.samhsa.gov/data/release/2019-national-survey-drug-use-and-health-nsduh-releases. Accessed January 10, 2023.
4. Schenker Y, Hamm M, Bulls HW, et al: This is a different patient population. JCO Oncol Pract 17:e1030-e1037, 2021.
5. Paice JA. Cancer pain management and the opioid crisis in America. Cancer 124:2491-2497, 2018.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, December 7, 2022. All rights reserved.