Clinicians may prescribe a trial of opioids in carefully selected patients with chronic pain who do not respond to more conservative management and who continue to experience pain-related distress or functional impairment.

— Judith A. Paice, PhD, RN, and colleagues

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As reported in the Journal of Clinical Oncology by Judith A. Paice, PhD, RN, of Northwestern University, and colleagues, ASCO has released a clinical practice guideline on management of chronic pain in survivors of adult cancers.¹ The guideline was based on literature review by an expert panel, with a total of 63 studies forming the evidentiary basis for the recommendations. The panel was co-chaired by Dr. Paice; Michael Levy, MD, PhD, of Fox Chase Cancer Center; and Eduardo Bruera, MD, of MD Anderson Cancer Center. The guidelines are aimed at clinicians who provide care to cancer survivors. Due to limited high-quality evidence, many of the recommendations are based on expert consensus. Key recommendations are summarized/reproduced here.

Screening and Comprehensive Assessment

Clinicians should:

• Screen for pain at each encounter. Screening should be performed and documented using a quantitative or semiquantitative tool.
• Conduct an initial comprehensive pain assessment. Assessment should include an in-depth interview that explores the multidimensional nature of pain (pain descriptors; associated distress; functional impact; and related physical, psychological, social, and spiritual factors) and captures information about cancer treatment history and comorbid conditions, psychosocial and psychiatric history (including substance use), and prior treatments for the pain. The assessment should characterize the pain, clarify its cause, and make inferences about pathophysiology. Physical examination should accompany the history, and diagnostic testing should be performed when warranted.
• Be aware of chronic pain syndromes resulting from cancer treatments, prevalence of these syndromes, risk factors for individual patients, and appropriate treatment options.
• Evaluate and monitor for recurrent disease, second malignancy, or late-onset treatment effects in any patient who reports new-onset pain.

Treatment and Care Options

Clinicians should:

• 2.1. Aim to enhance comfort, improve function, limit adverse events, and ensure safety in the management of pain.
• 2.2. Engage patient and family/caregivers in all aspects of pain assessment and management.
• 2.3. Determine the need for other health professionals to provide comprehensive pain management care in patients with complex needs. If deemed necessary, the clinician should define who is responsible for each aspect of care and refer patients accordingly.
• Nonpharmacologic Interventions
• 2.4. Clinicians may prescribe directly or refer patients to other professionals to provide interventions to mitigate chronic pain or improve pain-related outcomes. These interventions must take into consideration preexisting diagnoses and comorbidities.

Pharmacologic Interventions—Miscellaneous Analgesics

• 2.5. Clinicians may prescribe the following systemic nonopioid analgesics and adjuvant analgesics to relieve chronic pain and/or improve function in patients with no contraindications including serious drug-drug interactions: nonsteroidal anti-inflammatory drugs; acetaminophen (paracetamol); and adjuvant analgesics, including selected antidepressants and selected anticonvulsants with evidence of analgesic efficacy (such as the antidepressant duloxetine and the anticonvulsants gabapentin and pregabalin) for neuropathic pain conditions or chronic widespread pain.

(Qualifying statement: The panel acknowledges that many other systemic nonopioids, including many other antidepressants and anticonvulsants, drugs in many other classes (such as the so-called muscle relaxants, benzodiazepines such as clonazepam, N-methyl-D-aspartate receptor blockers such as ketamine, and α-2 agonists such as tizanidine), and varied neutraceutical and botanicals marketed as complementary or alternative medicines, are taken by some patients and may benefit some of them. However, the efficacy of these agents and their long-term effectiveness have not been established.)

• 2.6. Clinicians may prescribe topical analgesics (such as commercially available nonsteroidal anti-inflammatory drugs; local anesthetics; or compounded creams/gels containing baclofen, amitriptyline, and ketamine) for the management of chronic pain.
• 2.7. Corticosteroids are not recommended for long-term use in cancer survivors solely to relieve chronic pain.
• 2.8. Clinicians should assess the risks of adverse effects of pharmacologic therapies, including nonopioids, adjuvant analgesics, and other agents used for pain management.
• 2.9. Clinicians may follow specific state regulations that allow access to medical cannabis or cannabinoids for patients with chronic pain after a consideration of the potential benefits and risks of the available formulations.

(Qualifying statement: Currently, 23 states and the District of Columbia allow for medical cannabis, although it is illegal on the federal level. There is insufficient evidence to recommend medical cannabis for the first-line management of chronic pain in cancer survivors. However, evidence suggests it is worthy of consideration as an adjuvant analgesic or in the management of refractory pain conditions. There is also insufficient evidence to recommend one particular preparation of cannabis over another, and the U.S. Food and Drug Administration has not approved any drug product containing or derived from botanical marijuana.)

Pharmacologic Interventions—Opioids

• 2.10. Clinicians may prescribe a trial of opioids in carefully selected patients with chronic pain who do not respond to more conservative management and who continue to experience pain-related distress or functional impairment. Nonopioid analgesics and/or adjuvants can be added as clinically necessary.
• 2.11. Clinicians should assess the risks of adverse effects of opioids used for pain management.

(Qualifying statement: Although there is literature describing dysimmune effects and tumor-proliferative effects from opioid drugs (both of which may be of particular concern in the cancer survivor population), there is insufficient evidence to determine whether there are clinically important risks. The expert panel believes that further clinical investigation is required to assess these concerns. Physicians should be made aware of these evolving questions, and patients and their families may be informed about them as part of a discussion of the potential harms of long-term opioid therapy.)

Risk Assessment, Mitigation, and Universal Precautions With Opioid Use

Clinicians should:

• 3.1. Assess the potential risks and benefits when initiating treatment that will incorporate long-term use of opioids.
• 3.2. Clearly understand terminology such as tolerance, dependence, abuse, and addiction as it relates to the use of opioids for pain control.
• 3.3. Incorporate a universal precautions approach to minimize abuse, addiction, and adverse consequences of opioid use such as opioid-related deaths. Clinicians should be cautious in co-prescribing other centrally acting drugs, particularly benzodiazepines.
• 3.4. Understand pertinent laws and regulations regarding the prescribing of controlled substances.
• 3.5. Educate patients and family members regarding the risks and benefits of long-term opioid therapy and the safe storage, use, and disposal of controlled substances. Clinicians are encouraged to address possible myths/misconceptions about medication use and should educate patients about the need to be cautious when using alcohol or sedating over-the-counter medications or in receiving centrally acting medications from other physicians.
• 3.6. If opioids are no longer warranted, clinicians should taper the dose to avoid abstinence syndrome. The rate of tapering and the use of co-therapies to reduce adverse effects should be individualized for each patient. ■

Disclosure: For full disclosures of the study authors, visit www.jco.ascopubs.org.

Reference

1. Paice JA, Portenoy R, Lacchetti C, et al: Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 34:3325-3345, 2016.