The Implications of Opioid Use in Treating Cancer-Related Pain

Since 1995, approximately 20% of patients with cancer pain who receive opioids are at a higher risk of developing nonmedical opioid use disorders.

In a recent editorial published in JAMA Oncology,¹ authors reviewed the results of a consensus panel on pain management in patients with advanced cancer.² The panel analyzed clinical situations in which patients with cancer-related pain either had a diagnosis of opioid use disorder (OUD) or had nonmedical opioid use behaviors. The investigators then invited a group of clinicians with expertise in palliative care, pain management, and addiction medicine to make recommendations for the course of treatment for these patients.

More than two-thirds of the clinicians already had waivers from the US Drug Enforcement Agency for the prescriptions of buprenorphine. The consensus of the panel was that patients with a recent history of OUD and cancer pain should receive buprenorphine or methadone.

This solution raised several issues. First, oncologists and internists may be unfamiliar with these opioids or the complexity of titration of patients receiving methadone. The authors noted that there is limited understanding of the role of buprenorphine in the management of cancer-related pain. Further, these opioids are also addictive, requiring frequent monitoring.

The possibility of referring a patient to a methadone clinic was fully rejected by the panel of clinicians because of the difficulty of the situation that patients are already experiencing.

In the patients with behaviors of nonmedical opioid use, increased vigilance and support was recommended over referral to a methadone clinic. The Compassionate High Alert Team for example, provides intense interdisciplinary care to patients with nonmedical opioid use in supportive and palliative care and has been shown to dramatically reduce nonmedical opioid use behaviors.

Opioids continue to be the main course of treatment for cancer-related pain. Patients’ risk for developing nonmedical opioid use behaviors was known, but largely ignored when opioid recommendations were issued in the 1990s.

Unfortunately, one result of the opioid epidemic is that patients with cancer-related pain are receiving lower opioid doses. Prescribers are also facing barriers like the Prescription Monitoring Program database, ordering and interpreting urine drug screens, frequent need for prior authorization or refusal from insurers, and inadequate stocks of opioids in pharmacies.

As a result of these barriers, clinicians are decreasing their involvement with opioid management and are referring patients to supportive and palliative teams. These referrals can take weeks or months, leaving patients with cancer in considerable pain.

The rules, regulations, and policies designed to combat the opioid crisis are preventing patients who actually need them from receiving the appropriate opioid prescriptions. Cancer centers need to develop and fund interdisciplinary teams that can provide extra layers of support and help relieve the burden of burned-out oncology teams.

“Our main opportunity is to develop much more sophisticated drugs capable of targeting the nociceptive pathway with minimal or no influence outside that area. Unfortunately, one of the major barriers to achieve new ways of relieving pain and suffering in patients with cancer is the lack of support for research in these important aspects of the cancer care,” the authors concluded.

Reference

1. Arthur J, Bruera E. Managing cancer pain in patients with opioid use disorder or nonmedical opioid use. JAMA Oncol. 2022;8(8):1104–1105.doi:10.1001/jamaoncol.2022.2150