Opioid Use for Patients with Cancer

Sponsoring Organization: American Society of Clinical Oncology (ASCO)

Background

The U.S. Centers for Disease Control and Prevention recently released a major clinical practice guideline for using opioids in patients with chronic pain; however, it specifically excluded patients with cancer (NEJM JW Gen Med Dec 15 2022 and MMWR Recomm Rep 2022; 71:1). Now, a new guideline from ASCO addresses opioid use in patients with cancer. An expert panel used data from systematic reviews and randomized trials to make 13 recommendations for opioid use. Only 3 were evidence-based, and 10 were developed by expert consensus; 3 other topics were identified but had insufficient evidence to make a recommendation.

Key Recommendations

• No specific opioids are recommended over others for either opioid initiation or rotation.
• Opioids should be initiated at the lowest possible dose, starting with as-needed dosing of immediate-release compounds.
• Use of nonopioid agents, particularly nonsteroidal anti-inflammatory drugs, can be continued as needed.
• Insufficient evidence exists to recommend specific ranges of dosage escalation, but increases of 25% to 50% are used commonly.
• Patients with renal or hepatic impairment require particularly close monitoring. Opioids can be selected based on their method of metabolism or excretion (i.e., toxic metabolites might accumulate with morphine use in patients with renal impairment), but evidence is weak to support specific recommendations.
• Breakthrough pain in patients who already are receiving round-the-clock opioids can be managed with immediate-release opioids at a dose of 5% to 20% of the morphine equivalent daily dose. No specific short-acting opioid is recommended.