Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review (original) (raw)
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A systematic review of randomized trials on the effectiveness of opioids for cancer pain
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In all recommended guidelines put forth for the treatment of cancer pain, opioids continue to be an important part of a physician's armamentarium. Though opioids are used regularly for cancer pain, there is a paucity of literature proving efficacy for long-term use. Cancer is no longer considered a "terminal disease"; 50% to 65% of patients survive for at least 2 years, and there are about 12 million cancer survivors in the United States. There is a concern about side effects, tolerance, abuse and addiction with long-term opioid use and a need to evaluate the effectiveness of opioids for cancer pain. The objective of this systematic review was to look at the effectiveness of opioids for cancer pain. A systematic review of randomized trials of opioids for cancer pain. A comprehensive review of the current literature for randomized controlled trials (RCTs) of opioids for cancer pain was done. The literature search was done using PubMed, EMBASE, Cochrane library, clinical...
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Balancing opioid analgesia with the risk of nonmedical opioid use in patients with cancer
Nature Reviews Clinical Oncology, 2018
Pain is one of the most frequent and distressing symptoms in patients diagnosed with cancer. It might be short term as a result of invasive procedures, surgery, radiation therapy or chemotherapy, or it might be chronic (Table 1). Clinical evidence supports the use of opioid analgesics as the gold standard in cancer-related pain 1 , but their benefits must be carefully balanced against potential complications. Some patients receiving opioid therapy for pain engage in nonmedical opioid use (NMOU) or diversion, which can result in untoward adverse effects, accidental overdose or even death of the patient or others. Over the years, this issue has become increasingly concerning, culminating in an opioid overdose epidemic in the USA and other countries that has left the medical community, government agencies and other stakeholders grappling with ways to address it 2. Contrary to previous perceptions, emerging data suggest that patients with cancer are also at risk of NMOU 3,4. In this Review, we examine the role of opioids in managing cancer-related pain, the risk of NMOU and substance use disorder (SUD) and methods to achieve the right balance between the two in order to ensure safe opioid use. Opioids for cancer-related pain Opioids produce analgesia by binding to opioid receptors along the nociceptive pathway to reduce transmission of the impulses and perception of pain at the somatosensory cortex. Some pain syndromes 5,6 (Table 1) might be controlled appropriately with non-opioids, such as NSAIDs and acetaminophen and/or adjuvant analgesics (medications that are mainly indicated for conditions other than pain, such as seizure and depression, but that can also have analgesic effects when used alone or in combination with other analgesics) 1. When pain is persistent and refractory to these measures, opioids are usually necessary. Opioids include morphine, oxycodone, hydrocodone, tramadol, hydromorphone, oxymorphone, fentanyl, buprenorphine and methadone. Morphine is considered the prototype opioid analgesic and the first drug of choice in cancer-related pain, mostly because it is relatively more common, available and accessible-but not necessarily more effectivethan the other opioids. In fact, multiple randomized controlled trials have found no major differences between morphine and other opioids in regard to analgesia and adverse effect profiles 1. The use and titration of methadone are complex and should preferably be reserved for professionals with a high level of expertise, such as supportive or palliative care specialists and pain medicine specialists 1. Concerns have been raised about the efficacy of buprenorphine, owing to its partial agonist activity, which might result in limited additional analgesic benefit but increased likelihood of adverse reactions
Opioids in cancer and chronic non-cancer pain therapy - indications and controversies
Acta Anaesthesiologica Scandinavica, 2001
Indications for strong opioids for cancer-related pain as well as for chronic non-cancer pain are that non-opioid drugs, and other less risky therapies, fail and that the pain is opioid-sensitive. The WHO analgesic ladder principle continues to serve as an excellent educational tool in the efforts by WHO in collaboration with the World Federation of Societies of Anaesthesiologists (WFSA) and The International Association for the Study of Pain (IASP) to increase knowledge of pharmacological pain therapy and increase availability of essential opioid analgesics worldwide. Opioids differ in pharmacodynamics and pharmacokinetics, and patients have different pharmacogenetics and pain mechanisms. Sequential trials of the increasing numbers of available opioid drugs are therefore appropriate when oral morphine fails. Controversies continue concerning diagnosis and handling of opioid-insensitive pain in cancer and chronic non-cancer pain, opioid-induced neurotoxicities, risks of tolerance, addiction, pseudo-addiction, and methods for improving effectiveness and C ANCER patients may be in an acute, curative-therapy phase, in remission, tumour free, apparently cured but with severe pain as complications of antitumour therapy. In any of these phases they may suffer from acute and chronic somatic and visceral pain, which may be nociceptive, inflammatory, and neuropathic pain. Neuropathic pain is caused by the tumour directly impinging on, or infiltrating nervous tissue. Treatment-induced neuropathic pain is especially problematic as it may persist in patients apparently cured of their cancer. This comprises neuropathic pain from surgical damage of nervous tissue, scar after surgery or irradiation encroaching upon nerves, and neurotoxic effects of radiotherapy and chemotherapy (1). Bone metastases near joints and skeletal muscles cause incident pain from movement. Breakthrough pain can arise in visceral organs related to smooth muscle contractions or tumour emboli and ischaemic, infarction pain. Opioids alone, or co-administered with non-opioid analgesics and adjuvant drugs, can relieve pain caused by cancer in a majority of patients (1, 2). Indi-1059 decreasing adverse effects of long-term opioid therapy, treating breakthrough pain with immediate release oral and transmucosal opioids. Consensus guidelines have recently been developed in the Nordic countries concerning the ethical practice of palliative sedation when opioids and other pain-relieving therapies fail in patients soon to die. Guidelines for long-term treatment with strong opioids of chronic non-cancer-related pain are also being developed in the Nordic countries, where very diverging traditions for the usage of such therapy still exist.
Cancer-Related Pain Management and the Optimal Use of Opioids
Acta médica portuguesa
Pain relief is vital to the treatment of cancer. Despite the widespread use and recognition of clinical recommendations for the management of cancer-related pain, avoidable suffering is still prevalent in patients with malignant disease. A gap exists between what is known about pain medical management and actual practices of patients, caregivers, healthcare professionals and institutions. Opioids are the pillar of the medical management of moderate to severe pain. The prescription of opioid analgesics â by a registered medical practitioner for absolute pain control â is a legitimate practice. In this article we look at patientsâ fears and physiciansâ generalhesitations towards morphine and alike. We examine misconceptions that yield fallacies on the therapeutically use of opioids and, therefore, sustain inadequate pain management.
Physician-related barriers to cancer pain management with opioid analgesics: a systematic review
Journal of opioid management
The purpose of this review is to summarize the results of studies on physician-related barriers to cancer pain management with opioid analgesics. A literature search was conducted in PUBMED, using a combined text word and MeSH heading search strategy. Those articles whose full texts were not available in PUBMED were retrieved from the electronic databases of specific journals. Sixty-five relevant articles, published in the period from 1986 to 2006, were identified. Physicians' barriers to cancer pain management were studied in questionnaire surveys and in the reviews of drug prescribing documents. The results of the articles found were analyzed with respect to (a) knowledge, beliefs, concerns, problems endorsed or acknowledged by physicians treating cancer pain, (b) physicians' skills in pain assessment, and (c) adequacy of opioid prescription. This review revealed mostly general and common physician-related barriers to cancer pain management: concerns about side effects to ...
Opioids in cancer-related pain: current situation and outlook
Supportive Care in Cancer, 2019
Purpose Despite progress in treatments, cancer pain remains underestimated, poorly assessed and under-treated. Prescribing strong opioids, because of their specificities, requires precision in management considering their pharmacology but also a clear understanding of recommendations. Some clinicians highlight the risk of addiction, excessive sedation and respiratory depression and their need for information. Our objective in this review is to suggest some clinical guidance for the positioning and daily use of opioids within cancer pain management. Methods Critical reflection based on literature analysis and clinical practice. Results Strong opioids may be initiated as soon as pain diagnosis is defined. Factors to consider are pain aetiology, opioid pharmacokinetics and pharmacodynamics, genetic polymorphism, physiology (age, gender, weight and pregnancy), comorbidities (especially renal, hepatic, cardiovascular diseases), chronobiology, environmental factors, medication interference and treatment adherence. Achieving the best-balanced opioid treatment for background pain is complex, mainly due to the variable benefit/risk ratio between individuals and the experience of breakthrough cancer pain. Opioid initiation alongside a dynamic reassessment of pain should be fully integrated into the patient's management to optimise analgesia. The efficacy and safety of a strong opioid treatment need to be re-evaluated and adapted to individuals constantly as it varies over time. Conclusions Cancer pain is multimorphic and permanently changing due to disease evolution, curative treatments and disruptive events (concomitant treatments, pain from associated disease, comorbidities and complications, modifications of the environment). Well-managed opioids are the cornerstone of a complex environment requiring multidisciplinary dynamic assessments integrated into the patient's care pathway.
An Exploratory Analysis on the Effectiveness of Four Strong Opioids in Patients with Cancer Pain
Pain Medicine, 2012
Objective. This analysis, carried out in the context of a wider observational prospective study, tried to explore whether four World Health Organization/ step-III opioids (morphine, oxycodone, fentanyl, and buprenorphine) had different effectiveness when using several different outcomes and endpoints. Design. Cross-sectional and longitudinal design. Setting. Oncologic, palliative, and pain centers in Italy. Patients. Two hundred fifty-eight cancer patients monitored over a 3-week follow-up program. Intervention. Not applicable. Outcome Measures. The analgesic efficacy was assessed using effectiveness endpoints, such as pain intensity, pain intensity difference (PID), proportion of nonresponders (NR) and full-responders (FR) subjects, percentage of switches and dose escalation. Results. Mean values of PID led to differences among opioids ranging from 10% to 30%. FR (PID Ն 30%) were more frequent in buprenorphinefentanyl-oxycodone groups than in morphine; NR (PID Յ 0%) were variable. The percentage of switches resulted three times more frequent when using morphine than buprenorphine (24.4% vs 8.6%). An increase of dose Ն5% a day was observed in 33.3% of fentanyl patients vs 15% of buprenorphine. As a whole, opioids show some different behaviors on the basis of the considered endpoints. Conclusions. The observed results, even if the small sample size and the nature itself of the study do not allow a definitive evaluation of the effectiveness of the drugs, underline a degree of variability among opioids and address toward a correct planning of a comparative randomized clinical trial that is now underway in Italy. For this reason, a confirmative effectiveness randomized controlled trial is required.