NEW YORK (Reuters Health) - When it comes to treating pain in patients with opioid-use disorder and advanced cancer, a panel of experts generally favors continuing treatment with methadone or buprenorphine-naloxone.
For patients whose pain is not helped with these medications, the panel recommends adding a full-agonist opioid for patients with a prognosis of weeks to months, according to apublished in JAMA Network Open. For those with a longer prognosis - months to years - panel members deemed adding a full-agonist opioid to be of uncertain appropriateness.
The panel also suggested dividing doses of methadone and buprenorphine-naloxone into two to three doses a day, rather than one.
“Addiction treatment continues to be important in patients with advanced cancer, including those who are at the end of life and those who have longer prognoses,” lead author Dr. Jessica Merlin of the University of Pittsburgh School of Medicine/UPMC told Reuters Health by phone. “There are different ways to accomplish that and that is what this paper is about.”
Dr. Merlin is associate professor of medicine and co-director of the Challenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, the Tailored Retention and Engagement in Equitable Treatment of Opioid Use Disorder and Pain (TREETOP) and the Palliative Recovery Engagement Program (P-REP) at UPMC.
To explore options for treating pain in patients with opioid-use disorder (OUD), she and her colleagues conducted two online modified Delphi panels that solicited the perspectives of palliative-care and addiction clinicians on the appropriateness of different approaches to pharmacological management of pain and OUD in patients with advanced cancer. Pain treatment in such patients often centers around opioids.
The panels looked at two scenarios: a 50-year-old patient with advanced cancer with OUD and a prognosis of weeks to months and a similar patient with advanced cancer with OUD and a prognosis of months to years.
The panel concluded that for a patient with OUD taking buprenorphine-naloxone, it would be appropriate to continue the medication with thrice-daily dosing. For patients with a prognosis of weeks to months, the panels deemed it appropriate to add a full-agonist opioid, but for those with a prognosis of months to years they deemed adding a full-agonist opioid to be of uncertain appropriateness.
When it came to patients with OUD taking methadone dispensed at a methadone clinic, the panel deemed it appropriate for clinicians to take over prescribing and to divide the dose into two or three times a day. For these patients, it was also deemed appropriate to add a full agonist when they had a prognosis of weeks to months but of uncertain appropriateness when the prognosis was months to years.
“I preface all of this by saying that nothing is a substitute for clinical judgment,” Dr. Merlin said. “I think this paper empowers clinicians to make certain clinical choices.”
In a perfect world, clinical decisions would be based on the results of clinical trials, said Dr. Otis Brawley, Bloomberg Distinguished Professor of Oncology and Epidemiology at Johns Hopkins University in Baltimore, Maryland.
“Here there is no evidence whatsoever,” Dr. Brawley told Reuters Health by phone. “So, you go to the next-best thing, professional opinion. And I have a bad feeling about that to the extent that we are turning medicine into democracy. On the other hand, this is probably the best thing we can do short of a clinical trial.”
One thing people need to understand is that “those of us treating cancer are very uncomfortable treating cancer pain,” Dr. Brawley said, adding that the opioid epidemic has made cancer specialists even more uncomfortable. He was not involved in the new recommendations.
Buprenorphine and naloxone work well for mild to moderate pain in someone who does not have a long history with narcotics, Dr. Brawley said. But for most people with OUD, this medication will not be adequate. For those patients, it makes sense to go directly to methadone, he added.
“Methadone is a significant pain killer,” Dr. Brawley said. “In fact, before oxycodone and other new drugs got us in trouble, methadone was the way to go and it sort of is again.”
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