Opioid Guidelines Putting Pain Management for Patients With Cancer at Risk, Letter Says

Inconsistencies and lack of evidence in opioid prescribing guidelines are confusing clinicians who care for long-term patients with cancer and survivors and have the potential to jeopardize patients’ pain management, according to an opinion column in JAMA Oncology.

“Opioid prescribing practices are a function of complicated decision making processes, and clinicians express frustration about how to best navigate an increasingly overwhelming set of institutional, regulatory, and policy requirements around opioid prescribing while being good stewards and advocates for their patients with pain,” wrote Salimah H. Meghani, PhD, MBE, of the Department of Biobehavioral Health Sciences, New Courtland Center for Transitions and Health, Leonard Davis Institute of Health Economics, University of Pennsylvania, and Neha Vapiwala, MD, a radiation oncologist at the university’s Perelman School of Medicine.

They note that in studies of long-term opioid therapies, patients with cancer are invariably excluded based on study criteria. This has policy implications, as the CDC has created guidelines for the treatment of chronic pain based on those studies. Doctors have reported increasing difficulty in treating patients for cancer-related pain.

There are 3 reasons why this is happening, the authors wrote.

One, the CDC made an "arbitrary distinction" between patients with active cancer and those who have completed treatment, they said. But pain doesn’t work that way in cancer survivors, they wrote, citing an American Cancer Society study of 4903 survivors, who said that pain was among the top 3 symptoms interfering with quality of life in the first year after diagnosis, and that similar levels of pain existed between those in active treatment and those who were not.

Two, the CDC guideline is inconsistent with one from the National Comprehensive Cancer Network (NCCN) used by cancer specialists. The recent NCCN guidelines for adult cancer pain continue to recommend that persistent cancer pain be managed with regularly scheduled extended-release or long-acting opioid formulations, as well as short-acting ones to control breakthrough pain. In addition, cancer-related pain may persist for years, they wrote.

But the CDC recommends avoiding the use of long-acting opioids, especially alongside immediate-release opioids.

Third, the recommendation by the CDC to prefer nonpharmacologic therapy (such as physical therapy or cognitive behavioral therapy) and nonopioid pharmacologic therapy is not backed up by any evidence for patients with cancer. Such treatments might also be out of reach for patients if the therapies are not covered by insurance and may be challenging to access for patients with minority racial backgrounds or low incomes, worsening existing healthcare disparities in the treatment of pain, they note.

Taken together, these issues add to an already “appalling burden of unrelieved cancer pain,” the authors wrote.

They called for the CDC, the NCCN, the American Medical Association, and the American Society of Clinical Oncology to work together to resolve inconsistencies and communicate those changes not only to oncologists but also primary care providers, who may play a role in managing cancer pain.

Reference

Meghani SH, Vapiwala N. Bridging the critical divide in pain management guidelines from the CDC, NCCN, and ASCO for cancer survivors [published online May 31, 2018]. JAMA Oncol. doi: 10.1001/jamaoncol.2018.1574.