Shifting Views on Cancer Pain Management: A Systematic Review and Network Meta-Analysis

CONTEXT

Strong opioids are the cornerstone in the treatment of cancer-related pain.

OBJECTIVES

This study aims to compare analgesic effectiveness of different strong opioids for the treatment of cancer-related pain.

METHODS

PubMed and Embase were searched for RCTs that compared strong opioids for treatment of cancer-related pain against one another. A network meta-analysis was conducted and the related Surface Under the Cumulative RAnking (SUCRA)-based treatment ranks were calculated. Primary outcome was pain intensity (numerical rating scale (NRS)) and/or the percentage of patients with ≥50% pain reduction, after 1 and 2-4 weeks.

RESULTS

Sixteen RCTs (1813 patients) were included. Methadone showed, with a high certainty of evidence, increased ORs for treatment success at 1 week, compared with morphine, buprenorphine, fentanyl, and oxycodone, range 3.230-36.833. Methadone had the highest likelihood to be the treatment of preference (ToP) (SUCRA 0.9720). For fentanyl, ORs were lower, however significant and with high certainty. After 2-4 weeks, methadone again showed the highest likelihood for ToP, however, with moderate certainty and nonsignificant ORs. The combination of morphine/methadone, compared with morphine, buprenorphine, fentanyl, hydromorphone, methadone, and oxycodone achieved a treatment effect of mean NRS difference after 2-4 weeks between -1.100 and -1.528 and had the highest likelihood for ToP.

CONCLUSION

The results suggest that methadone possibly deserves further promotion as first-line treatment for the treatment of cancer-related pain.

Risks and benefits of oral modified-release compared with oral immediate-release opioid use after surgery: a systematic review and meta-analysis

Prescription of modified-release opioids for acute postoperative pain is widespread despite evidence to show their use may be associated with an increased risk of adverse effects. This systematic review and meta-analysis aimed to examine the available evidence on the safety and efficacy of modified-release, compared with immediate-release, oral opioids for postoperative pain in adults. We searched five electronic databases from 1 January 2003 to 1 January 2023. Published randomised clinical trials and observational studies on adults who underwent surgery which compared those who received oral modified-release opioids postoperatively with those receiving oral immediate-release opioids were included. Two reviewers independently extracted data on the primary outcomes of safety (incidence of adverse events) and efficacy (pain intensity, analgesic and opioid use, and physical function) and secondary outcomes (length of hospital stay, hospital readmission, psychological function, costs, and quality of life) up to 12 months postoperatively. Of the eight articles included, five were randomised clinical trials and three were observational studies. The overall quality of evidence was low. Modified-release opioid use was associated with a higher incidence of adverse events (n = 645, odds ratio (95%CI) 2.76 (1.52-5.04)) and worse pain (n = 550, standardised mean difference (95%CI) 0.2 (0.04-0.37)) compared with immediate-release opioid use following surgery. Our narrative synthesis concluded that modified-release opioids showed no superiority over immediate-release opioids for analgesic consumption, length of hospital stay, hospital readmissions or physical function after surgery. One study showed that modified-release opioid use is associated with higher rates of persistent postoperative opioid use compared with immediate-release opioid use. None of the included studies reported on psychological function, costs or quality of life.

Pharmacological Treatments and Therapeutic Drug Monitoring in Patients with Chronic Pain

Pain is an unpleasant sensory and emotional experience that affects every aspect of a patient's life and which may be treated through different pharmacological and non-pharmacological approaches. Analgesics are the drugs most commonly used to treat pain, and in specific situations, the use of opioids may be considered with caution. These drugs, in fact, do not always induce optimal analgesia in patients, and several problems are associated with their use. The purpose of this narrative review is to describe the pharmacological approaches currently used for the management of chronic pain. We review several aspects, from the pain-scale-based methods currently available to assess the type and intensity of pain, to the most frequently administered drugs (non-narcotic analgesics and narcotic analgesics), whose pharmacological characteristics are briefly reported. Overall, we attempt to provide an overview of different pharmacological treatments while also illustrating the relevant guidelines and indications. We then report the strategies that may be used to reduce problems related to opioid use. Specifically, we focus our attention on therapeutic drug monitoring (TDM), a tool that could help clinicians select the most suitable drug and dose to be used for each patient. The actual potential of using TDM to optimize and personalize opioid-based pain treatments is finally discussed based on recent scientific reports.

Use of Opioids for Adults With Pain From Cancer or Cancer Treatment: ASCO Guideline

PURPOSE

To provide guidance on the use of opioids to manage pain from cancer or cancer treatment in adults.

METHODS

A systematic review of the literature identified systematic reviews and randomized controlled trials of the efficacy and safety of opioid analgesics in people with cancer, approaches to opioid initiation and titration, and the prevention and management of opioid adverse events. PubMed and the Cochrane Library were searched from January 1, 2010, to February 17, 2022. American Society of Clinical Oncology convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

The evidence base consisted of 31 systematic reviews and 16 randomized controlled trials. Opioids have primarily been evaluated in patients with moderate-to-severe cancer pain, and they effectively reduce pain in this population, with well-characterized adverse effects. Evidence was limited for several of the questions of interest, and the Expert Panel relied on consensus for these recommendations or noted that no recommendation could be made at this time.

RECOMMENDATIONS

Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Opioids should be initiated PRN (as needed) at the lowest possible dose to achieve acceptable analgesia and patient goals, with early assessment and frequent titration. For patients with a substance use disorder, clinicians should collaborate with a palliative care, pain, and/or substance use disorder specialist to determine the optimal approach to pain management. Opioid adverse effects should be monitored, and strategies are provided for prevention and management.Additional information is available at www.asco.org/supportive-care-guidelines.

Cancer pain: Results of a prospective study on prognostic indicators of pain intensity including pain syndromes assessment

BACKGROUND

Pain is a prevalent symptom in patients with advanced cancer. Recognition of prognostic factors associated with pain intensity, could help provide better assessment, leading to better pain management.

AIM

identifying prognostic factors which could guide improvements on cancer pain classification.

DESIGN

a prospective observational study on chronic cancer pain, exploring the association between average mean pain intensity during a 28 days study follow-up and patients' clinical and pain-related characteristics, including pain syndromes. To evaluate these associations, a mixed model was built.

SETTING/PARTICIPANTS

Patients attending a Palliative Care and Pain Outpatient Clinic from May 2015 to June 2019 were screened. Patients with moderate to severe cancer pain who were already receiving or needed treatment with third step WHO ladder opioids were enrolled in the study. Data from 342 patients with at least one follow-up visit were analyzed.

RESULTS

Pain intensity decreased significantly for all patients during time (p < 0.001). Age, sex, emotional distress, pain duration and neuropathic pain presence evaluated by the Douleur Neuropathique 4 Questions (DN4) questionnaire were not significantly associated to pain intensity. Breakthrough/episodic pain was associated with higher pain intensity during follow-up (p < 0.001). The diagnosis of pain syndrome was overall significantly associated with mean pain intensity during follow-up (p = 0.016). Particularly, the concurrent presence of visceral and soft (p = 0.026) or soft and nervous tissue pain (p = 0.043) were significantly related to worse outcome, whereas pain due to only soft tissue damage with better outcome (p = 0.032).

CONCLUSIONS

The recognition of specific pain syndromes may help to better classify cancer pain.

Opioid use prior to admission for chemotherapy induced febrile neutropenia is associated with increased documented infection, sepsis, and death

PURPOSE

Cancer patients on chemotherapy are at risk for developing febrile neutropenia and infections. Opioids have been associated with immune suppression and risk of infection. We aimed to investigate opioid use associated with infections and death among cancer patients admitted with febrile neutropenia.

METHODS

A total of 481 patients admitted for chemotherapy-induced febrile neutropenia were reviewed. There were 274 patients with opioid prescriptions (OP) within 10 days of hospitalization and 207 patients without opioid prescriptions (NOP) for >1 year of hospitalization. The primary outcomes were microbiologically and clinically documented infection as defined by the International Immunocompromised Host Society (IHS), sepsis by clinician, systemic inflammatory response syndrome (SIRS) criteria, and sequential organ failure assessment (SOFA) score.

RESULTS

Documented infection occurred in 192 (70%) of patients with opioids compared to 99 (48%) with non-opioids, p < 0.001. Similar results were observed in sepsis by SOFA score with 173 (63%) opioids versus 92 (44%) non-opioids, p < 0.001, and sepsis by SIRS with 225 (82%) and 115 (56%) respectively, p < 0.001. Multivariable analysis showed opioid use has an increased adjusted odds of documented infection by 7.13 fold (95% CI 3.97-12.78), Sepsis by SOFA by 2.39 fold (95% CI 1.33-4.29), and Sepsis by SIRS by 1.87 fold (95% CI 1.13-3.10). Multivariable analysis for death/hospice showed that opioids had 2.30 fold (95% CI 1.16-4.57) increase in adjusted odds of death/hospice within 30 days of discharge.

CONCLUSION

The data supports that patients with prior opioid use is associated with increased odds for infection, sepsis and death than non-opioid users admitted with febrile neutropenia.

Update on cannabis and cannabinoids for cancer pain

PURPOSE OF REVIEW

The prevalence of cancer pain will continue to rise as pain is common among the survivorship and general cancer population. As interest in cannabis and cannabinoids for medicinal use including pain management continues to rise, there is growing need to update and review the current state of evidence for their use. The literature was searched for articles in English with key words cannabis, cannabinoids, and cancer pain. The sources of articles were PubMed, Embase, and open Google search.

RECENT FINDINGS

In a double-blind randomized placebo-controlled trial including a 3-week treatment period of nabiximol for advanced cancer patients with pain refractory to optimized opiate therapy, improvements in average pain were seen in the intention to treat population (P = 0.0854) and per- protocol population (P = 0.0378).

SUMMARY

To date, preclinical data has demonstrated evidence to suggest promising potential for cancer pain and the urgent need to translate this into clinical practice. Unfortunately, due to limited data, for adults with advanced cancer being treated with opiate therapy, the addition of cannabis or cannabinoids is not currently supported to address cancer pain effectively.

Trends in chronic opioid therapy among survivors of head and neck cancer

BACKGROUND

Survivors of head and neck cancer (HNC) have increased risk of opioid misuse.

METHODS

Using Surveillance, Epidemiology and End-Results-Medicare data, we matched adults ≥66 years diagnosed with HNC 2008-2015 with cancer-free controls. We computed odds ratios (OR) for receipt of chronic opioid therapy (COT, claims for ≥90 consecutive days) for HNC survivors compared to controls each year after matching through 2016.

RESULTS

The cohort of HNC survivors declined from 5107 in the first year after diagnosis to 604 in the sixth year after diagnosis. For 5 years, rates of COT among HNC survivors exceeded that of controls. Differences between survivors and controls declined each year (ORs: year 1, 4.36; year 2, 2.60; year 3, 2.18; year 4, 1.85; and year 5, 1.35; all P-values <.05).

CONCLUSIONS

Among older HNC survivors, cancer-associated opioid use in the first years after diagnosis suggests that the benefit of opioids must balance the risk of opioid misuse.

Multidisciplinary intervention incorporating pharmacists in management of opioid-naïve patients with moderate to severe cancer pain

OBJECTIVE

This study aims to investigate the impact of intervention of multidisciplinary team incorporating pharmacists for management of opioid-naïve patients with moderate to severe cancer pain.

METHODS

A retrospective cohort study was conducted to compare pre- and post-multidisciplinary intervention groups in opioid-naïve patients with moderate to severe cancer pain. Primary outcome was the proportions of appropriate pain assessment and opioid titration. Secondary outcomes were pain intensity (PI), length of hospital stay, opioid escalation index percentage (OEI%) and incidences of opioid-related adverse events.

RESULTS

A total of 400 patients were included in the study (pre-intervention, n = 200; post-intervention, n = 200). Continuous improvement in pain assessment and titration was recorded after intervention. Though no substantial differences existed between groups in PI on the day of discharge, post-intervention group was associated with reduced length of hospital stay as well as decreased proportion of subjects with OEI% >5%. As for safety, significant decreases in constipation and vomiting were seen.

CONCLUSION

Findings suggest that interventions of multidisciplinary team incorporating pharmacists could improve cancer pain management for opioid-naïve patients. Pharmacists should be considered as an important member of a multidisciplinary team in good pain management.

Neuroimmune mechanisms of psychostimulant and opioid use disorders

Substance use disorders are global health problems with few effective treatment options. Unfortunately, most potential pharmacological treatments are hindered by abuse potential of their own, limited efficacy, or adverse side effects. As a consequence, there is a pressing need for the development of addiction treatments with limited abuse potential and fewer off target effects. Given the difficulties in developing new pharmacotherapies for substance use disorders, there has been growing interest in medications that act on non-traditional targets. Recent evidence suggests a role for dysregulated immune signaling in the pathophysiology of multiple psychiatric diseases. While there is evidence that immune responses in the periphery and the central nervous system are altered by exposure to drugs of abuse, the contributions of neuroimmune interactions to addictive behaviors are just beginning to be appreciated. In this review, we discuss the data on immunological changes seen in clinical populations with substance use disorders, as well as in translational animal models of addiction. Importantly, we highlight those mechanistic findings showing causal roles for central or peripheral immune mediators in substance use disorder and appropriate animal models. Based on the literature reviewed here, it is clear that brain-immune system interactions in substance use disorders are much more complex and important than previously understood. While much work remains to be done, there are tremendous potential therapeutic implications for immunomodulatory treatments in substance use disorders.

Trends in Opioid Use Among Older Survivors of Colorectal, Lung, and Breast Cancers

PURPOSE

Cancer survivors may be at increased risk for opioid-related harms. Trends in opioid use over time since diagnosis are unknown.

METHODS

Using data from SEER and Medicare, we conducted multilevel logistic regression analyses to compare chronic opioid use (≥ 90 consecutive days) among opioid-naïve survivors of colorectal, lung, and breast cancers diagnosed from 2008 to 2013 and matched with noncancer controls. Among cases and controls with chronic use, we compared rates of high-dose opioid use (average ≥ 90 morphine milligram equivalents daily).

RESULTS

We included 46,789 survivors and 138,136 noncancer controls. In the first year after the index date (survivor's diagnosis date), chronic use among colorectal and lung cancer survivors exceeded chronic use among controls (colorectal cancer: odds ratio, 1.34; 95% CI, 1.22 to 1.47; lung cancer: odds ratio, 2.55; 95% CI, 2.34 to 2.77). Differences in chronic use between survivors and controls declined each year after the index date. Chronic use among breast cancer survivors was less than that of controls each year after the index date. Survivors with chronic use were more likely to have a high daily dose than controls with chronic use in the first 3 to 5 years.

CONCLUSION

Among three large populations of older cancer survivors, chronic opioid use varied by cancer. However, by 6 years after diagnosis, survivors were no longer more likely to be chronic users than controls. Strategies for appropriate pain management during and after cancer treatment should take into account the risks associated with chronic high-dose opioid use.

Do complementary and integrative medicine therapies reduce healthcare utilization among oncology patients? A systematic review of the literature and recommendations

PURPOSE

Complementary and integrative medicine (CIM) is frequently used by oncology teams for reducing physical and emotional side-effects related to cancer treatment. In light of the changing healthcare system, evidence is needed regarding the economic implications of these interventions. The purpose of this study was to: (1) systematically examine the literature for links between CIM interventions and healthcare utilization (2) provide recommendations for growing this area of research.

METHOD

PubMed and EBSCO databases were reviewed for articles reporting on healthcare utilization associated with CIM therapy use in oncology populations. CIM intervention characteristics and healthcare utilization were extracted and summarized from 7 articles meeting inclusion criteria.

RESULTS

Studies included various CIM modalities. Most studies targeted physical symptoms (i.e., pain, infection, nausea/vomiting; n = 4). Healthcare utilization included medication use/cost (n = 4) and hospitalization length/cost (n = 5). All four studies (prospective/retrospective between-group, n = 2; within-subject pre-post, n = 1; RCT, n = 1) examining medication reduction noted decreased medication costs or use. Mixed findings emerged for studies examining hospitalizations (retrospective between-group, n = 2; within-subject pre-post, n = 1; RCT, n = 2), with only one study (retrospective between-group) indicating lower hospitalization duration in the CIM group.

CONCLUSIONS

Findings indicate the potential for CIM therapy to reduce healthcare utilization in oncology populations, particularly medication use. However, this research is limited both in size and quality. To increase the uptake of these interventions and to advocate for insurance coverage of CIM interventions, high quality economic evaluations are needed.

Prospective analysis of safety and efficacy of medical cannabis in large unselected population of patients with cancer

BACKGROUND

Cancer is a major public health problem as the leading cause of death. Palliative treatment aimed to alleviate pain and nausea in patients with advanced disease is a cornerstone of oncology. In 2007, the Israeli Ministry of Health began providing approvals for medical cannabis for the palliation of cancer symptoms. The aim of this study is to characterize the epidemiology of cancer patients receiving medical cannabis treatment and describe the safety and efficacy of this therapy.

METHODS

We analyzed the data routinely collected as part of the treatment program of 2970 cancer patients treated with medical cannabis between 2015 and 2017.

RESULTS

The average age was 59.5 ± 16.3 years, 54.6% women and 26.7% of the patients reported previous experience with cannabis. The most frequent types of cancer were: breast (20.7%), lung (13.6%), pancreatic (8.1%) and colorectal (7.9%) with 51.2% being at stage 4. The main symptoms requiring therapy were: sleep problems (78.4%), pain (77.7%, median intensity 8/10), weakness (72.7%), nausea (64.6%) and lack of appetite (48.9%). After six months of follow up, 902 patients (24.9%) died and 682 (18.8%) stopped the treatment. Of the remaining, 1211 (60.6%) responded; 95.9% reported an improvement in their condition, 45 patients (3.7%) reported no change and four patients (0.3%) reported deterioration in their medical condition.

CONCLUSIONS

Cannabis as a palliative treatment for cancer patients seems to be well tolerated, effective and safe option to help patients cope with the malignancy related symptoms.

Development of functionalized hollow microporous organic capsules encapsulating morphine – an in vitro and in vivo study

Carboxylic group functionalized hollow microporous organic capsules (HMOCs) are synthesized that show extraordinary high encapsulation efficiency of morphine·HCl and its promising prolonged release.

Additive Effects of Cointoxicants in Single-Opioid Induced Deaths

A forensic drug database (FDD) was used to capture comprehensive data from all drug-related deaths in West Virginia, with deaths also included from the northern New England states of Maine, Vermont, and New Hampshire. All four states serve predominantly rural populations under two million and all have similar state medical examiner systems that employ statewide uniform death certification policies and practices. This study focused on 1482 single opioid deaths (fentanyl, hydrocodone, methadone, and oxycodone) in the FDD from 2007-2011. We modeled relationships between the opioid concentrations and the presence or absence of the following commonly occurring non-opioid cointoxicants: benzodiazepines (alprazolam and diazepam), alcohol, tricyclic antidepressants, selective serotonin reuptake inhibitors, and diphenhydramine. Additional covariates of state, age, body mass index, and sex were included. Results showed that the presence of alcohol, benzodiazepines, and antidepressants were each associated with statistically significant lower concentrations of some but not all of the opioids studied, which may obscure the interpretation of postmortem toxicology results alone. Fentanyl concentrations appeared to be the least associated with the presence or absence of the variables studied, and cointoxicant alcohol appeared to be associated with lower concentrations in opioid concentrations than were most of the other factors in the model studied. These findings underscore the importance of documenting all potential cointoxicants in opioid-related deaths.

Injectable peptide hydrogels for controlled-release of opioids

Peptide-based hydrogels as a drug carrier system for the subcutaneous administration of morphine.

Strong opioids for noncancer pain due to musculoskeletal diseases: Not more effective than acetaminophen or NSAIDs

The classification of morphine as a step III analgesic, based on pharmacological data, creates a strong bias toward a belief in the efficacy of this drug. However, double-blind emergency-room trials showed similar levels of pain relief with intravenous acetaminophen as with intravenous morphine in patients with renal colic, low back pain or acute limb pain. In patients with chronic noncancer low back pain, morphine and other strong opioids in dosages of up to 100mg/day were only slightly more effective than their placebos, no more effective than acetaminophen, and somewhat less effective than nonsteroidal anti-inflammatory drugs (NSAIDs). In patients with osteoarthritis, strong opioids were not more effective than NSAIDs and, in some studies, than placebos. The only randomized controlled trial in patients with sciatica found no difference with the placebo. Chronic use of strong opioids can induce hyperalgesia in some patients. Hyperpathia with increased sensitivity to cold leading the patient to request higher dosages should suggest opioid-induced hyperalgesia. Pain specialists in the US have issued a petition asking that strong opioids be used in dosages no higher than 100mg/day of morphine-equivalent, in an effort to decrease the high rate of mortality due to the misuse and abuse of strong opioids (10,000 deaths/year in the US). Healthcare providers often overestimate the efficacy of step III analgesics, despite pain score decreases of only 0.8 to 1.2 points.

Opioid Receptors

Opioids are the oldest and most potent drugs for the treatment of severe pain. Their clinical application is undisputed in acute (e.g., postoperative) and cancer pain, but their long-term use in chronic pain has met increasing scrutiny. This article reviews mechanisms underlying opioid analgesia and other opioid actions. It discusses the structure, function, and plasticity of opioid receptors; the central and peripheral sites of analgesic actions and side effects; endogenous and exogenous opioid receptor ligands; and conventional and novel opioid compounds. Challenging clinical situations, such as the tension between chronic pain and addiction, are also illustrated.