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Experts highlight inconsistencies in guidelines on opioids for cancer pain
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Multiple agencies should collaborate to issue consistent guidelines for prescribing opioids to patients living with pain from cancer or its treatment, according to a viewpoint published in JAMA Oncology.
“Competing contemporary guidelines from diverse authoritative agencies carry the potential to confuse, if not seriously jeopardize, pain management for patients with cancer who are living with moderate to severe pain, adding to an already appalling burden of unrelieved cancer pain,” Salimah H. Meghani, PhD, MBE, RN, FAAN, associate professor of nursing and term chair of palliative care at University of Pennsylvania School of Nursing, and Neha Vapiwala, MD, associate professor of radiation oncology at Perelman School of Medicine, said in a press release.
Meghani and Vapiwala noted three particular areas in which CDC guidelines cause confusion, clash with guidelines set by other agencies, or recommend therapies that are either prohibitively expensive or inadequately supported by evidence.
First, the authors wrote, the CDC specifies that its opioid guidelines apply only to cancer survivors and not to patients receiving cancer treatment. Vapiwala and Meghani described this as an “arbitrary distinction” not backed up by evidence, noting that an American Cancer Society study found patients with cancer currently receiving treatment and survivors reported similar levels of pain.
Meghani and Vapiwala also wrote that the CDC guidelines are inconsistent with those set by the National Comprehensive Cancer Network, particularly on the topic of extended-release opioids. Although the CDC recommends that clinicians avoid long-acting opioids, the NCCN guidelines still recommend the drugs. The NCCN further recommends use of long-acting opioids concurrently with short-acting opioids to manage breakthrough pain — a practice the CDC expressly recommends avoiding.
CDC guidelines recommend use of nonpharmacologic therapy or nonopioid drugs for chronic pain. There is, however, “a lack of robust evidence” on nonpharmacologic therapies among patients who have survived from or are being treated for cancer, the authors wrote, adding that therapies that are considered effective are often prohibitively expensive.
“Already, opioid prescribing practices are a function of complicated decision-making processes,” the researchers wrote. “Clinicians who care for patients with cancer are frustrated by an increasingly overwhelming set of institutional, regulatory and policy requirements around opioid prescribing that can interfere with being good stewards and advocates for patients for their patients with pain. To this end, there is a need for key agencies and organizations (eg, the CDC, ASCO, NCCN and American Medical Association) to collaborate on resolving inconsistencies in guideline recommendations and communicating those recommendations in an accessible manner to oncology clinicians, as well as primary care clinicians who may manage or comanage cancer pain with oncologists.”
Additionally, Meghani and Vapiwala wrote further research would be necessary to refine future recommendations.
“Many of the current recommendations around opioid prescribing practices stem from expert consensus rather than empirical research, which is urgently needed to generate and develop informed guidelines for patients with chronic cancer-related pain,” they wrote. – by Andy Polhamus
Disclosures: The authors report no relevant financial disclosures.
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