Should opioids continue to be a component of pain management for children with cancer?
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Yes, in some cases.
Opioids are needed when the pain cannot be blocked with a regional intervention, or when the pain is severe and the patient is on active chemotherapy and cannot have acetaminophen or anti-inflammatories. The use of opioids should ideally be short-term, at the lowest effective dose and used as needed — we would want to add other lines of therapy when the rest of the medical picture allows.
The other circumstance in which opioids may not be avoidable is at the end of life. At that point, we “throw” everything we have to target symptom and pain control. We will do a regional block if we can, and all other lines of nonopioid therapy, but we may have to rely heavily on high doses of opioids. The goal is no longer to extend survival or to treat the cancer, but rather to provide comfort and symptom control.
The increased caution resulting from concerns about addiction has not changed the use of opioids in the pediatric population. Pain specialists have always had the algorithm of treating with nonpharmacologic in addition to pharmacologic interventions. Treat with a pain block if possible. Layer the different types of therapy. Then use opioids in conjunction with other therapies.
We always try to differentiate neuropathic pain from tissue pain, knowing that this differentiation will guide the choice of medications for pain. If we determine that a patient’s mechanism for pain is more nerve injury (from chemotherapy or surgery) rather than tissue injury, that may suggest that pain may not respond to opioids and lead the medication choice toward medications that are specific for neuropathic pain, such as gabapentin, pregabalin or tricyclic antidepressants. If we have to choose an opioid, we would select methadone, which is the only opioid that has effects on both tissue pain and neuropathic pain.
Based on my experience on the National Comprehensive Cancer Network panel that developed a set of guidelines for treating cancer pain among adults, the NCCN recommendations on pain management also emphasize using opioids judiciously and in combination therapies with nonopioid medications. Like in adults, in children, opioids should never be the only line of treatment, but rather part of a system of layered medications and nonmedication interventions for pain (psychological support and rehabilitation therapy being important nonmedication interventions).
Reference:
Swarm RA, et al. J Natl Compr Canc Netw. 2019;doi:10.6004/jnccn.2019.0038.
Doralina Anghelescu, MD, is a member of the division of anesthesiology in the department of pediatric medicine and director of the pain management service at St. Jude Children’s Research Hospital. She and Kyle J. Morgan, MD, co-authored a chapter on cancer pain management in the book Opioid Therapy in Infants, Children, and Adolescents. She can be reached at St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105; email: doralina.anghelescu@stjude.org.
Opioids should only be used in conjunction with other approaches.
Cancer pain, whether acute or chronic, is multifaceted. There is a physical component, but there also are substantial emotional, mental, relational and even spiritual components. Of all these components, physical pain is the only one that can be helped by opioids. The other (nonphysical) components of pain are made worse by opioids. Certainly, there is a role for opioids in pain management, but I would argue that we have improperly expanded and relied too heavily on that role. We’ve found ourselves in a situation where it is commonplace for children with chronic pain to be managed with opioids.
I have referred to this issue as a product of two problems: a historical problem and a modern problem. The historical problem was that pediatric cancer pain was grossly undermanaged because of our lack of understanding of pediatric pain, especially neonatal and infant pain. We also were unnecessarily worried about the risk for addiction among children. Additionally, there was a lack of access to opioids in many places around the world. So, a feeling began to develop in the world of pain medicine that we were doing children a disservice by undermanaging their pain.
Then, in the 1990s, we started to learn more about how children feel pain. In 1996, WHO published guidelines on cancer pain relief and palliative care for children. Other changes occurred in the world of pain management, like making pain the fifth vital sign. I think these things led to an overreaction to the “historical problem” and the pendulum swung toward overtreatment.
Hopefully we are correcting the pendulum, so it is somewhere back in the middle, where we are appropriately treating pain, but without unnecessary use of opioids.
It’s important to mention that children with cancer are surviving at much higher rates than ever before. If we can manage pain without creating a new problem that persists into survivorship, we should.
A study that came out of University of Michigan in 2015, published in Pediatrics, showed legitimate opioid use among patients before their high school graduation led to a 33% increase in opioid misuse after high school. If you’ve cured someone of their cancer, but they go on to misuse opioids into adulthood, that’s not the optimal outcome. I think we can do better.
Generally, the way I manage cancer pain is multimodal; I incorporate not only pharmacotherapy, but also nonpharmacologic elements including psychology, physical therapy, yoga, acupuncture, massage therapy and aroma therapy. Even the physical aspect of pain is best served in a multimodal fashion, employing and enlisting the help of all of our different analgesic pathways.
References:
Miech R, et al. Pediatrics. 2015;doi:10.1542/peds.2015-1364.
WHO. Cancer pain relief: with a guide to opioid availability, 2nd ed. 1996. Available at: apps.who.int/iris/handle/10665/37896. Accessed Nov. 25, 2020.
Kyle J. Morgan, MD, is a pediatric anesthesiologist and faculty member in the division of anesthesiology of the department of pediatrics at St. Jude Children’s Research Hospital. He can be reached at St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105; email: kyle.morgan@stjude.org.
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