Guidance needed for patients with cancer-associated pain who use nonmedical stimulants
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Key takeaways:
- Clinicians should continue prescribing opioids to patients who use nonmedical stimulants while increasing monitoring.
- Patients with cancer with a short prognosis should not transition to buprenorphine/naloxone.
Researchers have identified consensus-based guidance on managing opioid use for cancer-associated pain among patients who use nonmedical stimulants, according to study results published in Cancer.
The findings amplify the critical need for management strategies to address opioid use disorder in this patient population, researchers concluded.
Rationale and methodology
“As a palliative care and addiction nurse practitioner, I regularly encounter nonmedical stimulants in patients with cancer in practice,” Katie Fitzgerald Jones, PhD, researcher in the division of palliative care at VA Boston Healthcare System, told Healio. “The reason for stimulant use can be driven by various things, including cancer side effects — such as fatigue — to offset opioid side effects or because of an underlying stimulant use disorder. However, there is no consensus on managing stimulant use in those with cancer, so clinicians may be making it up as they go along, and decisions may vary according to prognosis.”
For this reason, Jones and colleagues aimed to provide consensus on management approaches to opioid decision-making for clinicians.
Researchers conducted two modified Delphi panels to assess the perspectives of 120 palliative and addiction experts (62% women; 78% white; 96% physicians). Panel A included 57 patients with cancer with a prognosis of weeks to months and panel B included 63 patients with a prognosis of months to years.
The investigators used a nine-point Likert scale from 1 (very inappropriate) to 9 (very appropriate) to review, rate and comment on each patient’s case. They applied a three‐step analytical approach to determine consensus and level of clinical appropriateness of management strategies, and thematically analyzed and coded expert comments to better conceptualize quantitative results.
Findings
Results showed that experts deemed it appropriate to continue opioids, increase monitoring and avoid opioid tapering for patients with cancer-associated and nonmedical stimulant use — regardless of prognosis.
In addition, researchers considered a buprenorphine/naloxone transition inappropriate for patients with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis.
“These findings were similar to our previously published work where we found that in the context of cancer, experts weighed heavily on the importance of pain control, favoring continuation of opioids with close follow-up and avoiding opioid tapering,” Jones said. “Experts in our study also embodied the spirit of harm reduction and considered rotation to buprenorphine to decrease the risk for opioid-associated harms with concurrent stimulant use. However, if patients with cancer had a stimulant use disorder, management strategies appeared less clear and underscored the need for future research.”
Researchers acknowledged study limitations, including the potential for low replicability of panel results. In addition, researchers only included nonprescribed stimulant use, but said that prescribed stimulant misuse could also “yield alternative treatment approaches.”
Implications
The findings highlight the need for integrated care models to address substance use during cancer treatment, Jones told Healio.
“The findings also indicate the urgent need for a research agenda that prioritizes substance use disorder as an important comorbidity in patients with cancer,” she added.
References:
- How should clinicians prescribe opioids for cancer-related pain in patients who use cocaine or methamphetamines? (press release). Available at: https://newsroom.wiley.com/press-releases/press-release-details/2023/How-should-clinicians-prescribe-opioids-for-cancer-related-pain-in-patients-who-use-cocaine-or-methamphetamines/default.aspx. Published Sept. 11, 2023. Accessed Sept. 11, 2023.
- Jones KF, et al. Cancer. 2023;doi:10.1002/cncr.34921.
For more information:
Katie Fitzgerald Jones, PhD, can be reached at katie.jones4@va.gov.
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