Conflicting guidance on opioid prescribing can jeopardize pain management for patients with cancer

Persistent pain and recurrent episodes of pain are common for those who are living with cancer, or for those undergoing cancer treatment. When used properly, prescription opioids have long been known to help combat pain experienced by people with cancer.

In the face of the worsening opioid epidemic, clinical guidelines have been published by multiple agencies to improve the way opioids are prescribed and to reduce the number of people who may misuse, abuse, or overdose from these drugs. One such influential guideline, The Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain, is shaping clinical care of patients with chronic pain, including persons who are living with chronic cancer related pain in the United States. However, some of the CDC guideline recommendations are inconsistent with the long-standing and current national cancer pain guidelines, such as the National Comprehensive Cancer Network (NCCN), causing confusion among clinicians who care for patients with cancer.

In an upcoming article in JAMA Oncology, lead-author Salimah H. Meghani, Ph.D., MBE, RN, FAAN, Associate Professor of Nursing and Term Chair of Palliative Care at the University of Pennsylvania School of Nursing (Penn Nursing), and co-author, Neha Vapiwala, MD, Associate Professor of Radiation Oncology and Vice Chair for Education in the Perelman School of Medicine at the University of Pennsylvania (PSOM), call for key agencies (CDC, NCCN, American Medical Association, American Society of Clinical Oncology) and other organizations to collaborate and resolve these inconsistencies. The article is available online first and will be published in the October 2018 issue of the journal.

"Competing contemporary guidelines from diverse authoritative agencies and organizations 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," said the authors.

Meghani and Vapiwala detail several key areas where the CDC guidelines for opioid prescription cause inadvertent confusion for oncology clinicians:

• The CDC guidelines apply to cancer patients who have completed cancer treatment (in contrast to those who are receiving current cancer treatment). Yet research shows that similar levels of pain are experienced by cancer patients who have completed cancer treatment and those who are under current or active cancer treatment.
• The CDC guidelines recommend avoiding prescribing long-acting opioids, especially concurrently with immediate-release opioids. But NCCN guidelines, which are used widely by oncology clinicians, indicate co-prescription of long- and short-acting opioids, the latter to manage pain flares that are common among cancer patients.
• The CDC also advises use of non-pharmacologic therapy and non-opioid pharmacologic therapy for chronic pain. But adoption of this guidance by oncology clinicians is hampered by lack of evidence that these other interventions are effective in managing moderate to severe pain. In addition, the few non-pharmacologic treatments that have demonstrated some effectiveness are cost prohibitive for many patients.

"Already, opioid prescribing practices are a function of complicated decision-making processes. 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 their patients with pain," said the authors. Thus, this article underscores the importance of accessibly communicating the streamlined guidelines to oncology clinicians and primary care clinicians who also care for cancer patients with chronic pain who are on long-term opioid therapy.

In the long-run, Meghani contends that there is a strong need to generate an empirical evidence base upon which the chronic cancer pain management guidelines can be based. "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."