Opioids for Cancer Pain

Publication Date: December 4, 2022
Last Updated: March 27, 2023

Treatment

Recommendation 1.1

Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. (EB, B, M, S)
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Recommendation 1.2

Prior to initiating opioid therapy, clinicians, patients, and caregivers should discuss goals regarding functional outcomes, shared expectations, and pain intensity, as well as any concerns about opioids. (IC, B, , S)
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Recommendation 2.1

For patients who are candidates to begin opioid treatment (see Recommendation 1.1), clinicians may offer any of the opioids approved by the FDA or other regulatory agencies for pain treatment. (Quality of Evidence: M/L) (EB, B, M, W)
Qualifying Statement: The decision of which opioid is most appropriate should be based on factors such as pharmacokinetic properties, including bioavailability, route of administration, half-life, neurotoxicity, and cost of the differing drugs. Tramadol and codeine have limitations that may make them less desirable than other opioids in this setting. Tramadol is a pro-drug, has limitations in dose titration related to a low threshold for neurotoxicity, and has potential interactions with other drugs at the level of cytochrome P450 (CYP) 2D6, 2B6, and 3A4. Codeine is a pro-drug, requiring CYP2D6 to allow it to be metabolized to morphine to achieve analgesic effects.
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Recommendation 2.2

Clinicians with limited experience with methadone prescribing should consult palliative care or pain specialists when initiating or rotating to methadone. (IC, B, , S)
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Recommendation 3.1

Opioids should be initiated at the lowest possible dose to achieve acceptable analgesia and patient goals. (IC, B, , S)
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Recommendation 3.2

Opioids should be initiated as immediate release and as needed (PRN) to establish an effective dose, with early assessment and frequent titration. (IC, B, , S)
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Recommendation 3.3

Patients who have been taking other analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs), may continue these analgesics after opioid initiation if these agents provide additional analgesia and are not contraindicated. (IC, B, , W)
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Recommendation 3.4

Evidence remains insufficient to recommend for or against the use of genetic testing, such as for polymorphism of CYP2D6, to guide opioid dosing. (, , , )
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Recommendation 3.5

Evidence remains insufficient to recommend any single set of ranges for dose escalation in opioid titration.

Note: In general, the minimum dose increase is 25–50%, but patient factors such as frailty, comorbidities, and organ function must be evaluated and considered when changing doses. (, , , )
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Recommendation 3.6

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. (IC, B, , S)
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Recommendation 4

Clinicians should proactively offer education and strategies to prevent known opioid-related adverse effects, monitor for the development of these adverse effects, and manage these effects when they occur. (IC, B, , S)
Note: Strategies for the prevention and management of common opioid-induced adverse effects are provided in Table 1.
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Recommendation 5.1

For patients with renal impairment currently treated with an opioid, clinicians may rotate to methadone, if not contraindicated, since this agent is excreted fecally. Opioids primarily eliminated in urine, such as fentanyl, oxycodone, and hydromorphone, should be carefully titrated and frequently monitored for risk or accumulation of the parent drug or active metabolites. Morphine, meperidine, codeine, and tramadol should be avoided in this population, unless there are no alternatives. (IC, B, , S)
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Recommendation 5.2

For patients with renal or hepatic impairment who receive opioids, clinicians should perform more frequent clinical observation and opioid dose adjustment. (IC, B, , S)
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Recommendations 6.1

In patients receiving opioids around the clock, immediate-release opioids at a dose of 5–20% of the daily regular morphine equivalent daily dose should be prescribed for breakthrough pain. (Strong recommendation for prescribing immediate-release opioids for breakthrough pain; Weak recommendation for dosing) (IC, B, , S)
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Recommendation 6.2

Evidence remains insufficient to recommend a specific, short-acting opioid for breakthrough pain. (, , , )
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Recommendation 7

Opioid rotation should be offered to patients with pain that is refractory to dose titration of a given opioid, poorly managed side effects, logistical or cost concerns, or trouble with the route of opioid administration or absorption. (EB, B, M, S)
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Use of Opioids for Adults with Pain from Cancer or Cancer Treatment

Authoring Organization

American Society of Clinical Oncology

Publication Month/Year

December 4, 2022

Last Updated Month/Year

November 13, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

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

Target Patient Population

Adults with pain from cancer or active cancer treatment.

Target Provider Population

Clinicians who provide care to adults with cancer

PICO Questions

  1. In what circumstances should opioids be offered?

  2. Which opioids should be offered?

  3. How should opioids be initiated and titrated?

  4. How should opioid-related adverse events be prevented or managed?

  5. How should opioid use be modified in patients with renal or hepatic impairment?

  6. How should breakthrough pain be managed?

  7. When and how should opioids be switched (rotated)?

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Home health, Hospice, Hospital, Long term care, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Treatment

Diseases/Conditions (MeSH)

D000072716 - Cancer Pain, D059390 - Breakthrough Pain

Keywords

pain, opioids, methadone, cancer pain

Source Citation

Paice JA, Bohlke K, Barton D, et al. Use of Opioids for Adults with Pain from Cancer or Cancer Treatment: ASCO Guideline. J Clin Oncol. 2022 Dec 05. doi: 10.1200/JCO.22.02198.

Supplemental Methodology Resources

Data Supplement, Evidence Tables

Methodology

Number of Source Documents
137
Literature Search Start Date
December 31, 2009
Literature Search End Date
February 16, 2022