How should clinicians prescribe opioids for cancer-related pain in patients who use cocaine or methamphetamines?

Clinicians treating cancer-related pain must consider whether and how to prescribe opioids to patients who use nonmedical stimulants such as cocaine and methamphetamines; however, no guidelines exist related to these common and challenging situations. In a new study, palliative care and addiction experts deemed it appropriate to continue opioids, increase monitoring, and avoid opioid tapering in such patients. The results are published by Wiley online in CANCER, a peer-reviewed journal of the American Cancer Society.

Using opioids and nonmedical stimulants together may increase the risk of various harms, including overdose and death. These harms may be especially pronounced in people with cancer, who may have compromised health and take multiple other medications.

To provide guidance on opioid management strategies for people with advanced cancer who use methamphetamines or cocaine, researchers recruited 120 palliative care and addiction experts and asked them to consider two different scenarios. In the first, a patient’s prognosis was weeks to months, and in the second, the prognosis was months to years. Experts reviewed, rated, and commented on the cases. They used a scale from 1 (very inappropriate) to 9 (very appropriate) to rate their opinions about different care-related actions, and they explained their responses.

The experts agreed that regardless of prognosis, clinicians should increase monitoring and continue opioids, without tapering. Such management strategies prioritize pain control and allow clinicians time to develop individualized harm-reduction approaches and refer to addiction specialists when appropriate. The use of buprenorphine/naloxone (an opioid medication that has a lower risk for overdose) was considered potentially appropriate in people with a longer prognosis, but inappropriate in people with a shorter prognosis. The experts noted that strategies aimed at reducing harms include frequent visits and patient education about the impurity and high potency of stimulant supplies, which often include illicit fentanyl.

“The study findings provide consensus-based guidance for clinicians who treat cancer-related pain and encounter stimulant use, and include management strategies they can bring immediately to their practice,” said lead author Dr. Katie Fitzgerald Jones of the VA Boston Healthcare System. “The results highlight a need for integrated care models to address substance use during cancer and create a research agenda that prioritizes substance use disorder as an important comorbidity in people with cancer.” 

Additional information
NOTE: The information contained in this release is protected by copyright. Please include journal attribution in all coverage. A free abstract of this article will be available via the CANCER Newsroom upon online publication. For more information or to obtain a PDF of any study, please contact: Sara Henning-Stout, newsroom@wiley.com

Full Citation:
“Expert consensus-based guidance on approaches to opioid management in individuals with advanced cancer-related pain and non-medical stimulant use.” Katie Fitzgerald Jones, Dmitry Khodyakov, Benjamin H. Han, Robert M. Arnold, Emily Dao, Jeni Morrison, Jennifer Kapo, Diane E. Meier, Judith A. Paice, Jane M. Liebschutz, Christine S. Ritchie, Jessica S. Merlin, and Hailey W. Bulls. CANCER; Published Online: September 11, 2023 (DOI: 10.1002/cncr.34921). 

URL Upon Publication: http://doi.wiley.com/10.1002/cncr.34921

Author Contact: Winfield Danielson, Winfield.DanielsonIII@va.gov

About the Journal     
CANCER is a peer-reviewed publication of the American Cancer Society integrating scientific information from worldwide sources for all oncologic specialties. The objective of CANCER is to provide an interdisciplinary forum for the exchange of information among oncologic disciplines concerned with the etiology, course, and treatment of human cancer. CANCER is published on behalf of the American Cancer Society by Wiley and can be accessed online. Follow CANCER on Twitter @JournalCancer and Instagram @ACSJournalCancer, and stay up to date with the American Cancer Society Journals on LinkedIn.

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