Expert consensus‐based guidance on approaches to opioid management in individuals with advanced cancer‐related pain and nonmedical stimulant use

Abstract

BackgroundClinicians treating cancer‐related pain with opioids regularly encounter nonmedical stimulant use (i.e., methamphetamine, cocaine), yet there is little evidence‐based management guidance. The aim of the study is to identify expert consensus on opioid management strategies for an individual with advanced cancer and cancer‐related pain with nonmedical stimulant use according to prognosis.MethodsThe authors conducted two modified Delphi panels with palliative care and addiction experts. In Panel A, the patient’s prognosis was weeks to months and in Panel B the prognosis was months to years. Experts reviewed, rated, and commented on the case using a 9‐point Likert scale from 1 (very inappropriate) to 9 (very appropriate) and explained their responses. The authors applied the three‐step analytical approach outlined in the RAND/UCLA to determine consensus and level of clinical appropriateness of management strategies. To better conceptualize the quantitative results, they thematically analyzed and coded participant comments.ResultsConsensus was achieved for all management strategies. The 120 Experts were mostly women (47 [62%]), White (94 [78%]), and physicians (115 [96%]). For a patient with cancer‐related and nonmedical stimulant use, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering. Buprenorphine/naloxone transition was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis.ConclusionStudy findings provide urgently needed consensus‐based guidance for clinicians managing cancer‐related pain in the context of stimulant use and highlight a critical need to develop management strategies to address stimulant use disorder in people with cancer.Plain Language Summary Among palliative care and addiction experts, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering in the context of cancer‐related pain and nonmedical stimulant use. Buprenorphine/naloxone transition as a harm reduction measure was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis.