Opioid pharmacotherapy in the management of cancer pain. A survey of strategies used by pain physicians for the selection of analgesic drugs and routes of administration

Abstract

Background. This survey documents the strategies used by pain control physicians in the selection of opioid drugs and routes of administration in the management of inpatients referred to a cancer pain service. Methods. The following approaches were prospectively evaluated during the treatment of 100 consecutive inpatients: 1) the influence of the evaluation of the goals of care on decision making, 2) selection of opioid drugs, 3) indications for changing opioid drugs and the frequency with which this strategy is used, and 4) selection of route of administration. Results. Eighty of the 100 patients underwent a total of 182 changes in drug, route, or both drug and route before discharge or death. The major reasons for change were to improve the convenience of treatment regimen in the setting of adequate pain relief (31.4%), diminish side effects in the setting of controlled pain (25.0%), reduce the invasiveness of therapy in the setting of controlled pain (19.3%), and simultaneously improve pain control and reduce opioid toxicity (17.7%). When opioid toxicity was the reason for change, physicians changed the opioid drug in 71% of cases and the route in 29%. When convenience or invasiveness were targeted, the physicians changed the route in 61% of cases and the opioid in 39%. Forty‐four patients required one or more change in the opioid, and 20 required 2 or more changes (range, 2‐6 changes). At the time of discharge (n = 82), morphine was more commonly selected than hydromorphone or fentanyl (39% vs. 23% vs. 17%) and the routes of administration were oral (57%), transdermal (18%), intravenous (18%), subcutaneous (5%), and intraspinal (4%), Therapeutic changes were associated with improvement in physician‐recorded pain intensity and a lower prevalence of cognitive impairment, hallucinations, nausea and vomiting, and myoclonus among patients who were discharged from the hospital. Conclusions. These data illustrate the application of strategies for selections of opioid drugs and their route of administration that are recommended in current guidelines for the management of cancer pain.

Clinical response to morphine in cancer patients and genetic variation in candidate genes

“…Even with the use of these alternative opioids, outcomes are often variable and unpredictable. 3 Moreover, it can be difficult to identify true opioid intolerance in cancer patients, where symptoms such as nausea or cognitive impairment may have multiple underlying aetiologies.…”

Opioid Analgesics in Primary Care: Challenges and New Advances in the Management of Noncancer Pain

“…Because of considerable interpatient variability in opioid responsiveness, it may take several trials of opioid regimens to find the drug that provides the best balance between pain relief and AEs (SORT level C). 37 Neuraxial opioid therapy (intrathecal or epidural) for chronic cancer and noncancer pain has become an increasingly used therapeutic modality in recent years. In general, patients may be considered candidates for neuraxial opioid therapy if conventional opioid therapy is ineffective or not tolerated, and less invasive strategies for managing difficult-to-treat patients (eg, opioid rotation) have failed (SORT level A).…”

“…As detailed in a subsequent section, this clinical heterogeneity has driven the development of opioid rotation, because patients who respond poorly to one opioid frequently achieve a favorable response by switching to another. 37,39 The decision to use strong opioids for the management of chronic pain is influenced by numerous factors, including the specific pain diagnosis, the severity of the pain, whether or not the patient has a history of drug abuse or diversion, the physician's …”

“…50,70 Studies of patients with chronic cancer or noncancer pain have shown that many patients must switch opioid medications at least once, and sometimes as many as 3 to 4 times, before achieving effective analgesia with tolerable AEs. 37,39 In such cases, the availability of multiple opioid analgesics is clearly crucial to achieving clinically satisfactory outcomes, and the development of new opioids or new formulations such as oxymorphone ER and IR, and morphine sulfate ER would provide new options.…”

Pharmacological mechanisms underlying the antinociceptive and tolerance effects of the 6,14-bridged oripavine compound 030418

“…Although opioid-derived alkaloids, particularly morphine, are the standard analgesic drugs of choice in the treatment of moderate to severe pain, these compounds cause various adverse reactions [1,2] . This observation implies that developing other analgesic drugs that exhibit high potency and fewer side effects as alternatives to morphine is still a challenge that remains for pharmacologists and medicinal chemists [3] .…”