Opioid Rotation in Cancer Pain Treatment

Schuster, Michael W.; Bayer, Oliver; Heid, F.; Laufenberg-Feldmann, R.

doi:10.3238/arztebl.2018.0135

Cited by 37 publications

(40 citation statements)

References 74 publications

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“…This approach is known as opioid rotation. 149,196,197 Establishing equianalgesic dosing can be challenging; studies have sought to establish safe conversion ratios and methods. [198][199][200][201][202] It is important to consider relative effectiveness when switching between oral and parenteral routes to avoid subsequent overdosing or underdosing.…”

Section: Opioid Rotationmentioning

confidence: 99%

Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

Swarm

Paice

Anghelescu

et al. 2019

Journal of the National Comprehensive Cancer Network

380

282

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In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.

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Section: Opioid Rotationmentioning

confidence: 99%

Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

Swarm

Paice

Anghelescu

et al. 2019

Journal of the National Comprehensive Cancer Network

380

282

View full text Add to dashboard Cite

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“…Opioid rotation may become necessary in 20-44% cancer pain patients which could lead to clinical improvement in about 40-80% of them upon rotation. [ 48 49 ]…”

Section: Discussionmentioning

confidence: 99%

“…[ 23 36 50 ] Opioid conversion to methadone should be done under clinical supervision with individualized dose titration to prevent serious adverse effects. [ 47 48 49 51 ]…”

Section: Discussionmentioning

confidence: 99%

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Methadone in Cancer Pain

Ramkiran

Thota

2020

Indian J Palliat Care

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Methadone has been an unique, versatile, cost effective, synthetic opioid utilized in nociceptive as well as neuropathic pain. Pain and palliative care physicians started accepting methadone in treatment of complex pain associated with advanced cancer and neuropathic pain syndromes in which conventional opioids were no longer effective. The challenge is in accepting methadone as a main stream first line opioid, from being considered as a second line replacement/substitution drug all these years. Methadone has a significant role as opioid rotation in refractory cancer pain, especially when started early leading to successful conversion. Advantages of methadone in paediatric patients with advanced cancer were its safety and efficacy as a first-choice opioid, availability as a liquid formulation and its infrequent dose requirements. Methadone is neither recommended nor justified to be used as an anti-cancer drug and its role as an anti-cancer agent is a misconception. Many guidelines were proposed after 2008 to address methadone safety. Most of them emphasized on prevention of cardiac arrhythmia and association of methadone with QTc prolongation rather than address the real issue. Methadone has been established to be safe when used in opioid naïve patients with careful titration instituted in an ambulatory setting and has equal success in opioid rotation in outpatient setup. Methadone prescription should be carried out by experienced pain and palliative care providers with careful dose titration and clinical monitoring.

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“…Tables of equianalgesic doses should be considered no more than a rough guide for determining the dose of the new drug. [ 24 ] A common practice is to reduce the initial converted dose by 25%–50% due to incomplete cross-tolerance. [ 25 29 30 ]…”

Section: Ethodsmentioning

confidence: 99%

Indian society for study of pain, cancer pain special interest group guidelines on pharmacological management of cancer pain (Part II)

Thota

Ramanjulu

Ahmed³

et al. 2020

Indian J Palliat Care

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The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group (SIG) guidelines on pharmacological management of cancer pain in adults provide a structured, stepwise approach, which will help to improve the management of cancer pain and to provide the patients with a minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire, based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking, was made available on the ISSP website and circulated by e-mail to all the ISSP and Indian Association of Palliative Care members. We recommend that analgesics for cancer pain management should follow the World Health Organization 3-step analgesic ladder appropriate for the severity of pain. The use of paracetamol and nonsteroidal anti-inflammatory drugs alone or in combination with opioids for mild-to-moderate pain should be used. For mild-to-moderate pain, weak opioids such as tramadol, tapentadol, and codeine can be given in combination with nonopioid analgesics. We recommend morphine as the opioid of the first choice for moderate-to-severe cancer pain. Sustained-release formulations can be started 12 hourly, once the effective 24 h dose with immediate-release morphine is established. Opioid switch or rotation should be considered if there is inadequate analgesia or intolerable side effects. For opioid-induced respiratory depression, μ receptor antagonists (e.g. naloxone) must be used promptly. Antidepressants and/or anticonvulsants should be used to treat neuropathic cancer pain, and the dose should be titrated according to the clinical response and side effects. External beam radiotherapy should be offered to all patients with painful metastatic bone pain. There is evidence on use of ketamine in cancer neuropathic pain, but with no beneficial effect, thus, it is not recommended.

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Opioid Rotation in Cancer Pain Treatment

Cited by 37 publications

References 74 publications

Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

Methadone in Cancer Pain

Indian society for study of pain, cancer pain special interest group guidelines on pharmacological management of cancer pain (Part II)

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