Best Practices for Optimizing Opioid Therapy in Patients with Cancer Pain

The COVID-19 pandemic may have temporarily overshadowed the opioid crisis in the United States, but deaths related to opioid overdose have risen to an all-time high in the past year. Although largely driven by synthetic opioids such as illicit fentanyl, frequently prescribed opioids have played a role in opioid overdose and opioid use disorder as well.

At the 2021 Hematology/Oncology Pharmacy Association annual conference, a panel of oncology pharmacists presented a stewardship approach to opioid therapy, focusing on the safe use of opioid analgesics in patients with cancer, who are significantly more likely to receive opioid therapy than individuals without a history of cancer. Reducing unnecessary fear of opioid use in patients with cancer is a critical part of an opioid stewardship model, according to Rabia Atayee, PharmD, BCPS, APh, Professor of Clinical Pharmacy, Palliative Care Specialist Pharmacist, University of California, San Diego, La Jolla.

“Understanding the basis of fear is important,” Dr Atayee said. “Ninety percent of the time it is related to fears of addiction or the stigma of being on pain medication, but there may be other issues related to suffering as part of their spiritual journey.”

Prescribing a pain management regimen should involve a shared decision-making approach. Providers should:

  • Use the lowest effective dose
  • Review monitoring parameters with patients
  • Give a 1-time dose of the opioid to maximum concentration and monitor with the patient (if feasible)
  • Consider using nonopioid analgesics, or opioids that the patient may not fear as much, given the patient’s underlying fear
  • Consider a nonpharmacotherapy treatment plan for pain management
  • Maintain continued communication between the patient (or the caregiver/loved ones) and providers.

“Although it’s important for providers to recognize that pain management may not be as optimal as they would like it to be, it’s also important not to swing the pendulum too far,” said Dr Atayee. “The goal is to minimize suffering.”

Cancer-related pain affects up to 50% of patients who are receiving active treatment and more than 70% of patients with advanced cancer, said Tanya J. Uritsky, PharmD, Clinical Pharmacy Specialist, Pain Medication Stewardship, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia.

The management of cancer pain can require high doses of opioids, Dr Uritsky said. Although some people may think that the goal of opioid stewardship is to decrease opioid consumption, the intent is rather the incorporation of appropriate prescribing and the safe use of opioids, with harm reduction measures to optimize analgesia and patient care.

“We should be mindful of the opioid epidemic, but we don’t want to lose sight of improved clinical outcomes,” she observed. “We must be careful not to jeopardize pain control just because we need to target certain guideline recommendations.”

The Centers for Medicare & Medicaid Services guidelines for chronic pain recommend a prescription drug monitoring program review and urine drug screening, daily limits of 90-mg morphine equivalents and prescription limits of 7 days, and the suggestion to taper off if there is no improvement in pain reduction.

The National Comprehensive Cancer Network (NCCN) guidelines recommend the use of caution when prescribing opioids concomitant with other sedating medications. The NCCN guidelines also list the following possible interventions: pain medication diaries; pill counts; more frequent outpatient visits/smaller quantity prescribing; lowest effective dose; multimodal analgesia; early referral to interventional pain specialists; education on appropriate disposal; and decreased doses if possible.1

“Common themes endorsed by all guidelines are the use of nonpharmacologic therapy and nonopioid pharmacologic therapy, and the assessment of an individual’s likely benefit and risk prior to initiating opioid treatment,” said Dr Uritsky. “Providers should also develop and implement strategies to minimize the risk of opioid misuse based on patient history and risk factors, and this should be followed with continuous monitoring and regular evaluations of effectiveness and necessity of opioid therapy.”

The importance of risk stratification cannot be overemphasized when prescribing opioids, said Julie Waldfogel, PharmD, BCGP, CPE, Clinical Pharmacy Specialist, the Johns Hopkins Hospital, Baltimore, MD.

The most common opioid risk assessment tools for patients with cancer are the CAGE (Cut Down, Annoyed, Guilty, and Eye Opener), and the SOAPP-R (Screener and Opioid Assessment for Patients with Pain–Revised) approaches.

When responding to aberrant behavior, Dr Waldfogel encourages the use of nonjudgmental discussion, as well as statements of nonabandonment. She also recommends establishing ahead of time referral links to substance use disorder and mental health services in the area.

“We should base our decisions on universal precautions, which means everybody receives monitoring, regardless; but we might change the frequency of that monitoring, depending on their risk level,” Dr Waldfogel advised. “It’s important to help change risk factors that can be changed, but if things can’t be changed, remember to prescribe naloxone when appropriate, and to teach patients about safe use and disposal,” she added.

“Finally, don’t forget to keep checking in with patients and reassessing benefits and risks,” Dr Waldfogel concluded.


  1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Adult Cancer Pain. Version 1.2021. February 26, 2021. Accessed May 12, 2021.

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