From the Guidelines
Opioids are generally considered superior to other pain medications for managing moderate to severe cancer-related pain, as they provide effective pain relief with a flexible dosing regimen, allowing for individualized treatment plans. According to the most recent and highest quality study, 1, opioids have been shown to effectively reduce pain in patients with moderate-to-severe cancer pain, with well-characterized adverse effects. The study highlights the importance of a multimodal approach to pain management, incorporating non-opioid analgesics and adjuvant medications as needed.
When selecting an opioid, it is essential to consider the patient's individual needs and medical history. Common opioids used for cancer pain management include morphine, oxycodone, hydromorphone, and fentanyl, with dosing regimens tailored to the patient's pain intensity and response to treatment. For example, morphine can be started at 5-15mg every 4 hours for oral immediate-release, while oxycodone can be initiated at 5-10mg every 4-6 hours.
Key considerations in opioid therapy include:
- Starting with immediate-release formulations and transitioning to extended-release versions once stable dosing is established
- Using rescue doses (usually 10-15% of the 24-hour total dose) to manage breakthrough pain
- Monitoring and managing side effects, such as constipation, nausea, sedation, and respiratory depression
- Incorporating non-opioid analgesics, like acetaminophen or NSAIDs, for mild pain or as adjuncts
- Considering adjuvant medications, such as gabapentinoids, for neuropathic pain
The most recent study, 1, emphasizes the importance of weighing the benefits and risks of long-term opioid use in cancer survivors, considering factors such as pain relief, functional improvement, and potential adverse effects. By prioritizing a patient-centered approach and staying up-to-date with the latest evidence, healthcare providers can optimize cancer pain management and improve patient outcomes.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Opioids in Cancer-Related Pain Management
- Opioids are commonly used to treat moderate or severe cancer pain, and are recommended for this purpose in the World Health Organization (WHO) pain treatment ladder 2.
- The evidence suggests that around 19 out of 20 people with moderate or severe pain who are given opioids and can tolerate them should have that pain reduced to mild or no pain within 14 days 2.
- However, the quality of evidence around the use of opioids for treating cancer pain is disappointingly low, with many studies at high risk of bias from several sources, including small study size 2.
Comparison with Other Pain Medications
- Nonsteroidal anti-inflammatory drugs, including aspirin, piroxicam, diclofenac, ketorolac, and the antidepressant medicine imipramine, may be at least as efficacious as opioids for moderate-to-severe background cancer pain 3.
- Morphine was generally not superior to other opioids, nor did it have a more favorable toxicity profile 3.
- A randomized, open-label, controlled trial found no significant difference between the numbers of patients responding to morphine or oxycodone when used as first-line treatment for cancer-related pain 4.
Efficacy of Specific Opioids
- Transdermal fentanyl has fair evidence for efficacy in cancer pain management, while morphine, tramadol, oxycodone, methadone, and codeine have poor evidence 5.
- A systematic review found that codeine, dihydrocodeine, transdermal fentanyl, hydromorphone, methadone, morphine, oxycodone, and tramadol are all used to treat cancer-related pain, but the quality of evidence for these interventions varies 6.
Adverse Events and Tolerability
- Most people will experience adverse events when taking opioids, and help may be needed to manage the more common undesirable adverse effects such as constipation and nausea 2.
- Between 1 in 10 and 2 in 10 people treated with opioids will find these adverse events intolerable, leading to a change in treatment 2.
- Opioid switching may be necessary to improve outcomes, and there is evidence to support switching between different opioids to achieve better pain control and tolerability 4.