Continued treatment with methadone or buprenorphine-naloxone is appropriate for patients with cancer-related pain and opioid use disorder (OUD), but the patient’s prognosis should inform the decision to add full-agonist opioids to treatment, according to expert consensus published in JAMA Network Open.
Researchers convened 2 panels of palliative care and/or addiction experts to develop consensus on the management of pain in patients with advanced cancer and OUD.
The 120 experts reviewed 2 clinical scenarios that described a 50-year-old patient with advanced cancer who was receiving anticancer treatment, had cancer-related pain, and had OUD.
The patient was treated with buprenorphine-naloxone in one scenario and with methadone in another. The patient’s prognosis was weeks to months for one panel and months to years for the other.
Dosing, Switching, and Adding Treatment
The panel members agreed that, for the patient receiving long-term daily buprenorphine-naloxone, continuing that treatment, with thrice-daily dosing, is preferred.
For the patient receiving methadone daily from a clinic, the experts recommended that the clinician take over prescribing and the patient receive 2 or 3 doses of methadone a day.
If pain was not adequately controlled for the patient receiving buprenorphine-naloxone 3 times a day, the experts agreed that switching to methadone 3 times a day is acceptable. Panel members did not recommend switching from methadone to buprenorphine-naloxone.
For a patient with a prognosis of weeks to months, the experts agreed that continuing buprenorphine-naloxone or methadone and adding a full-agonist opioid was appropriate if pain was not controlled.
The panel members were uncertain about the appropriateness of adding a full-agonist opioid for a patient with a prognosis of months to years. This decision might depend on the patient-practitioner relationship, the feasibility of close monitoring, and the planned duration of use.
The experts were uncertain about discontinuing buprenorphine-naloxone and starting a full-agonist opioid other than methadone for a patient with a prognosis of weeks to months. However, this approach was deemed inappropriate for a patient with a prognosis of months to years.
The experts also deemed it inappropriate to discontinue methadone and start a full-agonist opioid, regardless of prognosis.
“The findings of this qualitative study provide urgently needed, consensus-based guidance for clinicians and highlight critical research and policy gaps needed to facilitate implementation,” the study authors concluded.
Disclosures: Some study authors declared affiliations with various organizations and companies. Please see the original reference for a full list of disclosures.
Merlin JS, Khodyakov D, Arnold R, et al. Expert panel consensus on management of advanced cancer-related pain in individuals with opioid use disorder. JAMA Netw Open. Published online December 28, 2021. doi:10.1001/jamanetworkopen.2021.39968