Tuesday, February 17, 2015

Effective prescription of opioids to alleviate cancer related pain

by Akhila Reddy, MD
It is estimated that up to 90% of advanced cancer patients will experience pain and will require opioids during the course of their illness1. Although opioids can effectively treat cancer pain, there are still some challenges associated with their use.

One of the challenges is recognizing and treating opioid induced neurotoxicity (OIN). Timely detection and treatment of OIN will prevent unnecessary opioid dose escalation and consequent adverse effects which may include delirium, myoclonus, excessive sedation, hyperalgesia, and even death. The treatment of OIN is typically identifying and treating the trigger in certain cases along with either opioid dose reduction and/or opioid rotation2-4. Without adequate knowledge of opioid rotation ratios among different opioids, there is a risk for overdosing or uncontrolled pain5.

One such opioid which is frequently the opioid of choice for rotation to is methadone. Methadone is one of the most common opioids used in the treatment of cancer related pain. Prescribing methadone safely involves the knowledge of its metabolism, adverse effects, drug interactions, and also its mechanism of action at various receptor sites in addition to being familiar with the process (one day vs. 3 day switch) of opioid rotation to methadone6-8. A recent study found that 30% of cancer outpatients undergo opioid rotation and almost all cancer patients on opioids visiting a supportive care center will undergo opioid titration. As a consequence of opioid rotations and titrations, our patients may possess several unused or expired opioids. It is reported that 75% of prescription opioid abusers obtain the drug from their family or friends.9 Unsafe practices of storing or using the opioids may lead to increased availability of these drugs for others to misuse10. As clinicians prescribing opioids, it is our duty to educate patients about locking their pain medication, disposing off unused medications safely, and strictly not sharing them with others.
I’m looking forward to an interesting conversation about these topics. Join me @Reddysuppcare for a tweetchat about pain management in cancer patients.
T1: Prescribing opioids and opioid rotation in cancer patients
T2: Methadone in cancer patients
T3: How can palliative care clinicians address prescription opioid abuse?
1. Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. Feb 2012;13(2):e58-68.
2. Reddy A, Yennurajalingam S, Pulivarthi K, et al. Frequency, outcome, and predictors of success within 6 weeks of an opioid rotation among outpatients with cancer receiving strong opioids. Oncologist. 2013;18(2):212-220.
3. Reddy A, Yennurajalingam S, Desai H, et al. The opioid rotation ratio of hydrocodone to strong opioids in cancer patients. Oncologist. Nov 2014;19(11):1186-1193.
4. Mercadante S, Bruera E. Opioid switching: a systematic and critical review. Cancer Treat Rev. Jun 2006;32(4):304-315.
5. Webster LR, Fine PG. Overdose deaths demand a new paradigm for opioid rotation. Pain Med. Apr 2012;13(4):571-574.
6. Parsons HA, de la Cruz M, El Osta B, et al. Methadone initiation and rotation in the outpatient setting for patients with cancer pain. Cancer. Jan 15 2010;116(2):520-528.
7. Reddy A, Yennurajalingam S, Bruera E. Dual opioid therapy using methadone as a coanalgesic. Expert Opin Drug Saf. Nov 5 2014:1-2.
8. Salpeter SR, Buckley JS, Bruera E. The use of very-low-dose methadone for palliative pain control and the prevention of opioid hyperalgesia. J Palliat Med. Jun 2013;16(6):616-622.
9. Centers for Disease Control and Prevention (CDC) grand rounds: Prescription drug overdoses - a U.S. epidemic. MMWR Morb Mortal Wkly Rep 2012. Vol 61:10-13.
10. Reddy A, de la Cruz M, Rodriguez EM, et al. Patterns of storage, use, and disposal of opioids among cancer outpatients. Oncologist. Jul 2014;19(7):780-785.
What: #hpm chat on Twitter
When: Wed 1/7/2015 - 9p ET/ 6p PT
Host: Akhila Reddy, MD 
Facebook Event Listing: https://www.facebook.com/events/1410808352553443/

If you are new to Tweetchats, you do not need a Twitter account to follow along. Try using the search function on Twitter. If you do have a Twitter account, we recommend using nurph.com, for ease of following.

We will be posting the transcript and analytics here after the chat takes place. Chat Transcript and Chat Analytics courtesy of @Symplur

Pallimed | Blogger Template adapted from Mash2 by Bloggermint