Palliative Care Improves Pain Control with Reduced Opioid Use in Patients with Advanced Cancer

Web Exclusives — June 16, 2020

San Francisco, CA—Reducing pain without increasing the use of opioids is feasible in patients with advanced cancer, according to the results of a retrospective analysis presented at the 2019 ASCO Supportive Care in Oncology Symposium. Among the 300 patients seen by an inpatient palliative care team, 50% of patients achieved clinically improved pain control without an increase in oral morphine-equivalent daily dose.

“These data suggest that a multidimensional palliative care intervention is effective in improving pain control in many opioid-tolerant patients in the absence of an opioid dose increase,” said Ali Haider, MD, MBBS, Assistant Professor, Department of Palliative, Rehabilitation and Integrative Medicine, M.D. Anderson Cancer Center, Houston, TX.

A 30% increase in the total daily opioid dose is recommended for opioid-tolerant patients who are hospitalized with moderate-to-severe cancer pain, but opioid rotation and/or dose reduction have also been effective analgesic techniques, Dr Haider said. He added that because cancer pain is multidimensional, adjuvant medications and nonpharmacologic strategies can improve pain control.

Dr Haider and colleagues reviewed consecutive patients referred to their inpatient palliative care team between December 2017 and April 2018. The study included all patients who were receiving opioid medications and had at least 2 consecutive palliative consultations and an Edmonton Symptom Assessment Scale score of ≥4. Patients who had delirium based on the Memorial Delirium Assessment Scale were excluded from the analysis.

The study’s primary outcome was the achievement of clinically improved pain control at follow-up day 1, which required meeting the 3 criteria of documentation of pain as “well-controlled,” “better,” or “comfortable”; the absence of new and/or worsening pain; and the absence of opioid-induced neurotoxicity.

The researchers also assessed the patients’ demographics and clinical variables, including cancer type; opioid prescription type, route, oral morphine-equivalent daily dose; the presence of opioid rotation; psychological consultation; and changes in adjuvant medications (ie, corticosteroids, benzodiazepines, and neuroleptics).

The patients were divided into 2 groups: those who achieved clinically improved pain without an increase in opioids and those who had better pain control with an increase in daily opioid dose.

Improved Pain Control without Increasing Opioid Dose

Patient demographics (eg, age, sex, race, cancer type, and marital factors) were balanced in both groups, and patients had no significant risk for nonmedical opioid use. Of the 300 patients in the study, 196 (65%) achieved clinically improved pain control. Of those who achieved pain control, 85 (43%) did so without an increase in oral morphine-equivalent daily dose.

Patients who required an increase in opioids to achieve pain control had higher levels of fatigue, nausea, spiritual pain, and overall symptom distress. By contrast, improved pain control without opioid dose increase was associated with more adjuvant medication changes and less opioid drug rotation.

According to Dr Haider, a multidimensional palliative care intervention may be one reason for improved pain control by patients, but the study was limited by its observational design. Dr Haider pointed out that what is really needed to answer this question is the gold standard of research—a randomized controlled clinical trial focused on cancer pain in the hospitalized setting.

For oncologists who do not have access to inpatient palliative care services, Dr Haider noted that there are still opioid alternatives for pain relief. He discussed the concept introduced by Dame Cicely Saunders of total pain, which includes physical, emotional, social, and spiritual elements, and underscored the importance of careful consideration of patient narratives. Dr Haider also highlighted the significant impact that can be made in pain control through the use of counselors, social workers, and especially psychologists.

“This is just based on observational data, but there’s no doubt that our psychologists make a huge difference,” he concluded. “It’s really hard to highlight in a clinical study, but our psychologists are able to spend at least an hour with our patients, and this time has an enormous impact in the days that follow. Without this consultation, I don’t think we would be able to achieve the same response.”

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