Expert Panel Consensus on Management of Advanced Cancer–Related Pain in Individuals With Opioid Use Disorder

Abstract

IMPORTANCE Opioid use disorder (OUD) is an important comorbidity in individuals with advanced cancer, in whom pain is common. Full-agonist opioid medications are the cornerstone of cancer pain management, but the existing literature does not address how to manage cancer pain in patients with OUD. OBJECTIVETo conduct an expert panel to develop consensus on the appropriateness of management of cancer pain in individuals with co-occurring advanced cancer and OUD.EVIDENCE REVIEW A 3-round modified Delphi process was completed from August to October 2020 with 2 cases: patient with advanced cancer, pain, and OUD treated with buprenorphinenaloxone or methadone. Participants rated management strategies in round 1, discussed results in round 2, and provided final responses in round 3. ExpertLens, an online approach to conducting modified Delphi panels, was used. Participants were experts in palliative care, addiction, or both, recruited by email from palliative care and addiction-focused professional groups, lists from prior studies, and snowball sampling. Data analysis was performed from November 2020 to July 2021. FINDINGSOf 120 experts (median age, 40-49 years), most were White (78 participants [94%]), female (74 participants [62%]), and held MD or DO degrees (115 participants [96%]); 84 (70%)participated in all rounds. For a patient with OUD taking buprenorphine-naloxone, it was deemed appropriate to continue buprenorphine-naloxone with thrice-daily dosing. Continuing buprenorphine-naloxone and adding a full-agonist opioid was deemed to be appropriate for patients with a prognosis of weeks to months and of uncertain appropriateness for patients with a prognosis of months to years. For a patient with OUD taking methadone dispensed at a methadone clinic, it was deemed appropriate to take over prescribing and dose twice or thrice daily. Continuing methadone daily while adding another full-agonist opioid was deemed appropriate for patients with a prognosis of weeks to months and of uncertain appropriateness for those with a prognosis of months to years. CONCLUSIONS AND RELEVANCEThe findings of this qualitative study provide urgently needed, consensus-based guidance for clinicians and highlight critical research and policy gaps needed to facilitate implementation.

Palliative care interventions for people who use substances during communicable disease outbreaks: a scoping review

“…This review identified non-pharmacologic and pharmacologic recommendations for people who use substances, including opioid prescribing strategies for people on OAT. These recommendations are consistent with expert consensus recommendations about safer opioid prescribing for people receiving palliative care51 and management of advanced cancer-related pain in people with opioid use disorder 52. Based on individual circumstances and barriers, care plans should be individualised and adapted to provide high-quality, trauma-informed care that does not exacerbate barriers to care.…”

“…These recommendations are consistent with expert consensus recommendations about safer opioid prescribing for people receiving palliative care 51 and management of advanced cancer-related pain in people with opioid use disorder. 52 Based on individual circumstances and barriers, care plans should be individualised and adapted to provide high-quality, traumainformed care that does not exacerbate barriers to care. Furthermore, the majority of the knowledge about Open access symptom management during communicable disease outbreaks was from studies and guidelines about palliative care in community settings (eg, home), acute care units and palliative care units in high-income countries (USA, Canada and UK).…”

Expert Panel Consensus on State-Level Policies to Improve Engagement and Retention in Treatment for Opioid Use Disorder

“…24 To address this need, we conducted an online modified Delphi process to identify expert consensus on the effectiveness and implementability of different components of state-level OUD treatment policies. Delphi panels, which have been used to characterize effective alcohol policies, 25 drug policies, 26 and pain management strategies, 27 are a prominent and rigorous method for eliciting expert consensus to generate guidance on health-related policies in the absence of sufficiently conclusive scientific evidence for decision-making. 25,28…”

A Case for Palliative Care and Addiction Specialists Collaboration and Joint Research

“…This qualitative study solicited the opinion of 120 experts in palliative care, addiction, or both, of whom 70% participated in all 3 rounds. 5 Participants were asked to give recommendations on managing cancer pain in patients with advanced cancer and OUD treated with buprenorphine-naloxone or methadone. The variety of opinions among the experts in palliative care and addiction was striking.…”

“…Most responders deemed it appropriate for palliative care clinicians to prescribe methadone 2 to 3 times a day. 5 Although methadone is an effective analgesic used in cancer pain management, most experts agreed to remove the patient with OUD from a structured methadone maintenance program known to provide not only methadone but also monitoring in a way not done in the oncology setting (eg, daily or weekly urine drug screening and frequent visits with clinicians trained in addiction). The methadone maintenance program also provides counseling and behavioral therapies for a whole-patient approach to the treatment of substance use disorders.…”