Opioid Dose Titration for Severe Cancer Pain: A Systematic Evidence-Based Review

Abstract

Dosing strategies to achieve rapid analgesia in patients with severe or crescendo cancer pain are important. A systematic review of research trials for treatment of severe or crescendo cancer pain was conducted; nine studies were identified. Eight trials were prospective; two were randomized between different dosing strategies. Dosing frequency predicted onset to analgesia regardless of baseline opioid dose. None of the trials were associated with evidence of respiratory depression. The studies all suffered significant methodological problems limiting broad conclusions. Until better data exist, opioid dose titration for severe/crescendo pain will be guided by expert opinion and experience.

Pain and palliative medicine

“…If orders are easily available and training is present, care will be delivered. One area is the art of opioid titration for cancer pain, where the evidence base is weak [94]. A protocol that can be carried out by nurses with physician supervision has been developed and tested in 27 patients and is now undergoing further clinical trials [95].…”

Use of Opioid Analgesics Among Older Persons With Colorectal Cancer in Two Health Districts With Palliative Care Programs

“…Indeed, a common misconception is that opioid use will hasten death through respiratory depression, 38 although there is little evidence to support this belief when the drugs are appropriately titrated. 11,39,40 Reid et al 37 found that some cancer patients perceived opioids as a "last resort" for pain control and thus interpreted their physicians' offer of morphine for pain relief as a signal that death was near, rejecting the opioid as a consequence.…”

Solving Inverse Problems for Mechanistic Systems Biology Models with Unknown Inputs

“…Identified as one of the Grand Challenges for Engineering in the 21 st century by the National Academy of Engineering [2], it is a goal that today's biomedical engineering community strives to fulfill in order to make ground-breaking changes to current medical services offered as "one size fits all," such as titration of opioid for pain that is guided by expert opinion and experience [3] and vasopressor therapy titrated to mean arterial pressure greater than a fixed threshold value [4].…”

“…Considering that today's personalized medicine still relies heavily on manual drug titration (e.g., pain medicine [3] and vasopressor [4]) and population-based therapeutic index/drug levels (e.g., cancer [6], [7]), and also as evidenced by recent initiatives arising in academia (e.g., [8]), technological leap in systems biology including pharmacogenomics, pharmacokinetics, pharmacodynamics etc. can catalyze fundamental changes in the next-generation healthcare, by predicting the risk of disease development in an individual and providing personalized treatment recommendations such as automated drug selection and dose adjustments.…”