For opioid-tolerant patients with advanced cancer experiencing pain, relief does not necessarily have to come from a higher dose of opioids, according to findings presented at the 2019 Supportive Care in Oncology Symposium.1 The results of a retrospective analysis of 300 patients with advanced cancer receiving inpatient palliative care services showed that nearly half of patients who achieved clinically improved pain did so without an increase in an oral morphine equivalent daily dose. These outcomes suggest that a multidimensional palliative care intervention may prove to be effective in improving pain control in many opioid-tolerant patients without greater reliance on opioids, according to the study authors.
Ali Haider, MD
“Due to the multidimensional nature of cancer pain, nonopioid analgesics such as adjuvant medications and nonpharmacologic strategies such as counseling can be effective in reducing pain,” said Ali Haider, MD, Assistant Professor, Department of Palliative, Rehabilitation, and Integrative Medicine at The University of Texas MD Anderson Cancer Center, Houston. “However, we need a randomized controlled trial that is more focused on cancer pain in the hospitalized setting to confirm these findings.”
As Dr. Haider reported, for opioid-tolerant patients who are hospitalized with moderate-to-severe cancer pain, an increase of 30% of their total daily dose is recommended to achieve an effective analgesic response. However, other techniques, such as opioid rotation and opioid reduction in patients with hyperalgesia, have been shown to be effective. Adjuvant medications and nonpharmacologic strategies such as counseling have also demonstrated analgesic effects, said Dr. Haider.
To examine these nonopioid analgesic strategies, Dr. Haider and colleagues performed a retrospective observational chart review of consecutive inpatient palliative care consultations between December 2017 and April 2018 at a single institution. Patients on opioid medications who had at least two consecutive visits with the inpatient palliative care team and an Edmonton Symptom Assessment Scale (ESAS) pain score of at least 4 at consultation were included in the analysis. The researchers excluded patients who had delirium based on the Memorial Delirium Assessment Scale.
Dr. Haider and colleagues assessed patient demographics and clinical variables, including cancer type, opioid prescription data (type, route, oral morphine equivalent daily dose), presence of opioid rotation, psychological consultation, and changes in adjuvant medications (eg, corticosteroids, benzodiazepines, and neuroleptics). Demographic variables, such as age, gender, race, cancer type, and marital status, were well balanced between groups, and risk factors for nonmedical opioid use were not significant, Dr. Haider reported.
The study’s primary outcome was the achievement of clinically improved pain at follow-up day 1, which required meeting three criteria: (1) documentation of pain as either “well controlled,” “better,” or “comfortable;” (2) absence of new and/or worsening pain; and (3) absence of opioid-induced neurotoxicity.
Clinically Improved Pain Without More Opioids
As Dr. Haider reported, of the 300 patients analyzed in the study, clinically improved pain was achieved in 65% of patients (n = 196). It is important to note that of those patients who achieved clinically improved pain, 43% (n = 85) did so without an increase in an oral morphine equivalent daily dose.
Patients who achieved clinically improved pain with and without an increase in opioid consumption had a median pain score of 8 and 7, respectively. Although patients in both groups were fatigued, said Dr. Haider, patients who achieved clinically improved pain with an increase in an oral morphine equivalent daily dose had higher levels of fatigue, nausea, spiritual pain, and overall symptom distress. However, the baseline oral morphine equivalent daily dose did not differ between groups.
Finally, multivariate analysis showed that clinically improved pain without an increase in an oral morphine equivalent daily dose was associated with more adjuvant medication changes (P = .003), less opioid rotation (P = .005), and lower scores on symptom distress scale of ESAS (P = .04).
Although these findings bolster the rationale for employing multidimensional palliative care services, Dr. Haider acknowledged that the gold standard of a randomized controlled trial is needed to confirm the effectiveness of nonopioid analgesics for pain control.
Dr. Haider concluded his presentation by highlighting the words of Dame Cicely Saunders, an English doctor and pioneer in the field of palliative care: “Dr. Saunders introduced the idea of ‘total pain,’ which includes the physical, emotional, social, and spiritual dimensions of distress … and paid systematic attention to patient narratives,” said Dr. Haider. “The lesson is: Even if you don’t have palliative care services available, what is needed, besides opioid knowledge, is sitting with the patient, exploring a good history, and touching base with nonphysical aspects of care. Using psychologists, counselors, and social workers can be very effective as well.”
Closer Look at Study’s Palliative Intervention
Candice A. Johnstone, MD, MPH
Candice A. Johnstone, MD, MPH, Associate Professor at the Medical College of Wisconsin and Medical Director of Radiation Oncology, Kramer Cancer Center, St. Joseph’s West Bend, asked Dr. Haider to expound on the multidimensional palliative intervention used in the study. “Who were the team members, and what might have helped patients achieve pain control if opioids were not increased?” Dr. Johnstone asked.
“The definition of adjuvant medication included the use of gabapentinoids, less use of benzodiazepines, more use of neuroleptics, and obviously consulting our counselors and psychologists,” Dr. Haider replied. “Other than the psychological consultation, we lumped some of those adjuvant changes into one group. However, because of the retrospective nature of the study and the sample size, it’s difficult to know exactly which intervention made the difference.”
Anecdotally, however, Dr. Haider underscored the role played by psychologists in the inpatient palliative care team. “It’s difficult to highlight in a clinical study, but our psychologists do a wonderful job,” commented Dr. Haider. “Because they spend a considerable amount of time with the patient, they can have a huge impact. Without them, it’s hard to imagine we could achieve the same response.” ■
DISCLOSURE: Drs. Haider and Johnstone reported no conflicts of interest.
1. Haider A, Qian Y, Lu Z, et al: Factors associated with improvement in uncontrolled cancer pain without increasing opioid daily dose among patients seen by an inpatient palliative care team. 2019 Supportive Care in Oncology Symposium. Abstract 9. Presented October 25, 2019.