How should clinicians prescribe opioids for cancer-related pain in patients who use cocaine or methamphetamines?

Clinicians treating cancer-related pain must consider whether and how to prescribe opioids to patients who use non-medical stimulants such as cocaine and methamphetamines; however, no guidelines exist related to these common and challenging situations.

In a new study, palliative care and addiction experts deemed it appropriate to continue opioids, increase monitoring, and avoid opioid tapering in such patients. The results, "Expert consensus-based guidance on approaches to opioid management in individuals with advanced cancer-related pain and non-medical stimulant use," are published online in the journal Cancer.

Using opioids and non-medical stimulants together may increase the risk of various harms, including overdose and death. These harms may be especially pronounced in people with cancer, who may have compromised health and take multiple other medications.

To provide guidance on opioid management strategies for people with advanced cancer who use methamphetamines or cocaine, researchers recruited 120 palliative care and addiction experts and asked them to consider two different scenarios.

In the first, a patient's prognosis was weeks to months, and in the second, the prognosis was months to years. Experts reviewed, rated, and commented on the cases. They used a scale from 1 (very inappropriate) to 9 (very appropriate) to rate their opinions about different care-related actions, and they explained their responses.

The experts agreed that regardless of prognosis, clinicians should increase monitoring and continue opioids, without tapering. Such management strategies prioritize pain control and allow clinicians time to develop individualized harm-reduction approaches and refer to addiction specialists when appropriate.

The use of buprenorphine/naloxone (an opioid medication that has a lower risk for overdose) was considered potentially appropriate in people with a longer prognosis, but inappropriate in people with a shorter prognosis. The experts noted that strategies aimed at reducing harms include frequent visits and patient education about the impurity and high potency of stimulant supplies, which often include illicit fentanyl.

"The study findings provide consensus-based guidance for clinicians who treat cancer-related pain and encounter stimulant use, and include management strategies they can bring immediately to their practice," said lead author Dr. Katie Fitzgerald Jones of the VA Boston Healthcare System. "The results highlight a need for integrated care models to address substance use during cancer and create a research agenda that prioritizes substance use disorder as an important comorbidity in people with cancer."