Palliative Care Improves Pain Control with Less Opioids in Advanced Cancer

Reducing pain without increasing opioids is feasible in patients with advanced cancer, according to results presented at the 2019 ASCO Supportive Care in Oncology Symposium. In a retrospective analysis of 300 patients with advanced cancer receiving inpatient palliative care services, researchers found that nearly half of patients who achieved clinically improved pain did so 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 opioid dose increase,” said Ali Haider, MD, MBBS, Assistant Professor, Department of Palliative, Rehabilitation, and Integrative Medicine, Division of Cancer Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX.

According to Dr Haider, although a 30% increase in total daily opioid dose is recommended for opioid-tolerant patients who are hospitalized with moderate-to-severe cancer pain, opioid rotation and/or dose reduction have also been shown to be effective analgesic techniques. In addition, because cancer pain is multidimensional, adjuvant medications and nonpharmacologic strategies can improve pain control, he added.

For their analysis, Dr Haider and colleagues reviewed consecutive patients referred to their inpatient palliative care team between December 2017 and April 2018. The analysis included all patients receiving opioid medications who 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 end point was the achievement of clinically improved pain at follow-up day 1, which required meeting 3 criteria: documentation of pain as either “well-controlled,” “better,” or “comfortable”; the absence of new and/or worsening pain; and the absence of opioid-induced neurotoxicity.

The researchers also 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). Patients were divided into 2 groups: those who achieved clinically improved pain without an increase in opioids (the control group) and those who had better pain control with an increase in daily opioid dose.

Clinically Improved Pain without Increased Opioid Dose

As Dr Haider reported, demographics such as age, sex, race, cancer type, and marital factors were balanced in both groups, and risk factors for nonmedical opioid use were not significant. Of the 300 patients analyzed in the study, 65% (N = 196) achieved clinically improved pain. Notably, said Dr Haider, of those who achieved clinically improved pain, 43% (N = 85) did so without an increase in oral morphine equivalent daily dose.

Although patients in both groups were obviously fatigued, those who required an increase in opioids to achieve clinically improved pain had higher levels of fatigue, nausea, spiritual pain, and overall symptom distress. By contrast, clinically improved pain without opioid dose increase was associated with more adjuvant medication changes and less opioid rotation.

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

For oncologists who do not have access to inpatient palliative care services, however, Dr Haider noted that there are still opioid alternatives for pain relief. He shared the concept introduced by Dame Cicely Saunders of “total pain,” which includes the physical, emotional, social, and spiritual dimensions, and underscored the importance of paying systematic attention to patient narratives. Dr Haider also highlighted the significant impact that can be made by utilizing 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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