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Opioids in cancer-related pain: current situation and outlook

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Abstract

Purpose

Despite progress in treatments, cancer pain remains underestimated, poorly assessed and under-treated. Prescribing strong opioids, because of their specificities, requires precision in management considering their pharmacology but also a clear understanding of recommendations. Some clinicians highlight the risk of addiction, excessive sedation and respiratory depression and their need for information. Our objective in this review is to suggest some clinical guidance for the positioning and daily use of opioids within cancer pain management.

Methods

Critical reflection based on literature analysis and clinical practice.

Results

Strong opioids may be initiated as soon as pain diagnosis is defined. Factors to consider are pain aetiology, opioid pharmacokinetics and pharmacodynamics, genetic polymorphism, physiology (age, gender, weight and pregnancy), comorbidities (especially renal, hepatic, cardiovascular diseases), chronobiology, environmental factors, medication interference and treatment adherence. Achieving the best-balanced opioid treatment for background pain is complex, mainly due to the variable benefit/risk ratio between individuals and the experience of breakthrough cancer pain. Opioid initiation alongside a dynamic reassessment of pain should be fully integrated into the patient’s management to optimise analgesia. The efficacy and safety of a strong opioid treatment need to be re-evaluated and adapted to individuals constantly as it varies over time.

Conclusions

Cancer pain is multimorphic and permanently changing due to disease evolution, curative treatments and disruptive events (concomitant treatments, pain from associated disease, comorbidities and complications, modifications of the environment). Well-managed opioids are the cornerstone of a complex environment requiring multidisciplinary dynamic assessments integrated into the patient’s care pathway.

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Acknowledgements

Support was provided by Xavier Amores, M.D.; Viorica Braniste, M.D. & Ph.D. (Kyowa Kirin); Robert Campos Oriola, Ph.D and Marie-Odile Barbaza, MD, (Auxesia) for manuscript preparation.

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Authors and Affiliations

  1. Pain Management Unit, Hospital Saint-Louis, Paris, France

    Brigitte George

  2. Anaesthesia-Intensive Care Department, Cancer Centre Georges François Leclerc, Dijon, France

    Christian Minello

  3. Pain Management Unit, Mutualist Clinic of la Porte-de-Lorient, Lorient, France

    Gilles Allano

  4. Pain Management Centre, Grenoble-Alpes University Hospital, Grenoble, France

    Caroline Maindet

  5. Department of Supportive Care, Institut Curie, PSL Research University, Paris, France

    Alexis Burnod

  6. Oncology and Medical Specialties Department, Valenciennes General Hospital, Valenciennes, France

    Antoine Lemaire

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Brigitte George reports non-financial support from Kyowa Kirin, during the conduct of the submitted work; personal fees and non-financial support from Mundipharma, non-financial support from Grunenthal and Kyowa Kirin, outside the submitted work; participation to a clinical study without honoraria from Bouchara. Christian Minello reports non-financial support from Kyowa Kirin, during the conduct of the submitted work; personal fees and non-financial support from Takeda, and non-financial support from Kyowa Kirin, Mundi Pharma, Mylan Pharma and Grunenthal, outside the submitted work. Gilles Allano reports non-financial support from Kyowa Kirin, during the conduct of the submitted work; personal fees and non-financial support from Grunenthal, Mundipharma and Medtronic, and non-financial support from Kyowa Kirin, outside the submitted work. Caroline Maindet reports non-financial support from Kyowa Kirin, during the conduct of the submitted work; personal fees and non-financial support from Mundipharma, and non-financial support from Kyowa Kirin, Grunenthal, Hospira, Takeda, and Janssen Cilag, outside the submitted work. Alexis Burnod reports non-financial support from Kyowa Kirin, during the conduct of the submitted work; non-financial support from Kyowa Kirin, outside the submitted work. Antoine Lemaire reports non-financial support from Kyowa Kirin France, during the conduct of the submitted work; personal fees and non-financial support from Kyowa Kirin International, Mundi Pharma, Grunenthal and Takeda, personal fees from Mylan, and non-financial support from Kyowa Kirin France, Archimèdes Pharma, Teva, Prostrakan, outside the submitted work.

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George, B., Minello, C., Allano, G. et al. Opioids in cancer-related pain: current situation and outlook. Support Care Cancer 27, 3105–3118 (2019). https://doi.org/10.1007/s00520-019-04828-8

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