Expert Panel Consensus on Management of Advanced Cancer-related Pain in Individuals with Opioid Use Disorder

Abstract

Develop consensus on the appropriateness of cancer pain management strategies in individuals with co-occurring advanced cancer and OUD. Three-round modified-Delphi process with two cases: patient with advanced cancer, pain and OUD treated with buprenorphine/naloxone or methadone. Participants rated management strategies in Round 1, discussed results in Round 2, and provided final responses in Round 3 in an online modified-Delphi panel. Participants included experts in palliative care, addiction, or both, recruited by email from palliative care and addiction-focused professional groups, lists from prior studies, and snowball sampling. Of 120 experts, the majority of whom held MD or DO degrees (115, 96%), 70% participated in all rounds. For a patient with OUD on buprenorphine/naloxone, it was deemed appropriate to continue buprenorphine/naloxone with three-times-per-day dosing. Continuing buprenorphine/naloxone and adding a full-agonist opioid was deemed appropriate for patients with a prognosis of weeks-months, and of uncertain appropriateness for a prognosis of months-years. For a patient with OUD on methadone dispensed at a methadone clinic, it was deemed appropriate to take over prescribing and dose 2-3x/day. Continuing methadone daily while adding another full-agonist opioid was deemed appropriate for patients with a prognosis of weeks-months and of uncertain appropriateness for a prognosis of months-years. This qualitative study, urgently needed, consensus-based guidance for clinicians, and highlighted critical research and policy gaps needed to facilitate implementation. Findings underscore the importance of additional research to investigate optimal dosing of buprenorphine/naloxone and methadone in patients with advanced cancer pain and OUD, and factors influencing the preferred choice. Grant support from the Cambia Health Foundation.