Abstract
A clinical conundrum can occur when a patient with active opioid use disorder (OUD) or at elevated risk for the condition presents with cancer and related painful symptoms. Despite earlier beliefs that cancer patients were relatively unaffected by opioid misuse, it appears that cancer patients have similar risks as the general population for OUD but are more likely to need and take opioids. Treating such patients requires an individualized approach, informed consent, and a shared decision-making model. Tools exist to help stratify patients for risk of OUD. While improved clinician education in pain control is needed, patients too need to be better informed about the risks and benefits of opioids. Patients may fear pain more than OUD, but opioids are not always the most effective pain reliever for a given patient and some patients do not tolerate or want to take opioids. The association of OUD with mental health disorders (dual diagnosis) can also complicate delivery of care as patients with mental health issues may be less adherent to treatment and may use opioids for “chemical coping” as much as for pain control.
Highlights
Pain is prevalent in cancer patients, who have similar risks as the general population for opioid use disorder (OUD) [10]
A meta-analysis reported that pain prevalence was 39% among cancer patients who had curative treatment, 55% among those receiving anticancer treatment, and 66% of those with advanced disease, metastases, or those near end of life [11]
When opioid analgesics are being considered, cancer patients should be assessed for their personal risk for OUD, and the risks and benefits of opioid therapy should be discussed in a shared decision-making model
Summary
A population-based study of cancer patients using the Brief Pain Inventory (BPI) found that 55% had experienced pain in the prior week and this pain was moderate to severe (BPI ≥ 4) in 44% [1]. Even in patients who received curative treatment ≥6 months earlier, moderate to severe pain was reported in 49 and 41%, respectively. This proportion increases to 75 and 70%, respectively, in cancer patients for whom further anticancer treatments are no longer feasible. The inadequate treatment of cancer pain has been further elucidated in a literature review, which reported that 43% of cancer patients had under-treated pain [2]. In 2019, an estimated 17 million Americans with a history of cancer were alive and this number is expected to exceed 22 million by 2030; of this number about two–thirds (67%) were diagnosed with cancer
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