Use of Opioids for Adults with Pain from Cancer or Cancer Treatment

Publication Date: December 5, 2022

Last Updated: May 31, 2023

Overview

This patient guideline summarizes key takeaways from the American Society of Clinical Oncology (ASCO) guideline for the use of opioids for adults with pain from cancer or cancer treatment. The purpose of this guideline is to provide guidance for the safe and effective use of opioids in adults to manage pain caused by cancer or active cancer treatment.

When To Use Opioids

Early and effective pain management improves the quality of life and is a key component of cancer care. (, , , )

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Most patients with moderate to severe pain caused by cancer or active cancer treatment should be offered opioids to help manage pain. (, , , )

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Safe and effective use of opioids requires clear communication among patients and their caregivers. Prior to starting opioids, you should have a detailed discussion with your care team to determine if the potential benefits of opioid therapy will outweigh the potential risks. (, , , )

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Patient and Care Team Discussion - Before Starting Opioids

Discuss your goals and expectations
Identify what is causing your pain
Track the intensity of your pain
Discuss any fears or concerns you may have

Opioids come with potential risks. Before starting opioids, it is important to educate yourself as much as possible. Your family members or other caregivers should also learn as much as possible. (, , , )

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Before Starting Opioids

Before starting opioid therapy, your care provider may ask you about your current or prior use of alcohol, recreational substances, or other prescription drugs. (, , , )

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It is important, to be honest with your care provider. A history of substance use does not mean you cannot take opioids to help manage your cancer pain. A history of substance abuse does mean that you may require more monitoring during treatment. Your care provider may also consult a specialist to help determine the best approach to managing your pain. (, , , )

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Choosing A Medication

There is not a single opioid medication recommended over any others. Any Food and Drug Administration (FDA)-approved opioid medication may be used. (, , , )

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The choice of medication should be a shared decision between you and your care team and based on several factors. (, , , )

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The most common opioids for initial management include: codeine, hydrocodone, or oxycodone.

Things to keep in mind when choosing an opioid medication

How it works and its potential for pain relief
Potential side effects
Cost
How do you prefer to take it (pills, patches, liquids, etc.)
Availability of the medication in your area
Potential interactions with any other medications you are taking
Whether you have other medical conditions, such as kidney problems

Talk to your care provider about any other medications you may be taking and any other health issues you may be dealing with. This could help determine which medication(s) to use, or not to use. (, , , )

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If you have kidney problems, methadone should be used rather than other opioids like fentanyl, oxycodone, and hydromorphone. Additionally, if you have a kidney problem, you may also need frequent monitoring and dose adjustments to ensure the opioids are not causing additional damage. (, , , )

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Starting Medication

When starting opioids, it is important to start with the lowest possible dose needed to help manage your pain. (, , , )

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The first opioid medication you receive should be an immediate-release medication. This will help your care provider quickly identify how to help manage your pain with the lowest possible dose. (, , , )

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Opioids may be taken alone or with other pain relief medications. Talk to your care provider if you have already been taking other medications, such as aspirin, acetaminophen, or ibuprofen. In most cases, your care provider will tell you to continue taking these medications along with the opioids. (, , , )

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Every person is different, so there is no single dosage that works best as the lowest possible effective dose. Factors such as your age, cancer types, other conditions and diseases, how your body is working, and more, can all determine the right dosing to use for your situation. (, , , )

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Adjusting Medication

If you are already taking opioids and are still experiencing breakthrough pain, your care provider may prescribe an increase in the dosage of your medication. (, , , )

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While taking opioids, you may need to change medications or the dose of your current medications until you find what works best for you. This is normal, and just one of the many reasons why clear communication and frequent follow-up visits are important. (, , , )

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If the opioid medication prescribed for you is not relieving the pain or is causing unwanted side effects, or you have other concerns about the drug, tell your care provider. (, , , )

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Side Effects and Other Considerations

Even though opioids can help with pain relief, they may also come with unwanted side effects. (, , , )

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Your care provider will help you understand what those potential side effects are, how to prevent them, how to monitor them, and in some cases, how to manage them when they happen. (, , , )

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Common side effects caused by opioids include:

Constipation
Difficulty urinating
Feelings of nausea or vomiting
Mental problems, such as brain fog or confusion, hallucinations, depression, or an inability to focus
Disruptions with your endocrine system, such as erectile dysfunction, reduced libido, and infertility
Skin irritation or urges to itch or scratch
Difficulty breathing
Fatigue

NOTE - if you experience one or more of these symptoms you should tell your care provider right away!

Your care team will monitor you carefully while you are taking opioids. Monitoring is important to learn whether changes are needed to your medications or dosages and to make sure the benefits in pain relief you are gaining are greater than any potential harm. (, , , )

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Patient / Clinician Discussion Points and FAQ

Is there a specific type of opioid that is most effective for managing pain?
- For most people, there is no single medication recommended over any other medication.

Can I still take opioids for my cancer pain if I have a history of opioid or other substance use?
- Yes. A history of substance use does not mean you cannot take opioids to help manage your cancer pain. Your care team may monitor your progress more closely.

If I use opioids, will I become addicted?
- Opioids always come with a risk of abuse, but simply using an opioid does not guarantee addiction. If you are regularly and effectively communicating with your care team, and are following all care instructions, your chances of becoming addicted are significantly reduced.

Is genetic testing recommended to help understand the right opioid(s) and dosage(s) to use?
- There is not enough evidence to recommend genetic testing, such as for polymorphism of CYP2D6, to guide opioid dosing.

Are opioids expensive?
- Costs can vary significantly depending on the type of opioid, and whether there are generic versions available. Morphine, methadone, and immediate-release hydrocodone tend to be the least expensive. Out-of-pocket costs will vary depending on your insurance plan, and which product(s) are preferred by that plan. The cost may also vary by pharmacy. Ask your care team about any financial counseling services available to help you address this constantly changing landscape.

Additional Resources

Abbreviations

ASCO: American Society Of Clinical Oncology
FDA: Food And Drug Administration

Source Citation

Paice JA, Bohlke K, Barton D, et al. Use of Opioids for Adults with Pain from Cancer or Cancer Treatment: ASCO Guideline. J Clin Oncol. 2022 Dec 05. doi: 10.1200/JCO.22.02198.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.