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McMaster Textbook of Internal Medicine

The 3 most important recent advances in treating cancer pain with opioids

2021-12-07
Per Sjøgren
Recorded at the 6th McMaster International Review Course in Internal Medicine (MIRCIM).

Dr Per Sjøgren is a professor of palliative medicine in the Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark, and member of the International Scientific Expert Panel (ISEP) of Cicely Saunders International.

If you were to name the 3 most important recent advances in the management of cancer pain with opioids, what would they be?

Prof. Per Sjøgren, MD: First, the appearance of guidelines based on systematic reviews is a major step forward, and it is mandatory that these guidelines are continuously updated. However, as opioids are very old drugs, it is in fact remarkable that a substantial part of opioid management that takes place in everyday clinical practice is not based on solid evidence. On the contrary, the evidence is often weak.

Second, and according to recent randomized controlled trials on complex palliative care interventions, it is quite disappointing to note that pain management of patients with advanced cancer is not very successful. The major outcomes of these studies demonstrate a generally improved quality of life but seldom symptom control, including pain relief. Therefore, it is mandatory that the evidence-based pain and opioid management guidelines, which are based on international consensus, are implemented and adapted to local needs. Upcoming local studies from around the world focusing on cancer pain management programs demonstrate that meticulous monitoring and management strategies in relevant local environments, based on energetic teaching and mentorship, can upscale [the performance of] health-care professionals and provide excellent outcomes.

And third, I think we should focus on the long-term opioid exposure in the future, not only in cancer patients but also in [those with] chronic noncancer pain. We need to focus on addiction, physical dependance, tolerance development, opioid-induced hyperalgesia, cognitive dysfunction, and also the suppression of immune and reproductive systems. This may enhance effective opioid use and these are clearly new areas that should promote a highly warranted research agenda concerning these issues of long-term opioid use.

See also
  • Chronic pain, opioids, and CBT Dr William Goldberg, clinical professor of medicine at McMaster University and Chief of Medicine at St Joseph’s Hospital from 1962-1982, comments on the issue of chronic opioid use.
  • Opioids and osteoporosis Is osteoporosis caused by long-term use of strong opioids a significant clinical problem?
  • Opioids in the treatment of chronic pain A lecture by Dr Jenny Legassie, from McMaster University, Canada, delivered at McMaster International Review Course in Internal Medicine in Kraków in May 2017.
  • Medical opioid controversy. Part 2: Key CPG messages Dr Gordon Guyatt, Distinguished Professor at McMaster University's Department of Health Research Methods, Evidence, and Impact and one of the founders of EBM, discusses key messages from the new Canadian guidelines on opioid use in chronic noncancer pain.
  • Medical opioid controversy. Part 1 Dr Gordon Guyatt, Distinguished Professor at McMaster University Department of Health Research Methods, Evidence, and Impact and one of the founders of evidence-based medicine, discusses new Canadian guidelines on opioid use in chronic noncancer pain.
  • Brain tumors: High-yield information Dr Navya Kalidindi from McMaster University provides a state-of-the-art update on the diagnosis and management of brain tumors.
  • New oncology chapters In the last few weeks we have added several new oncology chapters in the McMaster Textbook of Internal Medicine. Here’s a quick summary of novelties worth exploring.
  • The concerning trajectory of opioid use disorder Dr Brittany B. Dennis, Dr Catherine Anne Lovatt, and Dr Elahn Pogue from McMaster University review current evidence for opioid substitution therapies and discuss risk mitigation and treatment selection for opioid use disorder (OUD).
  • The 3 most important recent advances in palliative care Dr David Currow from University of Technology Sydney, Australia, offers his views on the 3 most important recent advances relevant to everyday practice in palliative care.
  • Management of cancer pain: Challenging the evidence of the recent guidelines for opioid use in palliative care This narrative review outlines the role of guidelines on opioid use and summarizes recent knowledge regarding the consequences of long-term opioid therapy (L-TOT), in particular opioid addiction and deficiencies of the immune and endocrine systems. It also addresses new strategies to strengthen the L-TOT in the management of cancer-related pain among patients receiving palliative care.

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