About 1 in 3 adults with cancer pain report difficulty getting opioid Rxs...often due to payer rejects or limits for other uses.
But opioids are often needed...and these patients are excluded from typical opioid restrictions.
Follow a stepwise approach to treating cancer pain...and help overcome barriers and stigma.
Use a short-acting opioid every 3 to 4 hours as needed when acetaminophen, an NSAID, or the combo isn’t enough.
As a rule of thumb, if 4 or more short-acting opioid doses are consistently needed daily, switch to a long-acting form.
But continue the short-acting opioid for breakthrough pain. Increase the long-acting dose if prn doses are frequent.
Be aware, there’s no max opioid dose in patients with cancer...but over 250 mg/day of oral morphine is rarely needed. Plus doses are often limited by side effects (constipation, sedation, etc).
Include the cancer ICD-10 code on the Rx...to limit pharmacy callbacks. If changing the opioid regimen, include the reason (breakthrough pain, declining kidney function, etc).
Reinforce that patients should call your office if they need more frequent doses than their current Rx provides...to limit delays at the pharmacy due to early refill rejects, prior auths, etc.
For example, expect a prior auth to be required for nonstandard opioid doses...such as a fentanyl patch used q48h.
Also reevaluate benzos...and whether tapering is appropriate. Combining with opioids is risky.
Keep in mind, other adjuvant meds may help limit opioid doses.
Consider adding an NSAID for bone pain...a steroid for inflammation...or an antidepressant (duloxetine, nortriptyline, etc) or antiseizure med (gabapentin, etc) for neuropathic pain.
Ensure patients taking opioids for cancer pain have naloxone.
And remind them how to dispose of or donate unused opioids.
Access our resource, Managing Cancer Pain in Adults, for info on opioid titration, managing side effects, the role of cannabinoids, etc.
Also see our Opioid Resource Hub for more tips...including our Opioid Allergies and Equianalgesic Dosing of Opioids resources.
- https://www.nccn.org/professionals/physician_gls/pdf/pain.pdf (5-25-22)
- https://www.mdanderson.org/content/dam/mdanderson/documents/for-physicians/algorithms/clinical-management/clin-management-cancer-pain-web-algorithm.pdf (5-25-22)
- J Pain Symptom Manage. 2020 Nov;60(5):915-922
Prescriber's Letter. June 2022 No. 380608