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Perspectives

Safe and effective use of opioids in patients with advanced cancer

Alison White

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Abstract

Practical aspects of prescribing opioids for patients with cancer include selecting an initial opioid, switching opioids when analgesia is inadequate and overcoming barriers to opioid use such as patient concern about addiction and reduced life expectancy. It is also important to address the contribution of distress to pain and to recognise the limitations of opioids, such as opioid-induced hyperalgesia.

Key Points

  • Opioids are first-line therapy for the management of moderate-to-severe cancer-related pain and are also used to treat refractory breathlessness and cough in palliative care.
  • There is no difference in the analgesic and side-effect profile of the commonly used opioids, and choice of agent should take into consideration the convenience of dosing, flexibility to respond to pain and risk of renal or hepatic impairment.
  • Patients respond to opioid analgesia differently because of genetic variation in mu opioid receptors, and switching to another opioid should be considered if analgesia is inadequate or significant side effects develop.
  • Opioids may be used via different routes of administration, with subcutaneous and transdermal opioids indicated for patients whose condition is deteriorating and who are unable to swallow.
  • The experience of pain is mediated by psychological and existential distress, and failure to recognise distress may lead to inappropriate opioid use and risk of toxicity.
  • The fear of shortened life expectancy and addiction are common barriers to opioid use for both patients and physicians.

    Picture credit: © KatarzynaBialasiewicz/iStockphoto. Model used for illustrative purposes only.

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