Advertisement

Opioid use in gynecologic oncology in the age of the opioid epidemic: Part I - Effective opioid use across clinical settings, a society of gynecologic oncology evidence-based review

Published:February 20, 2018DOI:https://doi.org/10.1016/j.ygyno.2018.01.027

      Highlights

      • The appropriate role for opioids in pain management varies based on clinical setting
      • Opioids remain first line treatment for cancer-related pain
      • Consider minimizing opioid use in post-operative and survivorship settings
      • Patients should be counseled on expectations for & management of opioid side effects

      Abstract

      As the only oncologists that provide both medical and surgical oncologic care, gynecologic oncologists encounter an exceptionally broad range of indications for prescribing opioids, from management of acute post-operative pain to chronic cancer-related pain to end-of-life care. If we are to balance opioid efficacy, safety and accessibility for our patients, we must be intimately familiar with appropriate clinical use of opioids in a range of settings, and engage in the national conversation around opioid misuse and how associated regulations and legislation may impact us and our patients. This article examines the appropriate use of opioids across the range of clinical settings encountered in gynecologic oncology.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Gynecologic Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. World Health Organization. WHO's cancer pain ladder for adults. (cited 2016 June 23; Available from:) http://www.who.int/cancer/palliative/painladder/en/.

        • Swarm R.A.
        • et al.
        Adult cancer pain.
        J. Natl. Compr. Cancer Netw. 2013; 11: 992-1022
        • Dowell D.
        • Haegerich T.M.
        • Chou R.
        CDC guideline for prescribing opioids for chronic pain–United States.
        JAMA. 2016; 315: 1624-1645
      2. Organization, W.H. Lexicon of alcohol and drug trems published by the World Health Organization. (cited 2017 October 25; Available from:) http://www.who.int/substance_abuse/terminology/who_lexicon/en/.

        • Landrum L.M.
        • et al.
        Comprehensive care in gynecologic oncology: the importance of palliative care.
        Gynecol. Oncol. 2015; 137: 193-202
        • Hudcova J.
        • et al.
        Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain.
        Cochrane Database Syst. Rev. 2006; 4CD003348
        • Doyle D.
        3rd ed. Oxford Textbook of Palliative Medicine. xxv. Oxford University Press, Oxford; New York2004 (1244 p)
        • MacKenzie M.
        • Zed P.J.
        • Ensom M.H.
        Opioid pharmacokinetics-pharmacodynamics: clinical implications in acute pain management in trauma.
        Ann. Pharmacother. 2016; 50: 209-218
        • Kehlet H.
        • Wilmore D.W.
        Multimodal strategies to improve surgical outcome.
        Am. J. Surg. 2002; 183: 630-641
        • Carroll J.
        • Alavi K.
        Pathogenesis and management of postoperative ileus.
        Clin. Colon Rectal Surg. 2009; 22: 47-50
        • Meuser T.
        • et al.
        Symptoms during cancer pain treatment following WHO-guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology.
        Pain. 2001; 93: 247-257
        • Nelson G.
        • Kalogera E.
        • Dowdy S.C.
        Enhanced recovery pathways in gynecologic oncology.
        Gynecol. Oncol. 2014; 135: 586-594
        • Ahiskalioglu E.O.
        • et al.
        Effects of single-dose preemptive intravenous ibuprofen on postoperative opioid consumption and acute pain after laparoscopic cholecystectomy.
        Medicine (Baltimore). 2017; 96e6200
        • Ozmete O.
        • et al.
        Preoperative paracetamol improves post-cesarean delivery pain management: a prospective, randomized, double-blind, placebo-controlled trial.
        J. Clin. Anesth. 2016; 33: 51-57
        • Fujita N.
        • et al.
        A randomized placebo-controlled study of preoperative pregabalin for postoperative analgesia in patients with spinal surgery.
        J. Clin. Anesth. 2016; 31: 149-153
        • Ahn S.
        • et al.
        Analgesic efficacy of preemptive pregabalin administration in arthroscopic shoulder surgery: a randomized controlled trial.
        Can. J. Anaesth. 2016; 63: 283-289
        • Arici S.
        • et al.
        Preemptive analgesic effects of intravenous paracetamol in total abdominal hysterectomy.
        Agriculture. 2009; 21: 54-61
        • Kalogera E.
        • et al.
        Enhanced recovery in gynecologic surgery.
        Obstet. Gynecol. 2013; 122: 319-328
        • Nelson G.
        • et al.
        Guidelines for postoperative care in gynecologic/oncology surgery: enhanced recovery after surgery (ERAS(R)) society recommendations–Part II.
        Gynecol. Oncol. 2016; 140: 323-332
        • Kim N.
        • et al.
        A prospective evaluation of opioid utilization after upper-extremity surgical procedures: identifying consumption patterns and determining prescribing guidelines.
        J. Bone Joint Surg. Am. 2016; 98e89
        • Chapman T.
        • et al.
        Prospective evaluation of opioid consumption following carpal tunnel release surgery.
        Hand (N. Y.). 2017; 12: 39-42
        • Hill M.V.
        • et al.
        Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures.
        Ann. Surg. 2017; 265: 709-714
        • Hill M.V.
        • et al.
        An educational intervention decreases opioid prescribing after general surgical operations.
        Ann. Surg. 2018; 267: 468-472
        • Brummett C.M.
        • et al.
        New persistent opioid use after minor and major surgical procedures in US adults.
        JAMA Surg. 2017; 152e170504
        • Swegle J.M.
        • Logemann C.
        Management of common opioid-induced adverse effects.
        Am. Fam. Physician. 2006; 74: 1347-1354
        • Cochran B.N.
        • et al.
        Factors predicting development of opioid use disorders among individuals who receive an initial opioid prescription: mathematical modeling using a database of commercially-insured individuals.
        Drug Alcohol Depend. 2014; 138: 202-208
        • Kwon J.H.
        • et al.
        Frequency, predictors, and medical record documentation of chemical coping among advanced cancer patients.
        Oncologist. 2015; 20: 692-697
        • McPherson M.L.
        Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing.
        American Society of Health-System Pharmacists, Bethesda, MD2010
        • As-Sanie S.
        • et al.
        Opioid prescribing patterns, patient use, and postoperative pain after hysterectomy for benign indications.
        Obstet. Gynecol. 2017; 130: 1261-1268
        • Syrowatka A.
        • et al.
        Psychotropic and opioid medication use in older patients with breast cancer across the care trajectory: a population-based cohort study.
        J. Natl. Compr. Cancer Netw. 2016; 14: 1412-1419
        • Eisenhauer E.A.
        • et al.
        European-Canadian randomized trial of paclitaxel in relapsed ovarian cancer: high-dose versus low-dose and long versus short infusion.
        J. Clin. Oncol. 1994; 12: 2654-2666
        • Loprinzi C.L.
        • et al.
        The paclitaxel acute pain syndrome: sensitization of nociceptors as the putative mechanism.
        Cancer J. 2007; 13: 399-403
        • Loprinzi C.L.
        • et al.
        Natural history of paclitaxel-associated acute pain syndrome: prospective cohort study NCCTG N08C1.
        J. Clin. Oncol. 2011; 29: 1472-1478
        • Smith E.M.
        • et al.
        Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial.
        JAMA. 2013; 309: 1359-1367
        • Lutz S.
        • et al.
        Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline.
        Int. J. Radiat. Oncol. Biol. Phys. 2011; 79: 965-976
        • Andreyev J.
        Gastrointestinal complications of pelvic radiotherapy: are they of any importance?.
        Gut. 2005; 54: 1051-1054
        • Shadad A.K.
        • et al.
        Gastrointestinal radiation injury: symptoms, risk factors and mechanisms.
        World J. Gastroenterol. 2013; 19: 185-198
        • Lind H.
        • et al.
        Late symptoms in long-term gynaecological cancer survivors after radiation therapy: a population-based cohort study.
        Br. J. Cancer. 2011; 105: 737-745
        • Beriwal S.
        • et al.
        Preoperative intensity modulated radiation therapy and chemotherapy for locally advanced vulvar carcinoma: analysis of pattern of relapse.
        Int. J. Radiat. Oncol. Biol. Phys. 2013; 85: 1269-1274
        • Epstein J.B.
        • et al.
        A systematic review of orofacial pain in patients receiving cancer therapy.
        Support Care Cancer. 2010; 18: 1023-1031
        • Wiebe E.
        • et al.
        Pain and symptom assessment during multiple fractions of gynecologic high-dose-rate brachytherapy.
        Brachytherapy. 2011; 10: 352-356
        • Ikushima H.
        • et al.
        Pelvic bone complications following radiation therapy of gynecologic malignancies: clinical evaluation of radiation-induced pelvic insufficiency fractures.
        Gynecol. Oncol. 2006; 103: 1100-1104
        • Rao R.D.
        • et al.
        Efficacy of gabapentin in the management of chemotherapy-induced peripheral neuropathy: a phase 3 randomized, double-blind, placebo-controlled, crossover trial (N00C3).
        Cancer. 2007; 110: 2110-2118
        • Hershman D.L.
        • et al.
        Prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline.
        J. Clin. Oncol. 2014; 32: 1941-1967
        • Zoega S.
        • et al.
        Pain and other symptoms and their relationship to quality of life in cancer patients on opioids.
        Qual. Life Res. 2013; 22: 1273-1280
        • Kim Y.J.
        • et al.
        Retrospective review of symptoms and palliative care interventions in women with advanced cervical cancer.
        Gynecol. Oncol. 2015; 139: 553-558
        • Fisch M.J.
        • et al.
        Prospective, observational study of pain and analgesic prescribing in medical oncology outpatients with breast, colorectal, lung, or prostate cancer.
        J. Clin. Oncol. 2012; 30: 1980-1988
        • Greco M.T.
        • et al.
        Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer.
        J. Clin. Oncol. 2014; 32: 4149-4154
        • Utsumi F.
        • et al.
        Opioid needs of terminally ill patients with gynecologic malignancies.
        Int. J. Clin. Oncol. 2015; 20: 405-410
      3. Agency Medical Directors' Group. Opioid dose calculator. Available from: http://www.agencymeddirectors.wa.gov/opioiddosing.asp.

        • Manfredonia J.F.
        Prescribing methadone for pain management in end-of-life care.
        J. Am. Osteopath. Assoc. 2005; 105: S18-21
        • Gazelle G.
        • Fine P.G.
        Methadone for pain: no. 75.
        J. Palliat. Med. 2004; 7: 303-304
      4. American Pain Society Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 5th ed. 2003 (Glenview, IL)
        • American Cancer Society
        Cancer Survivorship Facts & Figures 2016–2017.
        (cited 2017 January 6 Available from:)
      5. National Cancer Institute Office of Survivorship. Survivorship definitions. (cited 2017 January 6 Available from:) http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-048074.pdf.

        • van den Beuken-van Everdingen M.
        Chronic pain in cancer survivors: a growing issue.
        J. Pain Palliat. Care. Pharmacother. 2012; 26: 385-387
        • Glare P.A.
        • et al.
        Pain in cancer survivors.
        J. Clin. Oncol. 2014; 32: 1739-1747
        • Vaz A.F.
        • et al.
        Quality of life and adverse events after radiotherapy in gynecologic cancer survivors: a cohort study.
        Arch. Gynecol. Obstet. 2011; 284: 1523-1531
        • Akkuzu G.
        • Kurt G.
        • Guvenc G.
        Learning needs of gynecologic cancer survivors.
        J. Canc. Educ. 2016; https://doi.org/10.1007/s13187-016-1118-y
        • Hammer S.M.
        • et al.
        Cancer-related impairments influence physical activity in uterine cancer survivors.
        Med. Sci. Sports Exerc. 2014; 46: 2195-2201
        • Stavraka C.
        • et al.
        A study of symptoms described by ovarian cancer survivors.
        Gynecol. Oncol. 2012; 125: 59-64
        • Vistad I.
        • et al.
        A study of chronic pelvic pain after radiotherapy in survivors of locally advanced cervical cancer.
        J. Cancer Surviv. 2011; 5: 208-216
        • Paice J.A.
        • Lacchetti C.
        • Bruera E.
        Management of chronic pain in survivors of adult cancers: ASCO clinical practice guideline summary.
        J. Oncol. Pract. 2016; 12: 757-762
        • Chapman Lindsay
        • dela Cruz Adriane M.
        • Hutto Jessica
        Opioid treatment agreements: helpful or hurtful?.
        Am. J. Psychiat. Residents' J. 2016; 11: 14-16
        • Kral L.A.
        Opioid Tapering: Safely Discontinuing Opioid Anagelsics.
        (cited 2017 July 16; Available from:)
        • Berna C.
        • Kulich R.J.
        • Rathmell J.P.
        Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice.
        Mayo Clin. Proc. 2015; 90: 828-842
        • Fishbain D.A.
        • Rosomoff H.L.
        • Cutler R.
        Opiate detoxification protocols. A clinical manual.
        Ann. Clin. Psychiatry. 1993; 5: 53-65
        • The Management of Opioid Therapy for Chronic Pain Working Group
        Defense D.O. VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy in Chronic Pain. 2003: 52-53
        • Reddy A.
        • et al.
        Frequency, outcome, and predictors of success within 6 weeks of an opioid rotation among outpatients with cancer receiving strong opioids.
        Oncologist. 2013; 18: 212-220
        • Arnold R.
        • Weissman D.E.
        Calculating opioid dose conversions #36.
        J. Palliat. Med. 2003; 6: 619-620
        • Abernethy A.P.
        • Wheeler J.L.
        • Zafar S.Y.
        Detailing of gastrointestinal symptoms in cancer patients with advanced disease: new methodologies, new insights, and a proposed approach.
        Curr. Opin. Support Palliat. Care. 2009; 3: 41-49
        • Mancini I.
        • Bruera E.
        Constipation in advanced cancer patients.
        Support Care Cancer. 1998; 6: 356-364
        • Tassinari D.
        • et al.
        Adverse effects of transdermal opiates treating moderate-severe cancer pain in comparison to long-acting morphine: a meta-analysis and systematic review of the literature.
        J. Palliat. Med. 2008; 11: 492-501
        • Tarumi Y.
        • et al.
        Randomized, double-blind, placebo-controlled trial of oral docusate in the management of constipation in hospice patients.
        J. Pain Symptom Manag. 2013; 45: 2-13
        • Hawley P.H.
        • Byeon J.J.
        A comparison of sennosides-based bowel protocols with and without docusate in hospitalized patients with cancer.
        J. Palliat. Med. 2008; 11: 575-581
        • Candy B.
        • et al.
        Laxatives or methylnaltrexone for the management of constipation in palliative care patients.
        Cochrane Database Syst. Rev. 2011; 1CD003448
        • Wald A.
        Constipation: advances in diagnosis and treatment.
        JAMA. 2016; 315: 185-191
        • Chey W.D.
        • et al.
        Naloxegol for opioid-induced constipation in patients with noncancer pain.
        N. Engl. J. Med. 2014; 370: 2387-2396
        • Cryer B.
        • et al.
        A randomized study of lubiprostone for opioid-induced constipation in patients with chronic noncancer pain.
        Pain Med. 2014; 15: 1825-1834
        • Davis M.P.
        • Walsh D.
        Epidemiology of cancer pain and factors influencing poor pain control.
        Am. J. Hosp. Palliat. Care. 2004; 21: 137-142
        • Kurita G.P.
        • et al.
        Prevalence and predictors of cognitive dysfunction in opioid-treated patients with cancer: a multinational study.
        J. Clin. Oncol. 2011; 29: 1297-1303
        • Stone P.
        • Minton O.
        European palliative care research collaborative pain guidelines. Central side-effects management: what is the evidence to support best practice in the management of sedation, cognitive impairment and myoclonus?.
        Palliat. Med. 2011; 25: 431-441
        • Schneider L.S.
        • Dagerman K.S.
        • Insel P.
        Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials.
        JAMA. 2005; 294: 1934-1943
        • Weinstein S.M.P.
        • Harrington R.K.
        • S. E.
        Assessing and treating pain.
        in: Storey Jr., C.P. UNIPAC 3: A Resource for Hospice and Palliative Care Professionals. 3rd ed. American Academy of Hospice and Palliative Medicine, Glenview, IL2012
        • Herndon C.M.
        • Jackson 2nd, K.C.
        • Hallin P.A.
        Management of opioid-induced gastrointestinal effects in patients receiving palliative care.
        Pharmacotherapy. 2002; 22: 240-250