For cancer pain, opioids are the first choice for moderate and severe pain treatment, so patients or family members often ask questions about the use of opioids for cancer pain, such as: "Will morphine and other opioids, which are indispensable for the treatment of cancer pain, become addictive if you eat too much?" Is opioid analgesia contradictory to antineoplastic therapy......"
Once doubts arise in one way or another, the end result is that many people tend to "endure and pass" without medication. Therefore, today we will answer some common questions about opioids in the treatment of cancer pain~
What are Opioids?
Opioids are a class of narcotic analgesic drugs that relieve pain and alter emotional responses to pain. It is an alkaloid extracted from the pulp of the unripe fruit of the opium poppy and its derivatives in vitro and in vivo, which exerts analgesic effects by inhibiting the upward conduction and downward control of pain. Opioids are the most commonly used and effective drugs used to treat cancer pain. Common opioids include morphine sulfate controlled-release tablets, oxycodone hydrochloride controlled-release tablets, fentanyl transdermal patches, morphine hydrochloride tablets, and others [1].
Is it addictive to use "morphine and other opioids" for cancer pain?
Drug addiction is characterized by a persistent, unscrupulous craving for the use of drugs, not for analgesia, but for the sake of achieving "euphoria." Modern medicine has continuously purified and improved morphine drugs, and has been able to make morphine drugs released in the human body in a slow and orderly manner, and there will be no blood concentration caused by instant-release morphine preparations (injections), which will rise and fall sharply, rarely produce euphoria, and can overcome psychological addiction.
In particular, when given orally or transdermally, there is little risk of mental dependence in cancer patients. Drug addiction should not be confused with drug tolerance (defined as a decrease in pharmacological sensitivity after long-term drug use) [1]. Is opioid analgesia contradictory to antineoplastic therapy?
Opioid analgesia is not contradictory to antineoplastic therapy. Many cancer patients believe that cancer pain is normal, and the tumor will not be painful when it is cured. Or think that pain treatment is only a "palliative" and can only improve the symptoms, which is of little significance; Anti-tumor therapy is the "root cause". In fact, this perception is unscientific.
Pain control is just as important for patients as it is to control tumors. The sooner the treatment, the better the effect, and it is best to do both at the same time. Because only when the pain is well controlled, the patient's condition may be more conducive to the treatment of the tumor. If cancer pain is not effectively solved, not only will the patient's quality of life be seriously reduced, but the continuous pain will often cause a series of psychological changes in the patient, such as despair, restlessness, irritability, etc., resulting in the patient's sensitivity to pain and further deterioration of the condition.
Effective control of cancer pain not only enhances the efficacy of cancer treatment, but also serves as a form of respect for patients with advanced cancer, enabling them to maintain their last dignity in the journey of life in a relatively painless state [1-2].
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Why do opioids not have a "ceiling effect"?
Unlike NSAIDs, opioids do not have a "ceiling effect" or "capping effect" (capping effect, meaning that increasing the dose after achieving the desired analgesic effect only increases the side effects but does not enhance their analgesic effects; Opioids, on the other hand, have no capping effect, i.e., the analgesic effect increases with increasing dose).
As long as the side effects of the drug are properly prevented, the dose of the drug can be increased proportionally on the basis of a full assessment of the patient's pain score, and there is no limit on the maximum dose. The ideal analgesic effect is one in which the patient is comfortable and functional, and side effects are tolerated [1,3]. Why should opioids be dose-titrated in patients with cancer pain?
The efficacy and safety of opioid analgesics vary greatly among individuals, and the individualization characteristics are significant, and the dose needs to be gradually adjusted to find a balance between analgesic efficacy and side effect tolerance to obtain the optimal dosage [4]. What are the common methods of opioid administration, advantages and disadvantages?
Oral administration: Opioids are administered orally, which is simple and convenient, safe and effective, low cost, and good patient compliance. However, a small number of patients who are unable to take oral drugs due to illness or other reasons, or who cannot achieve satisfactory analgesia with oral opioids, may require an alternative route of administration.
Transdermal administration: mainly fentanyl, buprenorphine. The advantages are that it is simple and convenient, the blood concentration is stable, and the patient is easy to accept. The disadvantage is that there are not many types of opioids that can be administered percutaneously, and they are not effective in patients with extremely wasting cachexia, and are limited by body temperature and sweating.
Rectal administration: Morphine sulfate, oxycodone extended-release tablets, etc. can be administered rectally, and this method is not suitable for patients with diarrhea, colostomy, hemorrhoids, anal fistula, or potential risk of infection.
Parenteral administration: including intravenous, subcutaneous, oral mucosa, and neuraxial administration[1].
Can long-term high-dose opioids be stopped abruptly?
Long-term use of high-dose opioids should not be stopped abruptly, and if opioids need to be reduced or stopped, a tapering approach is used to prevent withdrawal signs and symptoms. Reduce the total dose of opioids by 10%~25% until the daily dose is equivalent to 30mg of oral morphine, and the drug can be discontinued after two days of continuous use [4]. What are the common adverse effects of opioids?
As with almost all analgesics, the adverse effects of opioids mainly include: constipation, nausea, vomiting, drowsiness, itching, dizziness, urinary retention, delirium, cognitive impairment, respiratory depression, etc. With the exception of constipation, most of the adverse effects of opioids are temporary or tolerable. Adverse effects, such as nausea, vomiting, drowsiness, and dizziness, occur in the first few days of treatment in opioid-naïve patients [1]. For cancer pain, can I use two opioid extended-release preparations at the same time?
According to the principles of cancer pain treatment, patients should first undergo accurate pain assessment and dose titration, and then select a long-acting analgesic drug for analgesic therapy in order to adjust the drug dose and judge adverse drug reactions. In the standard treatment of pain, a choice of long-acting analgesic is sufficient [4].
In short, the most important thing in the treatment of cancer pain is to strictly follow the doctor's instructions and standardize the use of drugs, and the rational use of opioids is effective and safe. References:
[1] Title: Decryption of Cancer PainAuthor: Sima LeiPublisher: Tsinghua University PressPublished:2017-11-01.
[2] Yang Dong, Wang Jianying, Nie Wenwen, et al. Cancer pain management must be synchronized with tumor treatment[N].Health News,2022-04-20(007). DOI:10.28415/n.cnki.njika.2022.001490.
[3] Wang Guohua, Ma Qiayi. Don't put up with cancer pain! Rational use of opioids is effective and safe[J].Family Medicine. Medical Treatment and Drug Selection,2021,(11):40-41.
[4] Cancer Pain, Opioid Q&A, Zhang Yi, PSM Yaodun Public Welfare, 2023-10-06.
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