Nonsteroidal anti-inflammatory drugs (NSAIDS) or certain antidepressant medications may have similar efficacy to opioids in addressing chronic cancer-related pain, though more research is needed to determine the best strategies to deal with this type of pain, according to a recent study published by the American Cancer Society.
Opioids are commonly used to treat cancer-related pain in both the chronic and breakthrough pain (temporary flare up) settings, and is recommended in guidelines from institutions such as the World Health Organization. However, few studies have compared opioid use to placebo, and the jury may still be out on whether opioids are superior to NSAIDs outside of end-of-life care.
So, a group of researchers analyzed data from more than 150 clinical trials related to the management of cancer-related pain.
“The lack of evidence comparing opioid medicines to placebo for cancer pain probably reflects the ethical and logistical challenges associated with carrying out such trials. Yet these trials are necessary to guide clinical decision making,” lead researcher Dr Christina Abdel Shaheed from the University of Sydney School of Public Health, Faculty of Medicine and Health and Sydney Musculoskeletal Health which is an initiative of the University of Sydney, Sydney Local Health District and Northern Sydney Local Health District, said in a press release.
In a more in-depth analysis of the types of opioids commonly used, the researchers also discovered that morphine was typically no better than other opioids, nor did it come with fewer side effects.
“Despite being recommended worldwide for the treatment of cancer pain, morphine was generally not superior to other opioids, nor did it have a more favorable toxicity profile,” the researchers wrote. “Given the limited quality and quantity of research, there is a need to reappraise the clinical utility of opioids in people with cancer pain, particularly those who are not at the end of life, and to further explore the effects of opioids on immune system function and quality of life in these individuals.”
In a review of the few studies that did compare opioids to placebo for cancer-related pain, the researchers discovered that for breakthrough cancer pain, the opioid, fentanyl, when delivered as a nasal spray, under the tongue, or orally may be more effective than placebo for breakthrough pain, though not for long-term use. Fentanyl was also associated with more side effects than placebo.
When it came to long-term cancer pain, NSAIDS may be a better option, researchers found.
“People with background cancer pain may have an overall better life experience if there is less focus on using opioids to reduce their pain level,” says co-author Dr. Martin Underwood from the University of Warwick, in the United Kingdom, said in the release.
Opioids, however, tended to be superior in the end-of-life setting.
“In practice, opioids are indispensable for intractable pain and distress at the end of life. What is worth highlighting is that non-opioids, particularly NSAIDs, are surprisingly effective for some cancer pain, and may avoid the problems of dependence and waning opioid analgesia over time,” said co-author Dr. Jane Ballantyne, from the University of Washington School of Medicine, in the release.
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“The hope is that the findings can help guide doctors and patients to choose between different opioid treatment for cancer pain and empower individuals to consider alternatives if they are unable to tolerate opioid medicines or choose not to take them,” said senior author Dr. Mark Sidhom, from the Cancer Therapy Centre, Liverpool Hospital in Australia.
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