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.
Suggest a stepwise approach to treating cancer pain...and help overcome barriers and stigma.
Recommend 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, suggest switching to a long-acting form.
But advise continuing the short-acting opioid for breakthrough pain. Suggest increasing the long-acting dose if prn doses are frequent.
Educate that 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).
Encourage prescribers to include the cancer diagnosis code on the Rx...and document it in the patient's profile.
For "over morphine milligram equivalent" rejects, try the DUR code "M0, 1B"...if a cancer diagnosis is documented.
Urge patients to contact their prescriber early if they need more frequent doses than their current Rx provides...to limit delays.
For example, explain that a prior auth will likely 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...and can lead to prior auths.
Point out that other adjuvant meds may help limit opioid doses.
Suggest 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 strategies to titrate opioids, manage side effects, etc.
Learn how to provide expert pain management with our training program, RxAdvanced: Opioid Stewardship.
Also stay tuned for our RxAdvanced: Guide to Cannabis program...which includes details on safe use in oncology care.
- https://www.nccn.org/professionals/physician_gls/pdf/pain.pdf (5-23-22)
- https://www.mdanderson.org/content/dam/mdanderson/documents/for-physicians/algorithms/clinical-management/clin-management-cancer-pain-web-algorithm.pdf (5-23-22)
- J Pain Symptom Manage. 2020 Nov;60(5):915-922