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Balancing opioid analgesia with the risk of nonmedical opioid use in patients with cancer

Nature Reviews Clinical Oncology (2018) | Download Citation


The current opioid crisis has brought renewed attention and scrutiny to opioid prescriptions. When patients receiving opioid therapy for pain engage in nonmedical opioid use (NMOU) or diversion, untoward consequences can occur. New evidence suggests that patients with cancer might be at a higher risk of NMOU than was previously thought, but clinical evidence still supports the use of opioid analgesics as the gold standard to treat cancer-related pain, creating a dilemma in patient management. Clinicians are encouraged to adopt a universal precautions approach to patients with cancer receiving opioids, which includes screening all patients; discussing the risks, benefits, adverse effects and alternatives of opioid therapy; and providing education on safe use, storage and disposal. Use of urine drug tests, prescription drug monitoring programmes and close observation of behaviours related to opioid use help to ensure treatment adherence, detect NMOU and support therapeutic decision-making. These measures can optimize the risk–benefit ratio while supporting safe opioid use. In this Review, we examine the role of opioids in cancer pain, the risk of substance use disorder and methods to achieve the right balance between the two in order to ensure safe opioid use.

Key points

  • Clinical evidence supports the use of opioid analgesics as the gold standard to treat cancer-related pain.

  • When patients receiving opioids for pain engage in nonmedical opioid use (NMOU) or diversion, unwanted adverse effects, accidental overdose or even death of the patient or others can occur.

  • Growing evidence suggests that patients with cancer might be at higher risk of NMOU than previously thought.

  • Clinicians should adopt a universal precautions approach for the management of cancer-related pain, including screening of all patients with validated risk assessment tools to enable the identification of those at risk of NMOU.

  • Use of urine drug tests and prescription drug monitoring programmes and close observation of behaviours related to opioid use help to ensure treatment adherence, detect NMOU and support therapeutic decision-making.

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Nature Reviews Clinical Oncology thanks L. Blackhall, W. Leppert and S. Passik for their contribution to the peer review of this work.

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  1. Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA

    • Joseph Arthur
    •  & Eduardo Bruera


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The authors contributed equally to all aspects of the article.

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The authors declare no competing interests.

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Correspondence to Eduardo Bruera.

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