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Opioid Rotation, Methadone Urged for Hard-to-Treat Cancer Pain

Opioid Rotation, Methadone Urged for Hard-to-Treat Cancer Pain

BOSTON—Most advanced cancer patients suffer from pain that could be relieved
with broader use of opioid analgesics, according to Eduardo Bruera, MD, F.T.
McGraw Chair in the Treatment of Cancer, M.D. Anderson Cancer Center.

Dr. Bruera told oncologists at the 14th international meeting of the
Multinational Association for Supportive Care in Cancer (MASCC) and
International Association for Oral Oncology (ISOO) that they should learn how
to rotate opiates when one stops working—and consider prescribing methadone. He
also urged them to administer painkillers rectally and by subcutaneous
injection instead of resorting to intravenous delivery when pills are no longer
effective.

Dr. Bruera said that a key problem is diminishing effectiveness of opioids
over time despite escalating doses. Sometimes patients also develop
neurotoxicity. Instead of relying on just one opioid analgesic, oncologists
should develop expertise in the use of two or three that can be rotated when
one fails, he said.

"The good news is, most opioids are a good alternative to the existing
opioid," he told ONI. "There’s no clear idea that one is better, or that
a second one is better than the one the patient was getting. So you have a lot
of options according to your expertise."

Changing opioids is complicated, however. Dr. Bruera warned that doses are
not equivalent from one to another. "It’s not easy to predict how much of the
new opioid the patient is going to need by just looking at how much of the
previous opioid the patient is using," he said.

He recommended that the physician be ready to adjust the dose of the new
medication up or down. For the first 3 or 4 days after the switch, either the
doctor or a nurse should call the patient frequently to ask whether he or she
is sleepy or in pain. "After that, you can relax," Dr. Bruera said.

Methadone: The Ferrari of Opioids

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