03/28/2017

NCCN has published updates to the NCCN Guidelines® for Adult Cancer Pain

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®) for Adult Cancer Pain. These NCCN Guidelines^® are currently available as Version 1.2017. 

• Management of Pain in Opioid-Naïve Patients (PAIN-3)
  • For “ALL levels of pain” three bullets were added:
    • “Select the most appropriate medication based on the physiology of the patient’s pain.”
    • “Consider acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs)”
    • “Consider adding adjuvant analgesics (see PAIN-G) for specific pain syndromes (See PAIN-D)”
  • For “Mild Pain 1-3” a bullet was revised: “First consider non-opioids and adjuvant therapies, then consider titrating short-acting opioids for patients who require further intervention (See PAIN-E)”
• Under “Subsequent Pain Management” a bullet for “Mild Pain 0-3” was revised: “Reassess and modify regimen to minimize adverse effects; taper opioids and other treatments when no longer needed (See PAIN-E and See Pain-F)” (PAIN-6)
• Under “Ongoing Care” a bullet was revised: “Monitor for the use of analgesics as prescribed, especially in patients with risk factors for or history of substance abuse/diversion or cognitive dysfunction” (PAIN-7)
• Opioid Principles, Prescribing, Titration, Maintenance, And Safety (PAIN-E 1 of 12)
  • Under “General Principles” two bullets were added:
    • “Periodically review prescription drug monitoring program databases.”
    • “Be mindful of combining opioid medications with other medications that have a sedating effect (eg, benzodiazepines). http://www.fda.gov/downloads/drugs/drugsafety/ucm518672.pdf”
• Opioids And Risk Evaluation And Mitigation Strategy (REMS) (PAIN E 2 of 12)
  • A bullet was revised: “Opioids are the principal analgesics for moderate to severe pain, yet opioids pose risks to patients and society. In 2013 there were 43,982 drug-poisoning deaths in the United States, including 16,235 drug-poisoning deaths involving opioid analgesics. The opioid analgesic overdose deaths have plateaued, decreasing between2011 and 2013; however, drug poisoning still remains the number one cause of injury-related deaths. In the United States, poisoning is now the leading cause of death from injuries and 89% of poisonings are related to drugs. In 2008, of the 36,500 drug poisoning deaths, 14,800 (40%) involved opioid analgesics, compared to 5,100 cocain related deaths and 3,000 heroin related deaths.  Most people who overdose on prescription opioids not prescribed to them have been given (not bought or stolen) opioids from friends or family.”
  • Under  “Potential risk factors for misuse/abuse” two bullets were added:
    • “Young age less than 45 years”
    • “Patients with a history of legal problems or incarceration”

• Two definitions were added to the “Table 1 Glossary of Terms Related to Opioid Use”: (PAIN-E 3 of 12)
  • “Chemical coping”: “Misuse of medication in a non-prescribed way to cope with the various stressful events associated with the diagnosis and management of cancer”
  • “Diversion”: “The transfer of a prescribed medication from the person for whom it was prescribed to another person”
• Strategies to Maintain Patient Safety and Minimize the Risk of Opioid Misuse and Abuse During Chronic Opioid Use (PAIN-E 5 of 12)
  • Under “Support for high-risk patients” a bullet was added: “Consider encouraging naloxone availability for administration by caregivers as needed for patients taking opioids who are at high risk for respiratory depression and sedation”
• Management of Opioid Adverse Effects
  • Under preventive measures for constipation a bullet was added: “Patients taking daily opioids almost always require agents for management of constipation” (PAIN- F 1 of 3)
  • Under preventive measures for constipation a bullet was revised: “Stool softener Docusate alone may not provide benefit in well hydrated patients ” (PAIN- F 1 of 3)
  • Under motor and cognitive impairment a bullet was added: “Consider evaluation for driving impairment, often done through occupational therapy.” (PAIN- F 3 of 3)
  • Under respiratory depression a bullet was added: “Sedation often precedes respiratory depression; therefore, progressive sedation should be noted and adjustments in care made.” (PAIN- F 3 of 3)
  • Under sedation a bullet was added: “It is critical to recognize the difference between cancer-related fatigue and opioid-induced sedation. (See NCCN Guidelines for Fatigue).”
• Non-Opioid Analgesic (Nonsteroidal Anti-Inflammatory Drugs [NSAIDS] and Acetaminophen) Prescribing (PAIN-K 1 of 2)
  • Under NSAIDs a bullet was added: The FDA warns that long-term use of NSAIDs increases the risk of heart attack or stroke. http://www.fda.gov/Drugs/DrugSafety/ucm451800.htm”