ASCO GUIDELINES Bundle

4 Treatment ➤ Clinicians may prescribe topical analgesics (such as commercially available nonsteroidal antiinflammatory drugs; local anesthetics; or compounded creams/gels containing baclofen, amitriptyline, and ketamine), for the management of chronic pain. (Moderate Recommendation; EB-B-I) ➤ Corticosteroids are NOT recommended for long-term use in cancer survivors solely to relieve chronic pain. (Moderate Recommendation; EB-H-I) ➤ Clinicians should assess the risks of adverse effects of pharmacologic therapies, including nonopioids, adjuvant analgesics, and other agents used for pain management. (Moderate Recommendation; EB/ IC-B-I) ➤ Clinicians may follow specific state regulations that allow access to medical cannabis or cannabinoids for patients with chronic pain after a consideration of the potential benefits and risks of the available formulations. (Moderate Recommendation; EB-B-I) Qualifying statement. As of this writing, 23 states and the District of Columbia allow for medical cannabis, although it is illegal on the federal level. Currently, there is insufficient evidence to recommend medical cannabis for the first-line management of chronic pain in cancer survivors. However, evidence suggests it is worthy of consideration as an adjuvant analgesic or in the management of refractory pain conditions. There is also insufficient evidence to recommend one particular preparation of cannabis over another, and the Food and Drug Administration has not approved any drug product containing or derived from botanical marijuana. Opioids ➤ Clinicians may prescribe a trial of opioids in carefully selected cancer survivors with chronic pain who do not respond to more conservative management and who continue to experience pain-related distress or functional impairment. (Moderate Recommendation; EB-B-I) • Tables 3 and 4 provide guidelines intended to promote safe and effective prescribing. Nonopioid analgesics and/or adjuvants can be added as clinically necessary. ➤ Clinicians should assess risks of adverse effects of opioids used for pain management. Table 5 lists opioid-related long-term adverse effects. (Moderate Recommendation; EB/IC-B-I) Qualifying statement. Although there is literature describing dysimmune effects and tumor proliferative effects from opioid drugs (both of which may be of particular concern in the cancer survivor population), there is insufficient evidence to determine whether there are clinically important risks. The expert panel believes that further clinical investigation is required to assess these concerns. In the absence of actionable data, physicians should be made aware of these evolving questions, and patients and their families may be informed about them as part of a discussion of the potential harms of long-term opioid therapy, as described in Table 5.

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