Philadelphia—In a case of good intentions gone awry, clinical guidelines designed to stem the misuse, abuse, or overdose of opioids are also creating confusion regarding painkiller prescriptions for cancer patients, a new report suggests.

A Viewpoint article in JAMA Oncology points out that prescription opioids are part of the arsenal used in treating cancer patients, who often have persistent pain or recurrent episodes of pain.

In response to the opioid epidemic, however, clinical guidelines have been published by multiple agencies to control the way opioids are prescribed. Among them is the CDC Guideline for Prescribing Opioids for Chronic Pain. The article describes how some of the CDC guideline recommendations are inconsistent with the long-standing and current national cancer pain guidelines, such as the National Comprehensive Cancer Network (NCCN).

That is creating confusion for clinicians who care for cancer patients, according to University of Pennsylvania–led study authors. “Competing contemporary guidelines from diverse authoritative agencies and organizations carry the potential to confuse, if not seriously jeopardize, pain management for patients with cancer who are living with moderate to severe pain, adding to an already appalling burden of unrelieved cancer pain,” they write.

Among the problems with the CDC guidelines is that they:
• Make a distinction between cancer patients who have completed cancer treatment and those who are currently undergoing active cancer treatment; the guidelines apply to the former, but not the latter, although these patient groups often have similar levels of pain.
• Recommend against long-acting opioids, especially concurrently with immediate-release opioids, but NCCN guidelines advise coprescription of both because cancer patients often have pain flares.
• Advise use of nonpharmacologic therapy and nonopioid pharmacologic therapy for chronic pain, although these therapies lack an evidence base in managing moderate-to-severe pain or are cost-prohibitive.

“Already, opioid prescribing practices are a function of complicated decision-making processes,” the study authors emphasize. “Clinicians who care for patients with cancer are frustrated by an increasingly overwhelming set of institutional, regulatory, and policy requirements around opioid prescribing that can interfere with being good stewards and advocates for their patients with pain. Thus, this article underscores the importance of accessibly communicating the streamlined guidelines to oncology clinicians and primary care clinicians who also care for cancer patients with chronic pain who are on long-term opioid therapy.”