Fifth Bristol Opioid Conference: Revising the EAPC recommendations on opioids in cancer pain
The meeting started with a general introduction about the use and limitations of evidence-based medicine by Henry McQuay. In order to further set the stage for the guideline discussion, Geoff Hanks outlined some of the current important issues related to opioid therapy. Franco de Conno described the large variability in opioid availability across Europe, and Stein Kaasa addressed the need for proper assessment and classification of cancer pain, both in clinical work and research.
On behalf of the EPCRC opioid guidelines group (Work Package 3.1) Augusto Caraceni presented the process for development of the revised guidelines. The key questions to be answered by the guidelines had been selected through a Delphi process involving experts in the fields of cancer pain and palliative care. These key questions were partly based on the current EAPC recommendations, but additional issues had also been identified. For each issue, a systematic review had been performed, identifying the current evidence basis. The presentation of these 22 systematic reviews constituted the main part of the conference program.
After interpreting the evidence, each reviewer proposed key point recommendations, e.g. what should be the step III opioid of choice. The data presented and the following discussions at this Bristol meeting will form the basis for the contents of the revised guidelines.
The following issues had been reviewed and were presented and discussed at the conference:
• Step III opioid of first choice and methods for dose titration
• The use of alternative step III opioids: Oxycodone, methadone, hydromorphone, transdermal fentanyl, transdermal buprenorphine, and opioid combinations
• Special considerations for patients with renal and hepatic impairment
• Breakthrough pain
• Opioid rotation and equianalgesic dose ratios
• Routes of administration and spinal opioids
• The use of non-opioid adjuvant analgesics: NSAIDS, ketamine, antidepressants, and anticonvulsants
• Opioid side-effects, gastrointestinal and central
All issues were included in discussions expertly led by the two attending experts from outside Europe, Kathy Foley and Jim Cleary.
The meeting was fully booked with an audience actively participating in the discussions. During the sessions a lot of opinions were voiced that will influence the further development of the recommendations.
