Use of Opioids for Adults With Pain From Cancer or Cancer Treatment: ASCO Guideline

J Clin Oncol. 2023 Feb 1;41(4):914-930. doi: 10.1200/JCO.22.02198. Epub 2022 Dec 5.


Purpose: To provide guidance on the use of opioids to manage pain from cancer or cancer treatment in adults.

Methods: A systematic review of the literature identified systematic reviews and randomized controlled trials of the efficacy and safety of opioid analgesics in people with cancer, approaches to opioid initiation and titration, and the prevention and management of opioid adverse events. PubMed and the Cochrane Library were searched from January 1, 2010, to February 17, 2022. American Society of Clinical Oncology convened an Expert Panel to review the evidence and formulate recommendations.

Results: The evidence base consisted of 31 systematic reviews and 16 randomized controlled trials. Opioids have primarily been evaluated in patients with moderate-to-severe cancer pain, and they effectively reduce pain in this population, with well-characterized adverse effects. Evidence was limited for several of the questions of interest, and the Expert Panel relied on consensus for these recommendations or noted that no recommendation could be made at this time.

Recommendations: Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Opioids should be initiated PRN (as needed) at the lowest possible dose to achieve acceptable analgesia and patient goals, with early assessment and frequent titration. For patients with a substance use disorder, clinicians should collaborate with a palliative care, pain, and/or substance use disorder specialist to determine the optimal approach to pain management. Opioid adverse effects should be monitored, and strategies are provided for prevention and management.Additional information is available at

Publication types

  • Review

MeSH terms

  • Adult
  • Analgesics, Opioid / adverse effects
  • Cancer Pain* / drug therapy
  • Humans
  • Neoplasms* / complications
  • Neoplasms* / drug therapy
  • Pain / drug therapy
  • Pain / etiology
  • Pain Management
  • Substance-Related Disorders* / drug therapy


  • Analgesics, Opioid