Managing the Unique Challenges of Opioids in Cancer Care

Kate M. O'Rourke

Disclosures

June 26, 2017

With novel treatments leading to better survival for cancer patients, clinicians are now treating more survivors with persistent pain syndromes. And while cancer patients are already unique in terms of pain related to their disease and its treatment, the opioid epidemic, a huge problem in the United States, Canada, Australia, and different parts of Europe, adds another layer of complexity to treating cancer survivors with opioids.

During an educational session at the 2017 meeting of the American Society of Clinical Oncology (ASCO), experts in pain management discussed some of the challenges of opioid prescribing among cancer patients and provided practical takeaways on assessing patients and treating their pain.

Opioid Epidemic

"We are now caring for people who have cancer and who are cancer survivors, who are at risk for, or may have, pre-existing addiction," said Judith Paice, PhD, RN, director of the Cancer Pain Program at Northwestern University in Chicago, Illinois. "How do we provide the balance in delivering safe and effective analgesia?"

Dr Paice said that what patients in the United States learn from the media is that you start with prescription opioids, and in a very short period of time, you move to injecting heroin. "What the media has sometimes missed is that of those people who started with prescription opioids and then went on to use heroin, 75% never had a legal prescription for opioids. They were already stealing or buying the drugs illegally," she said.

While screening tools are available to determine a patient's risk for misuse, they have not been validated in cancer patients.[1] "The current proxy is to ask about family history and then past history. Sexual abuse and PTSD (post-traumatic stress disorder) are very strong predictors of addiction," said Dr Paice.

ASCO's practice guideline on managing chronic pain in adult cancer survivors[2] makes key recommendations about screening and comprehensive assessment and treatment and care options, as well as risk assessment, mitigation, and universal precautions. Clinicians should use a structured approach for managing opioids, including standardized documentation, pill counts, opioid treatment agreements, and urine drug screens. "Clinicians should use universal precautions when using opioids and do ongoing assessment," said Dr Paice. Patients should be educated about safe storage and disposal and weaned off opioids gradually at the appropriate time.

"We need to understand the definition of tolerance and addiction, and we need to incorporate universal precautions and understand the laws that regulate our practice," said Dr Paice. "Universal precautions are something that we use for all patients, otherwise implicit bias may get in the way. We assess and stratify [patient risk] based on our assessment findings, and then we decide whether it is safe to prescribe. Is the risk of diversion too high? Is the risk of drug use too high? We minimize risk as much as we can by providing structure in the environment, and then we monitor for drug-related behaviors once we do prescribe."

In March 2016, the Centers for Disease Control and Prevention released guidelines on the prescription of opioids for chronic pain unrelated to active cancer treatment in patients who are not receiving palliative or end-of-life care.[3] In May 2016, ASCO also released principles for balancing appropriate patient access to prescription opioids, while curbing misuse and abuse of these drugs.[4] It emphasized that cancer patients should be largely exempt from regulations restricting access to or limiting doses of prescription opioids in recognition of the unique nature of their disease, its treatment, and potentially life-long adverse health effects from having had cancer. States have wide authority to regulate prescription drug policies and have implemented a range of prescription drug monitoring programs. Regulatory requirements, however, do not always acknowledge the need to exempt cancer-related pain.

Cancer patients should be largely exempt from regulations restricting access to or limiting doses of prescription opioids in recognition of the unique nature of their disease.

Various studies capture some of the unique challenges of identifying patients at risk for using opioids inappropriately. In a chart review of patients referred for palliative care, only 4% had documentation of some evidence of addictive disease, but 18% were chemical copers, those who would use opioids in a nonprescribed way to cope with various stressful events.[5] Any patient with a history of coping chemically by using alcohol or drugs is more likely to adopt a maladaptive coping strategy involving opioids when faced with the multiple psychosocial and physical burdens accompanying a diagnosis of cancer.[6] All patients at risk should receive brief motivational interviewing with an objective, nonjudgmental, and empathic style that includes personalized feedback, particularly about markers of risk or harm.[6] If aberrant drug behavior is identified, a quick response is key, with addiction colleagues pulled in if needed. Possible solutions are numerous. "I have some patients to whom I only prescribe 1 week at a time," said Dr Paice.

I have some patients to whom I only prescribe 1 week at a time.

As a result of interventions designed to combat the prescription drug abuse epidemic, patients face new challenges in accessing opioids, with fewer clinicians willing to prescribe opioids, pharmacies reluctant to stock the medications, and payers placing strict limits on reimbursement.[1] Renata Louwers, a bladder cancer patient advocate who lives in Virginia and San Francisco, said she had problems accessing opioids for her husband, who died of bladder cancer. When noticing that a pain drug was low, she would call the oncologist's office and they would tell her that they could not fax or call in the prescription to the pharmacy-that she would have to drive to the doctor's office to pick it up (or they could mail it, though inconvenient). Pharmacies would never confirm over the phone whether they had the drugs, so she often drove to multiple pharmacies before she could fill the prescription.

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