Managing Cancer Pain in the Era of an Opioid Crisis

Roxanne Nelson, BSN, RN

June 13, 2018

CHICAGO — Opioids are commonly used to treat pain in patients with cancer, especially in those with advanced disease. But in the era of the opioid epidemic and crisis, there are growing questions and concerns over how to appropriately manage cancer-related pain and avoid misuse and overuse of these agents.

During a session at the American Society of Clinical Oncology (ASCO) 2018, experts discussed management strategies and screening techniques that can be used to curb aberrant opioid use.

One of the speakers, Egidio Del Fabbro, MD, program director of palliative care at Virginia Commonwealth University Massey Cancer Center, Richmond, discussed management strategies that can be used to address concerns about overuse and misuse in patients with cancer and highlighted a new concern.

With the recent media emphasis on the opioid abuse crisis, he said that some patients with cancer are now worried that they will become addicted. On the flipside, he is also becoming more and more "concerned about the possibility that our patients are being denied access appropriately to opioids."

"I think it has emboldened many to deny our patients opiates," he said. "I'll give you an example: I prescribed opioids to a patient who had metastatic bone disease — young male, never had an overdose. His morphine equivalent daily dose was 110 and he had a national chain pharmacy deny his opioids unless he was prescribed naloxone."

When Del Fabbro spoke with the pharmacist, he was told that it was "state law."

"I pointed out to him it wasn't Virginia state law, and in fact, patients with cancer pain are excluded specifically," he said. "But I think it's emboldened people to restrict opioids and to stop patients from getting appropriate treatment."

Two years ago, ASCO released a policy statement to remind lawmakers that patients with cancer are a "special population." Education efforts, monitoring programs, and government policies regarding opioid use should preserve the access of patients with cancer to necessary pain treatment.

Medicare has also recently announced that they will deny coverage for more than 7 days of prescriptions equivalent to 90 milligrams or more of morphine daily (using morphine equivalent as a standard for measuring opioid potency), but thus far, patients with cancer and those on hospice are exempt.

However, several private insurers, such as Cigna and Florida Blue have announced that they will no longer provide coverage for OxyContin (Purdue) prescriptions.

Additionally, the Centers for Disease Control and Prevention opioid guideline for chronic pain distinguishes between patients with cancer who are undergoing treatment, to whom the guidelines do not apply, and those who have completed cancer treatment, to whom the guidelines do apply. Thus, these guidelines have the potential to jeopardize pain management in survivors.

Del Fabbro added that they explain to patients "that we are specialists and understand the side effects of opioids. We understand their problem and we are not suggesting that opioids are medications that are easy to use, that are without risk, but we try and reassure them."

The entire team often meets with the patient to explain and to perhaps reduce this opioid phobia. Dr Egidio Del Fabbro

 "The entire team often meets with the patient to explain and to perhaps reduce this opioid phobia," he added. "But I think it's going to be an ongoing problem."

Looking Out for Substance Abuse Disorder

At the education session, Eduardo Bruera, MD, chair of the Department of Palliative, Rehabilitation and Integrative Medicine at the University of Texas MD Anderson Cancer Center in Houston, discussed the issue of opioid abuse.

"About 80% of patients receiving opioids for pain management will adhere to them as prescribed and will have no major difficulties with dose reduction or even discontinuing treatment if the pain resolved," he said.

However, the remaining 15% to 20% are at a risk for nonmedical opioid use or may ultimately develop substance use disorders.

Bruera explained that the definition of nonmedical opioid use is when opioid drugs, as well as other psychoactive agents, are used for distress rather than pain. This occurs in about 1 in 5 patients, but most are underdiagnosed until aberrant opioid use is detected.

Given the relatively high rate for nonmedical use, "universal screening is wise, and it's not that time-consuming," he said.

Several tools can be used to assess the patient's risk for an opioid use disorder, he explained.

One is the CAGE-AID questionnaire, an adaptation for drug use from the CAGE alcohol screening questionnaire (which asks four questions:  Have you ever felt you needed to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt Guilty about drinking? Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?).

"This is just four items and takes about 30 seconds to do," Bruera explained.

The other is the SOAPP-R (Screener and Opioid Assessment for Patients with Pain–Revised), which is a little bit more involved. "It has about 14 items and takes less than 3 minutes, and both are validated screening tools for drug abuse risk," he said.

A positive response to two or more questions indicates an 80% chance that the patient has a problem with alcohol or drugs and is at a higher risk for nonmedical use of opioids, Bruera said.

He explained that the SOAPP is very sensitive in detecting a risk, and the association between the SOAPP and the CAGE is very high. Patients who have a positive SOAPP test result tend to be male, are more likely to be younger, and are more likely to report higher levels of anxiety and pain.

Bruera pointed out that smoking can also be a red flag for risk. "When you look at the frequency of CAGE positive and history of drugs, it is exponentially higher among current and also previous smokers as compared to nonsmokers," he said. "As cigarette smoking has become less prevalent in our society, those who really are still doing it or have recently been doing it are more likely to have problems with alcohol and opioids," he commented.  

"And, of course, they had a higher history of illicit drug use and a higher pain complaint," he added.

Other indicators of a higher risk include a history of illegal drug use, mood swings, family history of substance abuse disorders, close friends with substance use disorders, and high Edmonton Symptom Assessment Scale scores on pain. Clinicians should also be aware of behaviors associated with nonmedical use of opioids, such as self-escalation of opioid use, reporting lost/stolen opioids, frequent visits to the emergency department requesting opioids, and concern voiced by family members.

Bruera also emphasized the importance of documentation, which a recent study found to be inadequate. At the Supportive Care Center at MD Anderson, he explained that of 432 patients who were evaluated by palliative care specialist, 18% were identified as using opioids in a nonprescribed way.

"Unfortunately, only 4% — only one quarter of those in whom the diagnosis was made — were documented, and that is a little bit of a problem," he said. Documentation is needed to ensure proper management of pain and to avoid unnecessary harm, he added.

Bruera and his team also looked at how well patients were storing opioids (and reported these findings in The Oncologist).

"We found that, unfortunately, 26% of the patients that we were treating at Anderson were sharing or losing them, and 19% of patients stored them in plain sight," he said.

Of the 300 patients in their survey, 69% also hid them in an unlocked location, 9% stored them in a locked location, 46% reported unused opioids in the home, and 74% were unaware of proper disposal methods. Bruera noted that a one-page educational tool on the safe use and storage of opioids that is now being used at their institution has substantially changed patient behavior.

Another issue is that patients may be intentionally or unintentionally diverting medication, as more than half (55%) of individuals who develop a substance use disorder get their opioids from family and friends. Urine drug screening is a method that can be used to assess for diversion. In one study of 1058 patients with cancer receiving palliative care, 6% underwent urine drug screens and just over half of them (54%) had abnormal results (Cancer. 2016;122:3732-3739).

"The ones that are most concerning is when the prescribed opioid was not in that urine," Bruera pointed out. "That raises the concern that the opioid is somehow being diverted."

The key is that there is a "harmony" that must be attained. "We need to reach a harmony between the appropriate use and feel free and feel safe to prescribe these agents, and also be watchful for those that might be at higher risk," he emphasized.

Finally, Bruera added that a very different opioid crisis faces much of the rest of the world. The United States makes up 5% of the global population but uses 56% of the opioids.

Access is a different story in the rest of the planet. Dr Eduardo Bruera

"The vast majority of patients die of cancer around the world without having received one single dose of an opioid analgesic for pain," he said. "And so access is a different story in the rest of the planet." 

Effective Management Strategies

In his talk at the education session, Del Fabbro discussed management strategies that can be used to address concerns about overuse and misuse in patients with cancer.

The overuse of opioids can lead to intense and severe consequences, including opioid-induced neurotoxicity, poor quality of life, addiction, overdose, and death, Del Fabbro explained. "Ongoing vigilance is necessary, even with the patient that is successfully treated and successfully managed."

The risk for overdose and death is probably lower in patients with cancer than in other groups, he noted, but one study found that patients with cancer who receive immediate-release opioids as needed have a higher risk for overdose death than do those who are given immediate-release scheduled or long-acting opioids.

Prescribing opioids, even for patients with cancer, also involves a "whole host of medical legal problems, both for patient and physician," Del Fabbro explained. "There have been a number of highly publicized criminal prosecutions of physicians who were treating patients for chronic nonmalignant pain."

It hasn't happened yet in cancer-related pain, "but it is something we need to be aware of, obviously," and "of course, as mentioned, we also need to be concerned about diversion."

Managing patients with aberrant behaviors, complex opioid regimens, and complex pain or those who are receiving high doses requires a multidisciplinary approach and preferably a referral to palliative care, he noted, as opioid use disorders are multifaceted.

The first step is to document a treatment agreement or a pain contract, which is a type of informed consent in which the patient acknowledges having received education about opioid use disorders. Documentation is also essential.

"You need a lot of documentation when you see these patients — documentation of the treatment agreements, documentation of a prescription monitoring program, and that it's being checked," said Del Fabbro. "Many states now regard this as mandatory or ask that this be mandatory."

Patients who continue to display aberrant behavior, or who aren't adhering to the prescribed regimen, will need to be seen more frequently, and the intervals between visits will be shorter.

That is why it makes more sense to refer the patient to a specialist team that is more familiar with complex patients and has more resources and to adopt an interdisciplinary approach, he pointed out.

Four Key Elements

Del Fabbro outlined four key management strategies for treating pain in patients with cancer: education, harm reduction, managing the psychological and spiritual distress, and risk mitigation.

For education, "you have to start at the beginning and explain that opioids should only be used for pain," said Del Fabbro.

"It may seem obvious, but I had a health practitioner tell me that he was using opioids at night for his insomnia," he told the audience. When  he asked the patient if he had any pain, the patient said no. "So we had a little bit of a conversation and after that, there was appropriate opioid use."

Risks and side effects need to be discussed, and function as an outcome should be emphasized. "It's important that patients realize that they may still be experiencing some pain, but that being more functional is a realistic goal," he commented.

Education is also important because many patients don't store or dispose of the opioids appropriately. Simple measures, such as an educational pamphlet outlining safety and "dos and don'ts," may be a helpful adjunct measure.

For harm reduction, Del Fabbro noted that strategies include the use of long-acting opioids and avoiding a rapid-acting opioid or excessive quantities. Supplies should be limited in both the inpatient and outpatient settings.

Selective naloxone use may also be indicated for those at very high risk or who have a history of a previous overdose. He noted, however, that naloxone is seldom prescribed for patients.

"My concern is that naloxone might be another pitfall, where we think there's an easy fix with one prescription for the opioid epidemic," he said, "much in the same way as we landed in this mess by assuming that opioids alone would be able to manage pain successfully."

Another strategy is opioid rotation, and several studies have shown that it can successfully improve pain, well-being, insomnia, and depression. The idea is that a high dose can be switched to a lower dose by changing the opioid. "And because of incomplete cross-tolerance, you're able to achieve better pain control at a lower dose," Del Fabbro said.

The third key strategy is to manage distress, as about 90% of patients with opioid use disorder and chronic pain also have comorbid psychiatric conditions.

Cognitive-behavioral therapy is probably the intervention that has the most evidence, but it is very time-consuming. Instead, Del Fabbro pointed out that motivational interviewing, a method shown to be successful for alcoholism, is effectively used at their institution.

"The idea is to express empathy for the patient," he said, such as acknowledging that patients are experiencing a difficult time. When encountering resistance from the patient, it is important to avoid an argument because it will likely increase resistance from the patient.

Patients should be asked about their goals and clinicians should explain that drug misuse will not help facilitate those goals and also push for self-efficacy. If this strategy doesn't work, an interdisciplinary team that specializes in caring for these patients needs to be brought into the paradigm.

Finally, for risk mitigation, Del Fabbro emphasized the importance of documentation, such as pill counts; that the patient has been provided with education; and that the treatment plan has been implemented. He also pointed to the need for routine documentation of the prescription monitoring program and using urine drug screenings.

"Adapted, universal precautions, unfortunately, need to be expanded even further for these patients who have an opioid misuse problem or even the potential," he said. "I think here, again, it's going to be necessary to refer either to a supportive care clinical or to a pain service."

American Society of Clinical Oncology (ASCO) 2018

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