Opioid Misuse in Cancer Patients: Fearmongering or Real Risk?

Roxanne Nelson, RN, BSN

December 04, 2018

SAN DIEGO — The opioid crisis has been in the mainstream media for several years now, and the misuse of these agents has been deemed a serious national problem. As the crisis continues, an unintended consequence is that cancer patients are finding it more difficult to obtain these drugs.

A pertinent question here is whether cancer patients are at high risk for opioid abuse and/or opioid-related death. Do barriers to access make any sense in this particular population?

At the Palliative Care in Oncology Symposium (PCOS) 2018, two experts presented opposing viewpoints on the issue.

Fearmongering

Charles von Gunten, MD, PhD, vice president of medical affairs, hospice, and palliative medicine, Kobacker House, in Columbus, Ohio, believes that the current debate is largely being driven by emotion rather than data.

"The evidence base for opioids for moderate to severe cancer pain is firm. It's settled. It's textbook," he said. "We must ensure that professionalism, and not fear, guides oncology practice."

Under the Obama administration, Health and Human Services Secretary Sylvia Mathews Burwell stated, "Opioid overdose is the leading cause of accidental death in the US."

Fear of opioids has spread across the country, explained von Gunten, "and emotion is now guiding practice — not data, not facts, but emotion."

This is not to say that opioid misuse is a not a problem, he emphasized. There has been an increasing number of opioid overdose deaths in the country, but as the data from the Center for Disease Control and Prevention (CDC) indicate, the increase is being driven by illicit fentanyl use, not prescribed fentanyl.

Most of the language is not about data or facts, von Gunten reiterated, and in fact, it's not about evidence at all. As an example, he cited a statistic that appeared in his alumni magazine: "1 out of 12 physicians accepted gifts from opioid manufacturers from 2013 to 2015.

"Well, do you feel the fearmongering as those doctors — those greedy doctors — they're being paid off by the drug companies to make all of our children addicts," he said.

Similar articles have appeared in the mainstream media, but he also pointed to an "interesting" article in the New England Journal of Medicine that asked the public who they felt was primarily responsible for the problem of prescription painkiller or opioid abuse. One third of respondents stated that they believed physicians were responsible, and 47% believed that monitoring prescribing was a very effective way of controlling the opioid epidemic.

Von Gunten pointed out that the Diagnostic and Statistical Manual of Mental Disorders (DSM) has eliminated addiction as a diagnosis so as to place addiction in a broader perspective, one that encompasses behavior beyond the compulsive use of a substance. The idea behind this broadened definition was to include adolescent and young adult risk-taking behavior, he explained.

"The best evidence about the broad term 'opioid use disorder' is that it's first observed in the late teens or early 20s," he emphasized. "That's the risk group, the young."

Conversely, the prevalence of opioid use disorder among those older than 18 years is only 0.37%, and prevalence decreases with age.

By contrast, the main risk factor for cancer is increasing age, he pointed out.

The DSM also mentions that the enormous problem of heroin addiction among military personnel in the Vietnam War largely dissipated once the soldiers returned home. "The majority stopped using it once they got back to the US," von Gunten noted. "It was not a fixed thing that went on and on forever, illustrating the extraordinary diversity of causes of addiction — it's not just exposure to the drug."

Some studies from chronic nonmalignant pain clinics indicate a 6% to 25% prevalence of opioid use disorder. But these studies only include patients being treated in these pain clinics; they do not take into account all patients with chronic nonmalignant pain. This is skewing the data, he argued. "The lack of high-quality incident studies of the general population and of those who are medically ill adds to it," he said.

Opiodophobia

Despite the media frenzy, von Gunten emphasized that the incidence of opioid use disorder is actually quite low, especially in comparison with alcoholism. Current data suggest that 60% to 70% of Americans have been exposed to alcohol, and there are about 16 million alcoholics and 88,000 alcohol-related deaths annually. Yet, "we're not talking about an alcohol epidemic," he said.

In contrast, there are currently two million opioid addicts in the United States, and 60,000 opioid-related deaths occur annually, according to the latest data.

The prevalence of opioid abuse disorder is particularly low among patients with cancer pain. "It is not a 'one prescription equals one addict,' which is what's out there," he said. "There is evidence that opioids are safe and effective for cancer-related pain. And they're the mainstay for cancer pain."

But unfortunately, "opioidophobia" exists in the cancer community. Von Gunten explained that he sees it routinely in his own practice among both physicians and patients. A huge social fear has developed over the use of pain medications, to the point that even when the drugs are made available, patients and caregivers are afraid to use them.

"We have pharmacies that will not stock the drugs because they're afraid of robberies related to the drug," he said, "And we have healthcare professionals who are spending time now learning about how to assess a patient as an addict instead of learning how to treat pain."

Consequences of Unregulated Access

Presenting the opposing viewpoint was Leslie Blackhall, MD, the section head for palliative care at the University of Virginia, Charlottesville.

Although playing the "bad cop," Blackhall noted that she agreed that opioids are the mainstay of cancer pain management.

"Cancer pain is incredibly common, and it is a source of great suffering," she said. "However, just because you have cancer doesn't mean that you can't have some kind of a substance use disorder."

According to the 2017 national substance use disorder questionnaire from the Substance Abuse Mental Health Services Administration, psychotherapeutic drugs, including sedatives, tranquilizers, pain relievers, and stimulants, are misused by about 18 million people (7.1%). Among those drugs, tranquilizers and pain relievers were the most commonly misused.

There are two principal sources for these drugs, Blackhall explained. "One is from a prescription that was given by a doctor, but more than half are coming from a friend or relative. So either we're prescribing them, or our patients are the source for other people who are getting them."

She agreed with von Gunten that data show that misuse of opioids by cancer patients "really is hard to come by." However, she pointed out that alcohol use is a risk factor for some cancers. "People with head and neck cancer have a very high rate of alcohol abuse," she said. "And there's indications they have a very high rate of substance use disorders."

In one study from 2014, the Opioid Risk Tool was used to screen patients at a palliative care clinic. The investigators found that 12% of patients had a history of prescription drug abuse or were currently engaged in prescription drug abuse. Similarly, a study from 2013 conducted at the University of Texas MD Anderson Cancer Center showed that 29% of patients were considered to be at high risk for opioid abuse.

"So I don't think it's zero people," she said; these studies suggest there are patients who are abusing/misusing opioids.

Overall, Blackhall reiterated that in the general population, people have a fairly high risk of having one type of problem or another regarding a substance use disorder. "And I would say it's not just opioids, because if you're giving someone opioids, benzos, and other drugs, and they have a cocaine abuse problem or they have an alcohol abuse problem, then they are at risk for misusing, diverting, or even inadvertently overdosing on the drugs that you're giving them," she explained

This is a topic that needs to be discussed, and "we should be talking about it," she emphasized. "We should be dealing with it, and I don't think this is such a hard thing to talk about."

She noted that there is a danger of the pendulum swinging too far. She recalled that in California during the 1980s, at least two thirds of oncologists did not have a Drug Enforcement Administration license and so could not prescribe anything that was higher in potency than Vicodin (hydrocodone bitartrate and acetaminophen). "They were afraid they were going to get arrested, and they assumed that their patients were becoming drug addicts, and that one Percocet (oxycodone and acetaminophen) means they'll be out there in the street shooting heroin or something," she said.

The pendulum then swung too far in the opposite direction, she said, "where everybody with a stubbed toe got Oxycontin (oxycodone) for it," said Blackhall. "There's good evidence to show that many more people were getting opioids than those who really needed them."

So at this juncture, there is legitimate concern about shifting backward, such that patients with legitimate needs could be denied pain medication. But the answer does not lie in pretending that this isn't a problem, she emphasized.

"It is a problem. I can guarantee you, it's a problem, and if you're not screening for it, you're missing the fact that some of your patients and their family members have that problem," she said.

Blackhall does not want to revert to the point where physicians are severely limited in what they can legally prescribe, but "I don't think we should be staying at the place where we're just putting our fingers in our ears and going, 'la, la, la, la, la,' " she said.

Her recommendation is for universal screening, and all patients at her clinic are evaluated at their first visit. The Opioid Risk Tool is used because it is brief and convenient. "Universal monitoring and universal education are how you use opioids safely," she said.

Summing It Up

The chair of the session, Susan G. Urba, MD, professor of medicine at the University of Michigan, Ann Arbor, noted that the debate addressed many of the issues that physicians are struggling with.

"I don't want to contribute to anyone's addiction or to their struggles with opioids, and I also don't want the opioids I'm prescribing being sold on the street for something else," she said. "That's in the back of my mind, and probably this is true for every practitioner."

Urba emphasized that physicians want to treat their patients. "We want to provide them with comfort, and it doesn't take a genius to agree, particularly at this meeting, that this is a very high priority for us," she said.

She explained that she runs a symptom management and supportive care clinic at her institution's cancer center and sees many patients who have pain that is difficult to manage. The decisions on how to treat pain are often not clear-cut or are not addressed in guidelines.

A patient with metastatic esophageal cancer, for example, which is associated with a high degree of pain, would certainly receive opioids, Urba said. "But what about the person who is now cancer free but has chronic pain that resulted from the cancer treatment?"

After undergoing chemoradiation, patients with head and neck cancer may be free of disease but have intense pain and require a very high level of opioids. Nonopioid drugs are recommended for many types of pain, such as neuropathic pain. But many of the patients referred to her clinic have already been prescribed these drugs and are still in pain, she noted. "They're being referred to me for consideration of opioids," she said.

In the American Society of Clinical Oncology's Clinical Practice Guideline for Neuropathic Pain, duloxetine (Cimbalta, Lilly) is given a moderate recommendation for the treatment of such patients, and several other agents may be offered, but there is no mention of opioids, Urba explained. "I would feel more comfortable having some data backing me up, so in my notes I make a very good case for them."

Such patients may be receiving opioids for a long time, she emphasized. "Some of them are cured, and this is their big problem, often for the rest of their life."

Overall, Urba feels that "we just have to use our head.

"Believe me, I'm wanting to treat pain, but I'm also wanting to feel like I'm abiding by standard practices," she said. "We want to provide good care for our patients, and yet we have got to make accommodations for those who struggle with substance use issues."

Dr von Gunten has relationships with AstraZeneca, Salix, Otsuka, Valient, and Progenics. Dr Urba has a relationship with Merck. Dr Blackhall has disclosed no relevant financial relationships.

Palliative Care in Oncology Symposium (PCOS) 2018. Presented November 16, 2018.

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