Oncologists: You Know Your $#!+

Kate Hitchcock, MD, PhD

Disclosures

June 02, 2021

Cancer being what it is, I would imagine that all oncologists end up becoming expert managers of pain medications. At our current level of technology, opiates are frequently going to enter that equation, and opiates mean constipation. The result of this is that my family thinks that I manage poop for a living. Most days that's not too far from the truth. The impression is probably reinforced when, time after time, a friend of the family undergoes surgery and is prescribed narcotics with exactly zero warning about their bowel effects, ends up in terrible suffering, and calls for advice on how to get un-stopped-up.

In my clinic I have written up a constipation prevention sheet that is given out with every prescription for opiates. It starts with hydration and a little stool softener at the top of the page, and progresses through magnesium citrate and enemas at the bottom (or as they are known here, "the nuclear option"). This program has never failed us so long as the patient actually inserts the recommended agent into the assigned orifice in a timely fashion. None of these medicines work well outside the body. All of them are available as inexpensive generics in every grocery and drug store, which means that almost all of my patients can lay hands on them without struggle.

I am a little perplexed, then, to learn that folks are prescribing massive quantities of new drugs invented to manage opioid constipation not controlled by these cheap, readily available agents. Pam Harrison has recently written in Medscape Medical News about a dramatic rise in the use of three peripheral mu-opioid receptor antagonists (PAMORAs), which have been around since 2008. Prescriptions for these increased more than tenfold from 2014 to 2018 ― from $13.6 million to $150.9 million, according to a recent report. Ms Harrison points out that this is particularly hard on Medicare, where during that period the number of patients on these drugs increased from around 4000 to more than 72,000. Arjun Gupta, the senior author on this recent paper, suspects that robust marketing that included a 2016 Super Bowl spot may explain the phenomenon.

I think that there is another factor at work here, a subset of placebo effect to which I suspect people in the United States are particularly prone. Patients feel better after they are given more expensive medication. I've had a couple of run-ins with broken bones and major surgeries over the past 10 years, and for me the combination of ibuprofen and acetaminophen works better than the oxycodone I was prescribed at the time.

When I suggest this to my patients, though, many tend to react as if I am attempting to deprive them of good care. They have serious pain, they tell me; only a prescription will do! Ditto sleep aids, GERD management, and, yes, laxatives. "Yeah, I only took it a few times, but it didn't seem to do anything, Doc. Can't you just prescribe me something?" I have to dig deep to find the patience to explain that no medicine is going to work if they won't take it consistently, and that more dollars will not change that. Tylenol, I tell them, is used as battlefield medication in many places; it's a strong drug! They roll their eyes and start thumbing through their phones to call their other oncologists.

Now, one thing I do not need more of is discussions with insurance companies. The frequent situation in which I, a specialist physician, have to argue with a nonspecialist over care I have clearly and justifiably recommended in order to get treatment approval is a topic for another time. But when I read articles like Ms Harrison's, I definitely understand that those companies, and by extension all of us, stand to experience serious harm from the prescription of expensive brand-name treatments where generic OTCs would have worked. It's a situation where I can understand demands for justification.

Do you find a need for the PAMORAs in your clinic? And how do you handle patient demands for prescriptions where they are not necessary?

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About Dr Kate Hitchcock
Kate Hitchcock, MD, PhD, is a radiation oncologist, biomedical engineer, and retired aircraft carrier driver who grew up as a Wyoming cowgirl. When she is not at the hospital, you can find her with Carolyn, Mary, Tyler, Nick, Marlee, and Colby the barking dog, enjoying the natural splendor of the great state of Florida. She thinks you should visit sometime and try to solve the puzzle of why the natives have so carefully shunted all of the tourists toward the House of Mouse. Connect with her on Twitter: @hitchcock_kate

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