Assessment of Opioid Misuse and Abuse Should Be Part of Cancer Pain Management

Wayne Kuznar

June 2019, Vol 10, No 3 - 2019 NCCN Conference


Orlando, FL—Maintaining patient safety and minimizing the risks for opioid misuse and abuse in the management of cancer pain require proper assessment and new strategies for pain management that include integrative interventions, according to Judith A. Paice, PhD, RN, Director, Cancer Pain Program, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago. She discussed this topic at the 2019 National Comprehensive Cancer Network (NCCN) Conference.

“Opioid medications are necessary for people with cancer at some point in their treatment trajectory,” said Dr Paice. Maintaining safe care is imperative in the face of 2 current public health crises, unrelieved pain and opioid misuse and overdose.

Simple solutions (ie, prescribing opioids for management of pain) have helped to create the current crisis. “It’s going to take complex solutions to address these 2 different public health crises,” she said.

Deaths from illicit use of synthetic opioids, heroin, and natural and ­semisynthetic opioids have been increasing over the past 2 decades, but “interventions designed to limit prescription opioids will not be addressing the primary problems associated with this epidemic right now,” Dr Paice said.

“We in oncology are faced particularly with this challenge: how do we achieve balance.…How do we provide pain control to people who need these medications in a time of an opioid epidemic?” Dr Paice asked.

Cancer Treatment and Pain

Several chronic pain syndromes are associated with cancer treatment, including lymphedema, osteoporosis, arthralgias, and myalgias. The updated NCCN guideline for adults with cancer pain recommends the use of integrative interventions in conjunction with pharmacologic interventions, as needed, especially in vulnerable populations (ie, frail, elderly) in whom standard pharmacologic interventions may be less well-tolerated.

Some of the intervention strategies that failed to achieve adequate analgesia include regional infusions (ie, epidural, intrathecal, regional plexus), percutaneous vertebroplasty/kyphoplasty, neuro­destructive procedures for well-localized pain syndromes (ie, spinal analgesics), neurostimulation procedures, and radio­frequency ablation (for bone lesions).

Opioids can have long-term adverse effects, said Dr Paice. “Now that we are treating people for longer periods of time, we see endocrinopathies, which can lead to amenorrhea, difficulty with performance, which also potentially can lead to long-term bone health issues and fatigue,” she said. “We certainly can see neurotoxicities like myoclonus or hyperalgesia, and sleep-disordered breathing problems, especially in people who are obese.”

Function Assessment a Key to Pain Management

In addition to the usual pain assessment, patients should be evaluated for the presence of risk factors for adverse events and misuse, particularly for opioids.

Pain assessment has changed over time and reliance on a pain score has decreased. Even more important is an assessment of the pain’s effect on function, Dr Paice said. Instead of aiming for a pain score of 0 on a 0 to 10 scale, medicines should be prescribed so that the patient can function better. For some patients, better function may mean a return to work; for others it may be the ability to walk around the block. “For our patients with advanced disease, it may be the ability to hold their grandchild,” she said. “The goal is related to function.”

Risk Factors for Misuse

Patients also must be assessed for their risk factors for misuse. In addition to asking about a history of smoking and alcohol use, “we need to also ask about current and past use of recreational substances, and we also need to ask about family history,” Dr Paice said. “That’s a very crude proxy for their genetic risk, but it also tells us about environmental risk if they’re living with these family members.”

Patients should also be asked if they have been sexually abused, which is a strong risk factor for addiction. If they answer “yes,” ask them if they have ever seen a mental health professional for this reason.

Universal precautions to mitigate risk of misuse include prescription drug monitoring programs, urine toxicology, and use of pain treatment agreements.

According to the updated guideline, treatment goals should be established with cancer survivors and their caregivers, and the effectiveness and necessity of opioids should be re-evaluated on a regular basis. In addition, providers should monitor for aberrant drug-taking behaviors.

Slow Titration Down

When opioids are no longer beneficial, a slow downward titration—10% per week or month—is advised. In addition, providers should optimize nonopioids and adjuvant analgesics, being cognizant of the risk for gastrointestinal bleeding with use of nonsteroidal anti-inflammatory drugs, especially in older patients.

“Use antidepressants instead of benzodiazepines as much as possible, and if people do have anxiety disorders and other metal health issues,…get them involved with psychiatric support,” she advised.

CDC Guideline on Opioid Prescribing Does Not Apply to Cancer-Related Pain Management

On April 9, 2019, the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), and the American Society of Hematology (ASH) issued a press release clarifying that the Centers for Disease Control and Prevention (CDC) guideline on opioid prescribing for pain did not intend to limit access to pain therapies for patients with cancer.1

The CDC letter specifies that its guideline is not intended to deny appropriate opioid therapy to patients with acute or chronic pain related to cancer or sickle-­cell disease, but rather to ensure careful consideration of all safe and effective options for pain management, with the goal of reducing inappropriate use.

The CDC guideline, released in March 2016, stated that 3 days or less of opioids “will often be sufficient” for the treatment of acute pain. In its letter to ASCO, NCCN, and ASH, the CDC notes that the guideline was mainly intended for primary care providers and should not apply to patients receiving active cancer treatment, palliative care, or end-of-life care.

The CDC further advises that the cancer-related pain management guidelines issued by ASCO and NCCN are appropriate, and “provide important guidance on the unique considerations when using opioids to control pain in cancer survivors without worsening the current opioid crisis.”1


Reference

  1. ASCO. CDC issues key clarification on guideline for prescribing opioids for chronic pain. April 9, 2019. www.asco.org/advocacy-policy/asco-in-action/cdc-issues-key-clarification-guideline-prescribing-opioids-­chronic. Accessed May 28, 2019.