Managing Cancer-Related Pain in the Era of the Opioid Crisis

As the opioid epidemic persists in the United States, there are growing questions and concerns over how to manage cancer-related pain and aberrant opioid use. During a session at the 2018 American Society of Clinical Oncology Annual Meeting, June 1-5, in Chicago, Illinois, Egidio Del Fabbro, MD, Virginia Commonwealth University Massey Cancer Center, discussed several management strategies that can be used to address these concerns.

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 minimum that’s required to manage patients on opioids includes:

• Differential diagnosis: identify tumor-related causes of pain and patient-related factors influencing pain perception and expression
• History of risk factors for chemical coping: tobacco use, depression, history of substance abuse, personality disorder
• Opioid agreement that includes outlining of patient obligations: receive opioids from a single provider and no early refills
• Psychological support, motivational interviews, and increased vigilance and structure for those at high risk for opioid misuse
• Documentation of all prescriptions, office visits, agreements, and instructions.

“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,” he explained. “Many states now regard this as mandatory or ask that this be mandatory.”

If a patient continues to display aberrant behavior or isn’t adhering to prescriptions, a physician will need to see them more frequently and the intervals between visits are shorter. Because of this, it makes sense to refer the patient to a specialist team who encounters these more complex patients frequently and has more resources and adopt an interdisciplinary approach, said Del Fabbro.

Who should be referred? According to Del Fabbro, those with high doses, complex pain, complex opioid regimens, or aberrant behavior.

For physicians treating patients with cancer by prescribing opioids, he highlighted 4 management strategies.

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.”

Physicians also need to discuss the risks and side effects, as well as emphasize function as an outcome. It’s important that the patient know they will experience pain, but that they will be more functional. Education is also important because many patients don’t store or dispose of the opioids in an appropriate manner. Simple measures, such as a pamphlet, may be useful, in combination with a personalized approach.

Harm reduction

Ways to optimize harm reduction include using long-acting opioids and avoiding a rapid-acting opioid or excessive quantities. Physicians should also limit supplies, not only in the outpatient setting, but also in inpatient settings.

“We seldom prescribe naloxone for our patients,” said Del Fabbro. “My concern is that naloxone might be another pitfall. Where we think there’s an easy fix with one prescription for the opioid epidemic. Much the same as we landed in this mess by assuming that opioids alone would be able to manage pain successfully.”

He added that it should be indicated for those at very high risk or who have had an overdose in the past.

Del Fabbro also noted the use of opioid rotation, where a physician can switch a patient’s high dosage of opioids to a lower dose by switching the opioid. Because of incomplete cross-tolerance, the patient can achieve better pain control at a lower dose.

Managing psychological and spiritual distress

To manage distress, the use of motivational interviewing has shown to be effective. The idea is to first express empathy for the patient, especially those struggling with substance use disorder. When encountering resistance from the patient, it is important to avoid argument, as it will likely increase resistance from the patient.

The physician should ask the patient their goals and explain that drug misuse will not help facilitate those goals, as well as push for self-efficacy. If this does not work, the physician should bring in an interdisciplinary team that is specialized for these patients.

Risk mitigation

Del Fabbro emphasized the importance of documentation: the pill counts, the education provided, and the plan that has been explained to the patient. He also reinforced the need for routine documentation of the prescription monitoring program and using urine drug screenings.

“Adapted, universal precautions, I think, 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.”