Pain Management in Cancer and the Risk of Patients Developing Opioid Use Disorder

As cancer treatments improve and death rates decline, more patients survive who are at risk of becoming addicted to pain medications they were prescribed to treat their cancer-related pain, explained Merrill Norton, PharmD, NCAC II, CCS, CCDP-D, of the University of Georgia.

During a session on pain management in oncology at the National Community Oncology Dispensing Association Spring Forum 2018, held March 1-3 in Dallas, Texas, Norton explained that as an addiction specialist, he is seeing patients whose cancer is in remission and who have opioid use disorder.

“It would be a hell of a thing for them to overcome cancer and become addicted,” Norton said.

Unfortunately, there isn’t a lot of research in the area, he added. The prevalence of chronic, nonmalignant pain among patients with cancer has been reported to be anywhere between 2% and 76%, depending on the patient population and how pain is assessed.

Similar to how not everyone who smokes or vapes will develop cancer, but it does increase their risk, not everyone who is treated for cancer pain with opioids will develop an addiction, but it does increase their risk. However, as the number of cancer survivors increases, healthcare providers have to be aware that those treated with opioids for their cancer-related pain may develop opioid use disorder.

Norton spent time going over the statistics of the opioid epidemic, which has been going on since about 1995 as best as experts can tell. In 2016, more than 64,000 people died from drug overdoses, which means that overdose deaths surpassed the individual death rates for almost all cancers with the exception of lung cancer. And the deaths from drug overdoses keep escalating, he added.

While the country is putting in place state and federal regulations designed to curb opioid use disorder and addiction, the American Society of Clinical Oncology (ASCO) has said patients with cancer should largely be exempt. In a May 2016 policy brief, ASCO noted that patients with cancer “represent a special population” due to the “unique nature of the disease.”

To ensure patient access to pain medications, ASCO recommended allowances in state prescription drug monitoring programs (PDMPs) so providers who treat cancer-related pain may prescribe “relatively large numbers of opioids,” as well as there be no prescription limits for patients with cancer.

Norton explained that PDMPs can be extremely important, but underused. In Georgia, participation in the PDMP was initially voluntary, but only a small handful of providers actually registered. Now the state has made it mandatory to register with the PDMP in order for providers to get re-certified.

However, ASCO also provided recommendations for treating patients with cancer with opioids to prevent opioid abuse. These recommendations include appropriately screening and assessing patients before and during opioid treatment; using abuse-deterrent formulations when possible; educating patients on safe use, storage, and disposal; increased access to naloxone; and developing prescription take-back programs.

Norton promoted the use of take-back programs, which provide a place for patients to bring back unused or unwanted opioids for proper disposal. In the oncology space, the unfortunate truth is that patients with cancer will die, and they will leave behind unused pain medications for their loved ones to deal with.

However, health systems and providers don’t always think about what happens to unused opioids. Norton had found that even large health systems don’t have a policy in place for how patients or families can dispose of unused opioids and the reason why not is because they simply hadn’t thought about it.

“Now’s the time to think about it,” Norton said.