Opioid Prescribing and Cancer Pain – Contemporary Challenges

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Pain Management

Each year, about 1.7 million Americans are diagnosed with cancer, and about 600,000 die from cancer. Fortunately, there are now over 16 million cancer survivors in the U.S. We know that pain is an issue for cancer patients, especially with advancing disease bringing about the end of life. We also know that cancer survivors may be plagued by chronic pain sequelae of their successful cancer treatment – surgery, chemotherapy, radiation therapy. Researchers have identified the potential of patients benefiting from strong opioid analgesics when they have advanced cancer and pain (Loguidice, 2017). This is important to note since many patients fear that they will die in pain once they have been diagnosed with cancer.

Professional imperative
In the United Stated, all clinicians who prescribe controlled substances should understand the professional imperative to address the prescription opioid epidemic, while keeping in mind the importance of individualized care and personalized pain management and treatment plans for each patient.

In 2011, the Institute of Medicine issued its groundbreaking report, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,” which estimated that more than 100 million Americans are affected by chronic pain. The April 2018 issue of Reason magazine cover headline, “America’s War on Pain Pills Is Killing Addicts and Leaving Patients in Agony,” highlighted the challenges of achieving balance that considers the needs of individual pain sufferers as well as societal issues.

For most patients who have experienced cancer and cancer-related pain, there is an unquestioned mandate to relieve their pain. Significant pain can be present at any stage of the disease, and may continue for long periods of time, even for the entire duration of the disease. Studies tell us that 30% to 40% of cancer patients have pain at the time of diagnosis, 55% during anticancer treatment and almost 40% after curative treatment.

Two out of every three patients with advanced, metastatic or terminal disease have burdensome pain. Unfortunately, almost 40% of all patients report their pain as moderate to severe. Pain, especially in the cancer patient, is a multidimensional experience comprised of physical, psycho-social, spiritual, cultural and situational factors. This complexity underscores the need for interdisciplinary strategies and multi-modal pain treatment approaches to achieve the best possible overall outcomes.

Chronic Cancer – Chronic Pain
Modern cancer treatments have resulted in patients living longer with chronic cancer and accompanying chronic cancer pain. The need for opioids as well as other medications and treatment modalities varies along the spectrum of disease. Early disease with milder pain levels may be adequately mitigated by non-opioid medications, or may require less potent opioids. Multi-modal strategies are useful at any point in the cancer experience. These strategies include patient education, psychological and spiritual support, integrative approaches such as acupuncture, massage, meditation, yoga, among others.

Opioids are a useful yet singular option in a balanced poly-pharmacy milieu of medications used to treat cancer related pain at various points throughout the disease experience. They are usually combined with other medications such as anti-inflammatory, anti-neuropathic, or other drugs depending upon the predominant type of pain at any given time – somatic, visceral, neuropathic, or mixed-type (Van den Beuken-van Everdingen, 2016).

In addition, procedural interventions such as nerve blocks, medication infusions, or neural stimulation treatment can play important roles in pain management. Supportive psycho-emotional therapy can be crucial to helping patients cope with their disease and treatment situations. Physical therapy approaches can help patients maintain their overall functionality. Integrative therapy strategies offer further layers of treatment options to manage pain and collateral symptoms and optimize quality of life.

Rational opioid analgesic therapy
The intended result of opioid prescribing is that more patients have access to rational opioid analgesic therapy. An unintended consequence is that more opioids are available for misuse, abuse, addiction, overdose, and diversion. In delineating symptom burdens among cancer survivors, a National Health Interview Survey (NHIS) | NHIS QOL survey found ongoing pain in 34%, psychological distress in 26%, and insomnia in 30% of survey respondents. Pain is but part of a number of collateral symptoms including anxiety, depression, dyssomnia – any one of which can interact with and aggravate another. While we do not have adequate facts to say that prescription opioids in the cancer patient – in active treatment as well as long-term survivors – are a gateway to illicit drug abuse (Frederick M. Perkins, 2000), we can take measures to stem the tide of drug abuse by diligent clinical care that includes risk management measures like toxicology screening, reviewing of state electronic prescription monitoring databases, vigilant patient follow-up, and collaborative team-based care (Jun J. Mao, 2007).

Pain management
The WHO 3-step ladder and its subsequent variations for treating pain all attempted to systematically match therapy to pain intensity. The National Comprehensive Cancer Network (NCCN), an alliance of 27 cancer centers in the United States, has long-established cancer pain management algorithmic guidelines that have focused on relieving pain. However, in response to the prescription opioid crisis, some current guidelines have placed a greater emphasis on opioid management over the relief of pain. The Centers for Disease Control and Prevention (CDC) is the leading national public health institute of the United States has published an opioid therapy guideline aimed at non-cancer pain; and the American Society of Clinical Oncology (ASCO) has issued guidelines for cancer pain management.

Further, the Centers for Medicare & Medicaid Services (CMS) has issued opioid prescribing guidelines for the Medicare population. Most of these measures are aimed at primary care providers who provide frontline pain care for most people.

From the outset, appropriate pain care requires diligent assessment and periodic reassessment with treatment adjustments based upon outcomes of the immediately preceding regimen. Vigilant longitudinal follow-up with attention to risk management along the way can help provide the best possible outcomes for the patient and for society as well. Providing opioids and other medications in needed amounts addresses pain without making available excessive medications for possible misuse or abuse, or intentional or inadvertent diversion.

Every available tool
With the right cancer treatments and a little luck, tumors are gone never to return; or, enduring remission occurs. But, even with the best cancer outcomes, there may be lasting after-effects of treatment. Post-chemotherapy painful peripheral neuropathy may require ongoing treatment for years on end. Likewise, chronic post-radiation therapy neuropathic pain may be a problematic sequela. Long-standing pain may follow many types of surgery – such as limb-amputation, post-mastectomy, post-thoracotomy, or post-laminectomy pain syndromes.

In these situations, non-opioid medications are typically indicated as first-line remedies; but it is not unusual for opioids to play a role as well, along with interventional procedures, rehabilitative approaches, integrative strategies, and more.

Every indicated therapeutic tool should be available to be used in rational and safe ways for as long as necessary to afford every patient the best health related Quality of Life (hrQoL) possible.

References
[1] Frederick M. Perkins, M. a. (2000). Chronic Pain as an Outcome of Surgery: A Review of Predictive Factors. The Journal of the American Society of Anesthesiologists, Inc.[PubMed][Full Text]
[2] Jun J. Mao, M. M. (2007). Symptom Burden Among Cancer Survivors: Impact of Age and Comorbidity. Journal of the American Board of Family Medicine. [PubMed][Full Text]
[3] Loguidice, C. T. (2017). Underprescription of Opioids in Cancer Patients During End of Life. Clinical Pain Advisor.[Ariticle]
[4] Van den Beuken-van Everdingen, H. J.-H. (2016). Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis. J Pain Symptom Manage.[PubMed][Full Text]


Last Editorial Review: September 3, 2018

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Larry C. Driver, M.D is Professor, Department of Pain Medicine, and Professor, Section of Integrated Ethics, Adjunct Ethicist for Clinical Ethics Consultation, at The University of Texas M. D. Anderson Cancer Center in Houston. He serves as the Education and CME Oversite Committee Chair for the American Academy of Pain Medicine, where has been a member for twenty years. His undergraduate education was at Austin College followed by medical education at The University of Texas Medical School at San Antonio. Anesthesiology Residency was completed at The University of Colorado Health Sciences Center in Denver, and he completed a Clinical Fellowship in Pain and Symptom Management at MD Anderson. Driver is Board Certified in Anesthesiology, Pain Medicine, and Hospice and Palliative Medicine. He was a Visiting Research Scholar in the Pellegrino Center for Clinical Bioethics at Georgetown University, and is a Mayday Pain and Society Fellow. He was the founding Chair and Medical Director of the Texas Pain Advocacy and Information Network (TxPAIN), is Past-President of the Texas Pain Society, and is Chair of the Texas Health and Human Services Commission Palliative Care Interdisciplinary Advisory Council. He has served on numerous state and national organizations’ boards and committees. Driver has been recognized in numerous Best Doctors, Top Doctors, Super Doctors and Who’s Who listings, and has received various state and national awards for his advocacy efforts. He is an elected Fellow of the Texas Academy of Science, an elected member of the University of Texas Academy of Health Science Educators, and is designated a UT Distinguished Teaching Professor. Interests include clinical pain and symptom management for patients with active cancer and advanced cancer, as well as cancer survivors; ethical issues surrounding those clinical situations; research focused on symptom burden and impact in cancer patients; and pain education and public policy initiatives.

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