INTENSE MEDIA COVERAGE of the opioid crisis has ranged from the dire statistics of addiction and death to some hopeful stories of treatment and recovery, but what may raise questions and concerns are the reports of people who start with a prescription opioid and then in a few weeks or months are injecting heroin. “What often gets missed in the more superficial coverage is that 75% of those people who started with prescription opioids and then went on to use heroin never had a prescription for prescription opioids. They were stealing them. They were buying them. They were people who already were misusing drugs. It is an important point that I am constantly sharing with patients,” Judith A. Paice, RN, PhD, shared with The ASCO Post.
Dr. Paice is Director of the Cancer Pain Program and Research Professor of Medicine at Northwestern University, Feinberg School of Medicine, Chicago. She is also the lead author of the ASCO Clinical Practice Guideline, Management of Chronic Pain in Survivors of Adult Cancers1 and outlined some of the key recommendations at the Lynn Sage Breast Cancer Symposium, sponsored by the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.2
Another important point to convey to patients is, “although we saw this increase in opioid deaths related to prescription opioids, that has actually plateaued,” Dr. Paice added. “Many of the people who are dying of opioids now are dying from heroin and synthetic fentanyl that has been imported illegally.”
Assess Pain and Addiction Risk
IN THE MIDST of the opioid epidemic, “a lot of pain clinics that treat chronic pain patients are simply taking the easy route, saying we are not going to prescribe any opioids. That would be unethical for those of us who treat people with cancer,” Dr. Paice said. “All patients need to have a thorough assessment, both of their pain, considering all of the potential syndromes that can arise from the treatments that we employ and the potential for second malignancies,” Dr. Paice advised.
“We also need to assess all the risk factors for addiction and use multimodal therapy, pharmacologic, and nonpharmacologic interventions,” she stated. These interventions include physical therapy and individualized exercise programs; integrative therapies, such as massage and acupuncture; psychological approaches, such as cognitive behavioral therapy and mindfulness; and neurostimulatory therapies.
Precautions and Safety
“USE UNIVERSAL PRECAUTIONS,” she continued, to minimize abuse addiction, and adverse effects. These precautions include urine toxicology, pill counts, and checking the Prescription Drug Monitoring Programs to identify people who are getting multiple prescriptions. In some cases, written or verbal agreements or contracts are used.
Wean patients gradually from opioids when they are no longer effective, Dr. Paice stated. This may take some “motivational interviewing” if patients are resistant to tapering off because they fear the return of pain.
“For all your patients, regardless of whether they are on active treatment, survivors, or at the end of life, we have got to teach them about safe drug storage and disposal,” she emphasized. That will prevent the opioids from being stolen or being flushed into the public water supply. ■
DISCLOSURE: Dr. Paice reported no conflicts of interest.
1. Paice JA, Portenoy R, Lacchetti C, et al: Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 34:3325-3345, 2016.