Judith A. Paice, RN, PhD
“WE’VE GOT A CHALLENGING TIME right now, trying to relieve pain during the time of an opioid epidemic,” Judith A. Paice, RN, PhD, acknowledged at the 2017 Lynn Sage Breast Cancer Symposium in Chicago.1 She cited a recent study reporting that up to 40% of cancer survivors are living with pain, and 5% to 10% have severe chronic pain that limits function.2
The pain is real, but so are fears and risks of addiction. “Patients are very fearful about opioid addiction, given the media attention to the current opioid abuse epidemic and the numbers of deaths that we are seeing. Many times, this fear is overblown or overestimated,” Dr. Paice said in an interview with The ASCO Post. But for some patients with cancer, the risk of addiction may be high, and the adverse effects of chronic opioid use may outweigh any short-term benefit of pain relief. “There is a lot that we can do as health-care professionals when we assess patients to determine if they are indeed at risk for addiction or dangerous side effects,” Dr. Paice stressed.
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 Cancers,3 which formed the basis for the recommendations she presented. The symposium was sponsored by the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.
Assessing the Risk of Addiction
GENERALLY, THOSE at risk for opioid addiction are people who misuse or abuse prescription or illicit drugs or alcohol now, or have done so in the past, as well as those who smoke cigarettes and gamble, or have done so in the past. It is important, Dr. Paice stressed, that patients understand questions about drugs, alcohol, cigarette smoking, and gambling refer not only to current but also past use and behavior.
A family history—whether biologic family members have or have had difficulties with alcoholism or drug abuse—“gives us a quick proxy for genetic risk and tells us what is available in the home environment,” Dr. Paice added.
“Finally, and the most difficult question to ask, is about history of sexual abuse. “We know that people who have been abused, especially as young children, preteens, early teens, have a very high risk of addiction,” Dr. Paice said.
“It takes some careful assessment about current or past smoking, current or past alcohol intake, current or past recreational drug use, and then taking all that information along with family history and sexual abuse history and categorizing patients. We triage people into low risk, medium risk, and high risk for addiction,” Dr. Paice explained.
It is optimal to have family members involved in discussions about pain and the risk of addiction, “so we can all talk openly,” Dr. Paice said. Sometimes family members can be so fearful of the patient becoming addicted, even when the risk is very low, they may withhold the medicines from the patient.
Multiple Pain Management Strategies
THERE ARE MULTIPLE strategies for managing pain, Dr. Paice emphasized. “We should always be assessing and reassessing whether opioids are indicated at every step of the way. We should always be using a multimodal approach and that includes nonpharmacologic techniques, integrative therapy, interventional techniques, adjuvant analgesics, and psychological counseling. But here is the challenge—it is really hard to get those other things paid for.”
In response to a question raised at the symposium about trying to secure reimbursement or payment for nonpharmacologic interventions, Dr. Paice advised making sure there is a proper order and documentation in the patient’s record, although she acknowledged that may not be enough. She also suggested referrals to community resources, such as nonprofit organizations or health clubs, which may offer discounts to cancer patients or allow them to use the facilities during off hours. There are “creative strategies,” Dr. Paice said, “but they do take time.”
The decision to use opioids also depends on where patients are in their disease trajectory, Dr. Paice pointed out. “If the patient is a long-term survivor, we would really need to think carefully about whether a pain syndrome warrants the use of opioids, given the risks. It is all about the risk/benefit balance.”
“If someone is at the end of life, then of course, there is a different threshold of acceptance. But even for people who are at the end of life, at times, if we approach them with compassion and talk to them about addiction, and we’re concerned with their misusing drugs, then they might be open to other therapies to assist them in attaining sobriety. Even at end of life, this may be a meaningful goal.”
Use Universal Precautions
FOR CANCER PATIENTS who use opioids for pain management, “we need to use universal precautions to minimize the potential for abuse,” Dr. Paice said. These precautions include urine toxicology, pill counts, checking the Prescription Drug Monitoring Programs, and in some cases written or verbal agreements or contracts. Operating in all states except Missouri, the Prescription Drug Monitoring Programs can identify people who are getting multiple prescriptions, Dr. Paice noted, report when a patient last filled an opioid prescription, and often indicate whether insurance paid or not. “We may need to switch an opioid so the patient doesn’t have to pay out of pocket,” Dr. Paice said. “The Prescription Drug Monitoring Programs also indicates when a prescription can be filled again. So, it provides a lot of data that can be exquisitely helpful.” Some institutions, she noted, are linking the Prescription Drug Monitoring Programs with electronic medical records, so it can be accessed from the patient’s chart.
“If the patient is a long-term survivor, we would really need to think carefully about whether a pain syndrome warrants the use of opioids, given the risks.”— Judith A. Paice, RN, PhD
“The challenge in the clinic is you’ve got to set up the policies or the processes to make it easy to do the right thing,” Dr. Paice said. In an oncology clinic where urine toxicology is usually not ordered, the lab may not know how to process that easily, or the billing staff may not know how to code and bill it appropriately. “People have to work together to get these processes together and to know how to interpret the results appropriately,” Dr. Paice said.
It is also important to make sure these precautions are indeed universal. “If you only do the urine toxicology, for example, on the people who you think are a problem, there is implicit bias. Poor people, people of color, people with mental health illness or issues, and other vulnerable populations will be more likely to be tested. So to avoid bias, we need to advocate for universal precautions. It needs to be done on everybody.” Frequency of testing, however, may vary. Patients should understand it is not a punitive measure, Dr. Paice said, but assists in safe and effective pain management.
It is also important for health-care professionals to understand the laws regarding opioid prescribing. These laws are state-based law primarily, and “you need to understand the law where you practice,” Dr. Paice noted.
Limiting Supply of Drugs
“THERE ARE TIMES when I can only give someone a week’s supply of drug at a time because they simply cannot handle more,” Dr. Paice said. “Or sometimes we need to place someone in structured living or a nursing home because he or she simply cannot manage the medicines but clearly need them because of tumor burden.”
Some guidelines and legislation are proposing limiting opioid prescriptions to a 3-day supply, Dr. Paice noted. But that can present barriers for patients who are not at high risk of addiction and cannot travel every 3 days to pick up a new prescription. In addition, “the insurance companies are picking up on those recommendations and accepting them as a mandate,” Dr. Paice remarked.
Long-Term Side Effects
“WE ARE JUST LEARNING there are some long-term side effects of opioids,” Dr. Paice said. “There are long-term complications that when I first started in oncology as a staff nurse, we never saw because we only used opioids at the end of life. Now when we are using opioids for longer periods, we are seeing some of the hormonal changes that occur—suppressed testosterone, hyperprolactinemia—and that’s leading to changes in quality-of-life issues, such as libido, sexual function, and fertility, and probably contributes to a risk of osteopenia and osteoporosis, and some of the fatigue reported,” Dr. Paice stated.
Neurotoxicity effects include myoclonus, mood changes, and memory problems, and the “paradoxical effect” of hyperalgesia, with escalating pain in tandem with dose escalation. Sleep-disordered breathing includes new-onset sleep apnea and worsening of obstructive sleep apnea, particularly in those who are have large necks or who are obese.
“Be sure that when you are weaning people, you are not adding benzodiazepines or other sedating drugs. Then you are just replacing one problem with another.”— Judith A. Paice, RN, PhD
“There is even a signal that opioids can impair survival,” Dr. Paice noted, although the data on patient populations are very weak and the studies are retrospective with a small sample size, preventing drawing any conclusions.4 “We know from acute exposure to opioids, there is a risk of respiratory depression. But chronically, in the laboratory, apoptosis, angiogenesis, and changes in immune function are seen, which may ultimately affect survival. It is rather speculative but quite concerning in someone who is already at risk for potential recurrence,” Dr. Paice reported.
“It is definitely not safe to keep everyone on opioids for a long period. We really have to use clinical judgment to determine when opioids are indicated and when are they not.”
The Weaning Process
‘WHEN OPIOIDS are no longer needed, we wean,” Dr. Paice stated. “In most cases, you don’t need to go quickly. There aren’t good guidelines about weaning opioids in medically ill patients. Probably the best guideline comes from the Veterans Administration, and that recommendation is 10% per week. I often will even do 10% per month, because I want to get patient buy-in,” although patients may resist that effort. “Part of that resistance comes from fear. It doesn’t necessarily mean that someone is an addict or is misusing drugs. He or she remembers experiencing pain in the past and is worried that these drugs may be doing more than they might really be doing,” Dr. Paice noted.
“Be sure that when you are weaning people, you are not adding benzodiazepines or other sedating drugs,” Dr. Paice said. “Then you are just replacing one problem with another.” She advised presenting patients with a clear plan for tapering off opioids.
Safe Storage and Disposal
“WE NEED TO TEACH PATIENTS to safely store their medicines,” Dr. Paice stressed. Opioids that are not locked up are in danger of being stolen, and “people with cancer are going to be targeted,” she added.
“The real estate agents in the city of Chicago know all about the problem of stolen medicines,” Dr. Paice commented. “They have an open house, and many times a couple comes and one distracts the real estate agent and the other makes a beeline for the medicine cabinet. The real estate agents tell people in Chicago to empty their medicine cabinets.”
When opioids are no longer needed, patients should dispose of them, Dr. Paice suggested. “There are multiple ways they can be safely disposed of. We don’t want them going down into the sewage system and eventually entering the water supply. The Drug Enforcement Agency has partnered with the Environmental Protection Agency, and there is a national takeback program twice a year, in April and in October,” Dr. Paice noted. “You can bring in any pill, no questions asked, and they incinerate them so they are not going into the water supply.” For information on this disposal program, visit www.deadiversion.usdoj.gov.
DISCLOSURE: Dr. Paice reported no conflicts of interest.
2. Heathcote LC, Eccleston C: Pain and cancer survival: A cognitive-affective model of symptom appraisal and the uncertain threat of disease recurrence. Pain 158:1187-1191, 2017.
3. 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.
4. Boland JW, Ziegler L, Boland EG, et al: Is regular systemic opioid analgesia associated with shorter survival in adult patients with cancer? A systematic literature review. Pain 156:2152-2163, 2015.