Balancing Opioid Use to Relieve Cancer-Related Pain and Protecting Patients From Addiction and Death
A Conversation With Eduardo Bruera, MD
According to the Centers for Disease Control and Prevention (CDC), from 1999 to 2015, more than 183,000 people have died in the United States from overdoses related to prescription opioids, including methadone, oxycodone, and hydrocodone.1 To stem the epidemic in prescription opioid–related use and the increasing death rate, the CDC issued a guideline for prescribing opioids for chronic non–cancer-related pain,2 and, in 2016, ASCO published a new guideline on chronic pain management in cancer survivors.3
ASCO’s recommendations call for patients to be routinely screened for persistent pain at each office visit. They also advocate the use of systemic nonopioid analgesics to relieve chronic pain and the judicious use of opioids in patients who do not respond to conservative pain management approaches, along with precautions to minimize opioid abuse and addiction in these patients.
ASCO’s guideline was issued a year before a disturbing study by the American Cancer Society found there is a substantially higher use of opioid prescribing rates among cancer survivors—1.22 times higher—than among their counterparts who have never had cancer. Moreover, the rate of opioid use was prevalent even among survivors who were 10 or more years past their cancer diagnosis.4
These study results highlight the concern that for some cancer survivors, a return to pain-free normalcy after cancer and its debilitating treatment may not be possible. They also pose a dilemma for oncologists—and primary care clinicians—on how to balance the legitimate use of opioids in pain management and protect cancer survivors from the devastating risks associated with the prescription use of these drugs.
The most important challenge for all of us treating patients with cancer is to make sure that cancer-related pain is treated fast and effectively.— Eduardo Bruera, MD
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“A small percentage of patients will need opioid medications for a long period of time following a cancer diagnosis, and when that happens, these patients will need to be monitored by an expert to make sure these drugs are being used in a way that promotes the best performance function and comfort of these patients,” said Eduardo Bruera, MD, Chair of the Department of Palliative, Rehabilitation, and Integrative Medicine in the Division of Cancer Medicine at The University of Texas MD Anderson Cancer Center, Houston. “The most important challenge for all of us treating patients with cancer is to make sure that cancer-related pain is treated fast and effectively.”
The ASCO Post talked with Dr. Bruera about the use of opioid therapy in the treatment of cancer-related pain; how to ensure that patients and long-term survivors receive adequate palliation for their pain; and how to assess patients’ pain symptoms and their risk for opioid addiction.
Providing Relief for Cancer-Related Pain
How important is opioid therapy in the management of cancer-related pain?
Fortunately, some early-stage patients will have minimal or no pain from their malignancy. For example, patients receiving hormonal treatments or adjuvant chemotherapy will have less of a problem with pain than patients who undergo surgery, aggressive chemotherapy, or radiation, and for those in the first group, a nonopioid analgesic may be sufficient to manage their pain.
However, we know that approximately 80% of our patients who develop advanced, incurable cancer will experience pain as a main symptom of their disease and treatment, and literally all of those patients will need opioid analgesics to treat their pain—in some cases, unfortunately, for the rest of their lives. Even patients who do not develop advanced disease may have moments of significant pain during treatment. For example, patients undergoing bone marrow transplantation and patients with head and neck cancer or lung cancer receiving chemotherapy and radiation may need opioid analgesics, although usually just for a few days or weeks. So, opioid therapy is very common in cancer-related pain management.
Assessing Pain and Opioid Side Effects
How can oncologists ensure that their patients receive adequate pain palliation?
There are three steps that are useful in controlling pain. First, in the advanced-care setting, it is very important for oncologists to conduct an assessment of their patients’ pain symptoms. At our institution, we use the Edmonton Symptom Assessment System (ESAS), which is designed to assist in the assessment of 9 symptoms—pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, well-being, and shortness of breath—on a scale of 0 to 10, and can be completed in less than 1 minute.
The second step is to become familiar with prescribing opioid medications and effectively treating their side effects, such as constipation and nausea. The third step is to have access to a palliative supportive care specialist if the patient’s pain is not being effectively controlled with opioid medications.
Overcoming Obstacles to Effective Pain Management
Among the barriers to effective pain management are inadequate assessment by oncologists, underreporting of pain by patients, and overregulation of opioids by local and federal government agencies. How can these obstacles be overcome?
The complexity of treating cancer has increased enormously over the past 10 years. Oncologists have limited time to screen patients for pain symptoms and offer therapeutic interventions, and patients are often reluctant to raise the issue of pain because they worry about taking precious time away from their oncology visit. This is why taking advantage of the ESAS assessment tool is so crucial in pain management.
The patient can fill out the ESAS questionnaire in the waiting room and give it to the oncologist at their meeting. The oncologist can then use it as a tool to evaluate the level of pain the patient is experiencing, and, in addition to discussing the state of the patient’s cancer and treatment, they can discuss how to manage the patient’s chronic pain.
Each patient’s cancer experience is unique, and successfully managing chronic pain while optimizing the patient’s function and quality of life may take a number of approaches.— Eduardo Bruera, MD
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Restrictive government regulation on opioid prescribing for chronic pain certainly has had an impact on oncology care, although the CDC guidelines do not include recommendations for treating patients undergoing active cancer treatment, palliative care, or end-of-life care. At the moment of outpatient referral to palliative care, patients currently receive half the opioid dose they were receiving 7 years ago, a decrease from approximately 80 mg to 40 mg of equivalent morphine per day. This finding suggests that oncologists are facing increasing barriers to prescribing opiate painkillers and monitoring cancer pain.
Out-of-pocket insurance costs also add to the barriers preventing access to these medications and adequate pain control.
Patients with advanced cancer rarely achieve pain relief with nonopioid analgesics and will need opioid medications and perhaps consultation with a palliative care specialist to find adequate relief. Long-term survivors may also have persistent pain from their cancer treatment and need ongoing approaches for pain management; in this circumstance, it is probably best to avoid opiates and instead have the oncologist work with a palliative care specialist or physical medicine and rehabilitation specialist to restore patients’ functional ability and quality of life.
Predicting Addiction Risk
The reluctance to use opiate painkillers is due to their potential for abuse and addiction. What are the predictive factors for opioid addiction?
This is an important point because all patients have the potential to develop a substance use disorder, and there are no completely accurate ways to screen for substance use disorder risk. So it is very important to apply universal precautions when prescribing these medications to avoid profiling patients and making an error. It is crucial to risk-assess patients for opioid use disorder, and there are several tools oncologists can use to help guide safe and appropriate opioid prescribing.
As I mentioned earlier, clinicians should first conduct universal screening of all patients being considered for opioid therapy in combination with personal and family histories of drug or alcohol abuse. Two excellent simple screening tools for substance dependence include the CAGE-AID questionnaire (see sidebar), which has been adapted to include drug use, and the Screener and Opioid Assessment for Patients With Pain–Revised (SOAPP-R). Both of these tools are available at opioidrisk.com.
Studies show that patients who are younger; male; and have a mental health or substance abuse disorder, a history of alcohol abuse, or a history of tobacco use are at greater risk for aberrant opioid use. But this doesn’t mean that patients at risk should not be prescribed an opiate painkiller, because these patients have legitimate pain from their cancer and need relief.
Now adapted to include drugs (AID), the original CAGE questionnaire was a screening test for problem drinking
that was named as an acronym for its four questions:
- Have you ever felt you needed to Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt Guilty about drinking?
- Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid
of a hangover?
For patients with cancer-related pain who test positive on the CAGE-AID or SOAPP-R assessment, oncologists need to be vigilant about seeing them on a regular basis to monitor their pain levels. A small number of patients on opiates, regardless of CAGE-AID or SOAPP-R positivity status, will also develop aberrant behavior and, for example, request increases in their opioid dosages that are not consistent with their pain syndrome or report they have lost their medications and need additional prescriptions. These signs are all red flags of aberrant behavior.
Once a patient develops an aberrant behavior, we need to completely change our approach to that patient. We should be extremely vigilant and see the patient frequently to monitor for drug abuse, which may necessitate urine drug testing. Because caring for patients with cancer is so complex now, oncologists will not have time during a routine office visit to address a patient’s aberrant behavior. In that case, it is our recommendation that the patient be referred to a palliative and supportive care clinic for evaluation, because the patient may need an interdisciplinary approach to address his chronic pain.
As oncology providers, we have to be aware of the complex relationship between the need to control patients’ cancer-related pain and how to alleviate that pain by means other than opioid therapy. But if we have to use opioids, we have to consider how to avoid the potential for drug abuse and patient self-harm, because the goal of all treatment is to allow our patients to continue receiving their cancer therapy and be as pain-free and comfortable as possible so they can enjoy their life as much as possible.
There is no one-size-fits-all approach to treating patients with cancer-related pain. Each patient’s cancer experience is unique, and successfully managing chronic pain while optimizing the patient’s function and quality of life may take a number of approaches. They may include frequent screenings for pain at each office visit, using nonopioid analgesics or opioid therapy if the more conservative approach to pain management isn’t successful, and referring the patient to a palliative care specialist.
DISCLOSURE: Dr. Bruera reported no conflicts of interest.
1. Centers for Disease Control and Prevention: Prescription opioid overdose data. Available at www.cdc.gov/drugoverdose/data/overdose.html. Accessed December 6, 2017.
2. Centers for Disease Control and Prevention: CDC guideline for prescribing opioids for chronic pain. Available at www.cdc.gov/drugoverdose/prescribing/guideline.html. Accessed December 6, 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. Sutradhar R, Lokku A, Barbera L: Cancer survivorship and opioid prescribing rates: A population-based matched cohort study among individuals with and without a history of cancer. Cancer 123:4286-4293, 2017.