Despite the increasing public awareness of the danger of the overuse of prescription opioids, drug overdose deaths continue to rise in the United States. According to the Centers for Disease Control and Prevention (CDC), from 1999 to 2017, nearly 400,000 people died of an overdose involving opioids, including both prescription and illicit.1 In 2016, in response to the rising death rate from opioids and to stem the epidemic in prescription opioid–related use, the CDC issued a guideline for prescribing opioids for chronic non–cancer-related pain, which recommends that opioids be used at the lowest appropriate dose for the shortest period.2
Although the guideline was issued for use by primary care physicians, and not cancer specialists, the recommendation has had a chilling effect on both oncologists, who fear potential legal ramifications, and patients, who worry about becoming addicted to the medication. According to a recent study by the American Cancer Society Cancer Action Network and the Patient Quality of Life Coalition, over the past 2 years, nearly half of patients with cancer and more than half of those with other serious illnesses reported that their physician limited their pain treatment options because of laws, guidelines, or insurance coverage. In addition, 27% of cancer survivors reported being unable to get opioid pain medication because a pharmacist would not fill the prescription—more than double the percentage who reported similar issues in 2016—and 30% said their insurance did not cover the cost of the prescription, a 19% jump from 2016.3
Jamie H. Von Roenn, MD, FASCO
In response to a collaborative effort by ASCO, the American Society of Hematology (ASH), and the National Comprehensive Cancer Network® (NCCN®) for clarification of the CDC’s opioid prescribing guideline to ensure that cancer survivors and patients with sickle cell disease receive appropriate access to pain medication, on April 9, 2019, the CDC published a clarification letter it had sent to ASCO, ASH, and NCCN. The letter states that the agency’s guideline is not intended to deny clinically appropriate opioid therapy to any patients with acute or chronic pain from cancer and sickle cell disease and that the CDC “encourages physicians to continue to use their clinical judgment and base treatment on what they know about their patients, including the use of opioids.”4
GUEST EDITOR
Addressing the evolving needs of cancer survivors at various stages of their illness and care, Palliative Care in Oncology is guest edited by Jamie H. Von Roenn, MD, FASCO. Dr. Von Roenn is ASCO’s Vice President of Education, Science, and Professional Development.Protecting Patients From Cancer-Related Pain
In the summer of 2016, ASCO published its clinical practice guideline on chronic pain management in cancer survivors, which calls for patients to be routinely screened for persistent pain at each office visit. It also advocates for the use of systemic nonopioid analgesics to relieve chronic pain and the judicious use of opioids in patients who are not responding to conservative pain management approaches, along with precautions to minimize opioid abuse and addiction in these patients.5
Despite ASCO’s guideline and reassurances from the CDC that clinical practice guidelines “specific to cancer treatment, palliative care, and end-of-life care should be used to guide treatment and reimbursement decisions regarding use of opioids as part of pain control in these circumstances,” the debate among physicians about the role of opioid use in the treatment of cancer-related pain continues. How best to balance opioid use to relieve chronic cancer pain and protect patients from the possibility of addiction was the subject of an impassioned discussion between Leslie J. Blackhall, MD, Section Head of Palliative Care at the University of Virginia School of Medicine, Charlottesville, and Charles F. von Gunten, MD, PhD, Vice President of Medical Affairs Hospice & Palliative Medicine OhioHealth Kobacker House, Columbus, during the 2018 Palliative and Supportive Care in Oncology Symposium.
Leslie J. Blackhall, MD
Charles F. von Gunten, MD, PhD
The ASCO Post asked Drs. Blackhall and von Gunten to continue the conversation here.
Mainstay of Cancer Pain Management
How is the role of opioid use in the treatment of cancer-related pain changing? Is opioid use still the mainstay of cancer pain management?
Dr. Blackhall: Yes, opioids are still the mainstay for serious cancer-related pain. It is probably the only indication for opiates that we are convinced is effective for this type of pain.
Dr. von Gunten: I agree. The data are clear that opioid use in this setting is safe and effective for the majority of patients we treat. And the majority of patients will not experience adverse effects or a substance use disorder.
Assessing Patients for Addiction Risk
Although nonsteroidal anti-inflammatory drugs (NSAIDs) are often used as a first step for mild pain, they can have adverse effects on patients with cancer. What is the best way to approach treating severe chronic pain in cancer survivors? How should patients be assessed for the potential risk for addiction and current substance abuse disorder?
Dr. Blackhall: Many of our patients are not going to be candidates for NSAIDs, because they are taking anticoagulants or steroids, or they are on an immunotherapy and are having problems with platelet counts. This is where palliative care professionals can help assess a patient’s pain level and determine whether there are appropriate alternatives to opiates, such as nerve blocks, and to help treat other symptoms that might be exacerbating the patient’s pain.
Even if patients have or have had a history of substance use, they still deserve to have appropriate pain control for their cancer or its treatment. Our focus should be on safety and we shouldn’t be judgmental. The Opioid Risk Tool (www.drugabuse.gov/sites/default/files/files/OpioidRiskTool.pdf) is a good screening tool to assess a patient’s personal risk for opioid use disorder as well as whether there is a family history of substance abuse. If there is a family member with a substance abuse problem living in the house, for example, there should be a determination of how the medication can be stored safely.
“Even if patients have or have had a history of substance use, they still deserve to have appropriate pain control for their cancer or its treatment.”— Leslie J. Blackhall, MD
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Dr. von Gunten: It is true that NSAIDs cause more deaths each year than opioids. In patients with hematologic and renal complications because of cancer treatment, oncologists will want to weigh the risks and benefits of prescribing NSAIDs. Oncologists will not want to substitute NSAIDs for an opioid for all the risks that are well known.
In terms of assessing the risk for opioid use disorder, yes, it is prudent to screen for risk, but risk alone is not a reason not to prescribe an opioid. It may be a reason to include another specialist, for example, a palliative medicine physician, in the treatment plan, but the main message from all of our data is that opioids are safe and effective for the majority of people with cancer pain. We must not deprive these patients of pain relief over worry, anxiety, and unsubstantiated fear over the use of these medications.
Treating Unrelenting Pain
Some cancer survivors are still coping with ongoing chronic pain. How should unrelenting, chronic pain be treated?
“In terms of assessing risk for opioid use disorder, it is prudent to screen for risk, but risk alone is not a reason not to prescribe an opioid.”— Charles F. von Gunten, MD, PhD
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Dr. Blackhall: We see a fair number of cancer survivors who have long-lasting chronic pain from their cancer or its treatment. Unfortunately, there is no treatment that works really well for chronic pain. It behooves all of us to be on top of all possibilities to provide relief for these patients, including spinal cord stimulation for peripheral neuropathies for example. We must not abandon these survivors. There will be people who will need to continue to take opiate medication. Our hope is that in the future, we will find something better to relieve their pain. If we are going to take people off opiates who still need them, we have to have a better answer for them.
Dr. von Gunten: In some instances, we cause chronic pain from our cancer treatment, and it is our responsibility to ensure that the pain is managed as part of patients’ long-term survivorship. Oncology practice patterns differ around the country. In some practices, oncologists manage their patients’ survivorship; in other settings, oncologists transfer their patients’ care to a survivorship or chronic pain management clinic. An individual oncologist is the best judge for what makes sense in his or her practice.
There is irrational fear now in prescribing opioids, and it is overtaking rational thought. Most oncologists will advocate for their patients, going the extra mile to assure that they have access to the pain medication they need. In some cities, pharmacies are reluctant to fill opioid prescriptions for any reason. One way in which oncologists can help ensure that their patients receive the medication they need is to find a pharmacy they can work with to fill the prescription, such as hospital-based pharmacies, as opposed to the large-volume, discount pharmacies.
When I have a challenging patient, I will often talk with the pharmacist in the outpatient pharmacy and describe the patient’s issue and explain what I’m trying to achieve. Then I can answer any questions the pharmacist may have and make him or her part of the team.
Treating Patients With Substance Use Disorder
Dr. von Gunten, what is the risk for patients to become addicted to opioids if they have to take them indefinitely? How should patients with a drug use problem be treated for cancer-related pain?
Dr. von Gunten: It is a myth that opioids cause addiction. Patients may need to take opioids for a long period, the same way people with hypertension need to take blood pressure medicine for the rest of their lives or those with diabetes need to take lifelong insulin. Addiction is drug use that is out of control, preoccupation with a drug, or the recreational use of a drug for a nonmedical indication. This is not what we are talking about when cancer survivors use opioids, even for long periods.
In terms of how to treat patients with a drug abuse problem, for that small population of patients who already have an opioid use disorder or another substance use disorder, we have to treat both problems—the drug use problem and the cancer-related pain problem—at the same time. They require management by collaborating with drug abuse specialists, the same way we would collaborate with a patient’s cardiologist for heart disease.
“When I have a challenging patient, I will often talk with the pharmacist in the outpatient pharmacy and describe the patient’s issue and explain what I’m trying to achieve.”— Charles F. von Gunten, MD, PhD
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Taking a Complete Medical History
Dr. Blackhall, if oncologists learn about their patients’ use of alcohol and recreational drugs as part of a medical history, what should they do with that information? Once the risk for opioid addiction is determined, should they prescribe opioid or nonopioid medication accordingly?
Dr. Blackhall: If you are planning on prescribing chemotherapy, for example, you want to know if the patient is drinking heavily or has a drug abuse problem because he or she will have trouble tolerating treatment. This information is a vital part of the patient’s medical history. If you decide to proceed with the treatment, having this information will help you involve appropriate services early on to mitigate potential issues. In truth, this is just part of good oncologic care regardless of the patient’s possible need for opiates.
Taking a patient’s complete medical history provides a structure for when the patient needs pain medication to ensure its safe use. This approach is not just in terms of how to appropriately take the drug and monitor risk factors, but in educating the patient about properly storing the medication.
Assuaging Fear of Prescribing Opioids
The opioid crisis has caused some oncologists to limit prescriptions for the medication out of fear of potential legal jeopardy or concern that patients may become addicted to the medication. How can oncologists overcome this concern?
Dr. Blackhall: Organizations such as ASCO and the American Academy of Hospice and Palliative Medicine need to develop specific guidelines that fit the needs of patients with cancer-related pain, and that is different from nonmalignant pain. It would also be helpful to have specific guidelines that address how to prescribe opiates more safely when there is evidence of aberrant behaviors and how to respond when problems are identified.
“If we can develop a protocol that oncologists can follow, we can then prove to legislators crafting restrictions on opioid prescribing that we are not prescribing these medications unnecessarily.”— Leslie J. Blackhall, MD
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We have to have an appropriate strategy for people with advanced and incurable illness and for patients who might discontinue treatment if they don’t get good pain control. If we can develop a protocol that oncologists can follow, we can then prove to legislators crafting restrictions on opioid prescribing that we are not prescribing these medications unnecessarily.
Dr. von Gunten: During the 2019 Palliative Care and Supportive Care in Oncology Symposium, I surveyed participants to learn if they know physicians who are afraid to prescribe opioids for cancer-related pain, and the majority said they did. The survey was designed to show that fear and emotion are predominate in this discussion. Emotion and fear are not the same as facts when determining the best care for our patients.
The appropriate diagnosis and treatment of pain in the setting of cancer are well documented in patients’ medical records, the same way every other aspect of their care is documented. This process prevents legal consequences if an issue arises, and that applies to the management of cancer-related pain with opioids. Oncologists should not be afraid to prescribe these medications to patients.
(Editor’s Note: In 2018, the ASCO Educational Book published a study on pain management in the era of the opioid crisis. It concluded that the vast majority of patients with cancer need opioids for the management of pain and that oncologists can safely and effectively manage the majority of these patients. The study also found that “universal screening for risk factors and careful monitoring for the emergence of nonmedical opioid use behaviors help decide on the need to refer patients for specialized care.”6) ■
DISCLOSURE: Dr. Blackhall reported no conflicts of interest. Dr. von Gunten has received honoraria from Salix, Otsuka, and AstraZeneca; is a consultant/advisor for AstraZeneca; is on the speakers bureau of Salix; has provided expert testimony for Progenics, Salix, and Valiant; and has received travel/accommodations/expenses from Salix.
REFERENCES
1. Centers for Disease Control and Prevention: Understanding the epidemic. Available at www.cdc.gov/drugoverdose/epidemic/index.html. Accessed April 29, 2019.
2. Centers for Disease Control and Prevention: CDC guideline for prescribing opioids for chronic pain—United States, 2016. Available at www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Accessed April 29, 2019.
3. American Cancer Society Cancer Action Network. Key findings summary: Opioid access research project. Available at www.fightcancer.org/sites/default/files/ACS%20CAN%20PQLC%20Opioid%20Research%20Project%20Key%20Findings%20Summary%20Memo%20FINAL.pdf. Accessed April 29, 2019.
4. ASCO: CDC issues key clarification on guideline for prescribing opioids for chronic pain. Agency clarifies CDC guideline not meant to limit access to appropriate pain management for individuals with cancer, sickle cell disease. Available at www.asco.org/about-asco/press-center/ news-releases/cdc-issues-key-clarification-guideline-prescribing-opioids. Accessed April 29, 2019.
5. 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.
6. Bruera E, Del Fabbro E: Pain management in the era of the opioid crisis. Am Soc Clin Oncol Educ Book 38:807-812, 2018.
