Amitabh Gulati, MD

The opioid drug problem in the United States is a crisis, with unprecedented numbers of overdose deaths. The reaction to this has resulted in new federal laws and regulations aimed at restricting overuse and overprescribing of opioids. However, these well-intentioned actions, along with other attempts at the local level, have had the unintended consequence of contributing to the nationwide shortage of parenteral opioids in cancer centers and hospitals. Memorial Sloan Kettering Cancer Center (MSK) has experienced shortages of intravenous formulations, mainly of the two agents that have been most affected by new laws and regulations: fentanyl and hydromorphone.

Creative Techniques for Pain Management

Drug shortages have occurred before, and it’s necessary to have alternative strategies for pain management. For example, in the perioperative setting, we encourage our surgeons to use neuraxial blocks, after which they can switch to oral opioids that have not yet been affected by the shortage. We have also been more aggressive treating acute, postoperative, or chronic inpatient pain with peripheral nerve catheters and intravenous ketamine.

If properly delivered, these techniques can be effective analgesics in the absence of parenteral opioids. In patients with diffuse disease, where the patient with cancer has severe pain symptoms, we still have intravenous methadone (which has not been affected by the shortage) and other techniques, such as fentanyl patches, peripheral anesthetic catheters, and several types of nerve blocks. At MSK, we utilize state-of-the-art and creative multimodality techniques to manage pain in the face of the opioid shortage. So, we have been able to navigate our way through the current parenteral opioid shortage.

Identifying an emerging pain syndrome and knowing when to collaborate with a pain specialist are a vital part of supportive care.

— Amitabh Gulati, MD

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However, smaller cancer centers and hospitals around the nation may not have the same resources and skills found in a comprehensive cancer center and may have a difficult time managing cancer pain. One of our goals at MSK is to accelerate the educational opportunities in cancer pain management, not solely for our clinicians but also to partner with cancer societies to develop programs for busy medical oncologists, who might lack the knowledge to manage challenging pain syndromes and often refer their patients to specialists in the palliative care and pain sector.

However, a problem we’ve identified is that referral might be made too late in the pain syndrome, exacerbating the clinical situation and causing distress for the patient. Identifying an emerging pain syndrome and knowing when to collaborate with a pain specialist are a vital part of supportive care. We also seek to educate clinicians around the country on using nonopioid interventions to prepare them to deal with issues such as the current parenteral opioid shortage.

Novel Interventional Techniques

To develop a comprehensive approach to cancer pain management, we need to investigate novel nonopioid interventions. Some exciting new trials are looking at monoclonal antibodies that selectively target and inhibit nerve growth factor, but this research is still in its infancy. One such agent showing efficacy in treating pain in patients with cystitis, osteoarthritis, and chronic lower back pain is tanezumab, which is currently in phase III clinical trials for these three conditions.¹

Pain management is an intricate clinical challenge, and we need to educate our providers on the best practices in the use of opioids.

— Amitabh Gulati, MD

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Today’s state-of-the-art interventional therapies for managing cancer pain syndromes include electrical peripheral nerve stimulation techniques, which provide an effective nonopioid alternative. We employ these electrical peripheral nerve stimulation techniques in our center for postoperative pain syndromes. Other approaches are comprehensive intrathecal drug delivery, neuroablation techniques, and high-intensity ultrasonography. Some of these modalities are effective, enough to be added to our armamentarium as standard-of-care pain control.

Metastatic Disease and End of Life

There are certain clinical scenarios in which intravenous (IV) opioids, particularly morphine, are required for adequate pain control, such as widespread disease and severe neuropathic pain. Although opioids used for cancer pain have been left unrestricted by the new laws and regulations, the general environment created by the overdose crisis has had the unintended consequence of the IV drug shortages we now face.

When a patient with cancer reaches the stage when cure is no longer an option, there should be a multidisciplinary team in place to provide a full range of continuing care. Not only does this care include pain and other supportive care management, it also addresses the patient’s spiritual and psychological needs.

Education Needed to Reduce Overprescribing

The opioid drug overdose crisis is a multifactorial issue with no easy solution; however, due to a lack of accessible palliative care and pain specialists, community doctors are left to manage complicated pain issues. When I was in medical school, there were no courses on drug prescribing and the dangers of overprescribing and drug diversion. One way to address part of the opioid crisis is to intensify training that focuses on effective communication skills and the potential risks and benefits of opioids and when and how to initiate, maintain, modify, and continue or discontinue opioid therapy. Pain management is an intricate clinical challenge, and we need to educate our providers on the best practices in using opioids.

Closing Thoughts on Undertreated Cancer Pain

In cancer pain management, one of the pressing issues is the timely initiation of supportive and palliative care, which often comes too late in the continuum of care, resulting in unnecessary suffering. There is a strong body of evidence showing that patients who receive palliative care early in the treatment model have better outcomes. I’m a founding member and board

member of the Cancer Pain Research Consortium, which works to promote research leading to improve care for the suffering that arises from cancer pain. Clinically distinct pain syndromes have important distinctive clinical characteristics, which drive best-practice decision trees. It is, therefore, a major focus of the consortium to identify these measures and to use them to provide guidelines for timely specialist referral.

One goal is to have a network of physicians trained in interventional cancer pain management who can further spread their knowledge, broadening the network nationwide. We hope to partner with large cancer organizations, so that we can meet that goal. ■

Dr. Gulati is Director of Chronic Pain at Memorial Sloan Kettering Cancer Center, New York, Dr. Gulati is an anesthesiologist who specializes in treating cancer-related pain syndromes.

DISCLOSURE: Dr. Gulati reported no conflicts of interest.

Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.

REFERENCE

1. Patel MK, Kaye AD, Urman RD: Tanezumab: Therapy targeting nerve factor in pain pathogenesis. J Anaesthesiol Clin Pharmacol 34:111, 2018.