A vast majority of patients with cancer receiving opioids for the management of pain will adhere to the opioids as prescribed and will have no major difficulties with dose reduction and even treatment discontinuation if the pain syndrome resolves. However, about 20% of patients with cancer are at risk for behaviors consistent with the nonmedical use of opioid analgesics or will ultimately develop substance use disorders. To minimize this risk to the greatest degree possible, it is imperative to include a thorough risk assessment when conducting a comprehensive pain evaluation.
Judith A. Paice, PhD, RN
To shed light on opioid abuse risk assessment, The ASCO Post spoke with Judith A. Paice, PhD, RN, Director, Cancer Pain Program, Division of Hematology-Oncology, Northwestern University, Evanston, Illinois. In this role, Dr. Paice has a caseload of approximately 200 people with serious pain. Some of the patients experience pain related to active treatment, and others are survivors who have persistent pain as a result of previous cancer therapies.
Risk Assessment
Please describe how a risk assessment is conducted within the pain assessment process.
Pain assessment includes capturing the essential components of the pain experience: intensity, location(s), quality, current and past treatments, effect on function, emotional responses, social limitations, and other factors. We also ask about past and current misuse of substances, along with a family history of substance use disorder. The goal is to learn how we might best keep all patients safe.
Unfortunately, the opioid epidemic is real and prominent in the press, and there is much misinformation and misunderstanding. Many patients assume that because they require opioids, they must be addicted or at high risk for addiction. Clear, honest information needs to be provided about a person’s risk, whether it is minimal or high, and strategies that will be used to provide effective relief while reducing any threat of misuse should be discussed.
Screening Tools
Please discuss the screening tools used to identify at-risk patients.
A variety of screening tools have been developed to gauge a person’s risk of substance abuse. Unfortunately, to date, none have been validated in an oncology population. Therefore, questions about past/present drug use, family history, as well as a history of physical or sexual abuse and/or post-traumatic stress disorder should be included when obtaining a medical history. And this information should be included for all patients who might be prescribed controlled substances, not just those who are perceived as being at greatest risk of abuse. Other tools that are helpful in assessing risk include review of prescription drug monitoring program data along with urine toxicology to rule out the presence of unexpected substances.
“Opioids serve an essential role [in the management of cancer pain], and therefore, access to them is crucial.”— Judith A. Paice, PhD, RN
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Can you provide an example of triage by risk.
For instance, an oncologist will evaluate the information from the comprehensive assessment and triage to either prescribe opioids or decide not to prescribe opioids. If the pain syndrome and intensity necessitate opioids, and the risk for misuse or diversion is low, the standard of care would be to prescribe the correct opioid for that indication.
However, the more complicated evaluation is when there are few other options for pain control other than an opioid and it’s determined that the risk for misuse is high. A case may be a patient with myeloma who has extensive lesions throughout the skeleton causing severe pain, yet this patient has a current history of substance use disorder. For such a person, nonsteroidal anti-inflammatory drugs are contraindicated because of the risk of renal dysfunction, and interventional methods are challenging because of the extensive nature of the pain. In this case, opioids may be used for pain management along with highly structured risk mitigation strategies.
Undertreatment of Cancer Pain
The oncology community still struggles with undertreated cancer pain, which is being exacerbated because of recreational drug use that results in overdose. Can you comment on this clinical challenge?
Substance use disorder, and the epidemic of opioid overdoses, is a serious public health crisis. So too is undertreated pain. For many of us who have been in practice for a while, we remember a time when cancer pain was poorly treated. Opioids were administered only when people were in the final days of life. The doors to patients’ rooms were closed, so their moans did not upset other patients. We never want to return to those days, yet some of the strategies designed to reduce the opioid epidemic are making it difficult for those with cancer to obtain adequate relief. Opioids serve an essential role, and therefore, access to them is crucial. ■
DISCLOSURE: Dr. Paice reported no conflicts of interest.
