Opioid misuse in oncology pain patients

The Stigma Surrounding Opioid Use as a Barrier to Cancer-Pain Management: An Overview of Experiences with Fear, Shame, and Poorly Controlled Pain in the Context of Advanced Cancer

Cancer-related pain affects a majority of patients with advanced cancer and is often undertreated. The treatment of this pain is largely reliant on the use of opioids, which are essential medicines for symptom management and the maintenance of quality of life (QoL) for patients with advanced cancer. While there are cancer-specific guidelines for the treatment of pain, widespread publication and policy changes in response to the opioid epidemic have drastically impacted perceptions of opioid use. This overview therefore aims to investigate how manifestations of opioid stigma impact pain management in cancer settings, with an emphasis on the experiences of patients with advanced cancer. Opioid use has been widely stigmatized in multiple domains, including public, healthcare, and patient populations. Physician hesitancy in prescribing and pharmacist vigilance in dispensing were identified as barriers to optimal pain management, and may contribute to stigma in the context of advanced cancer. Evidence in the literature suggests that opioid stigma may result in patient deviations from prescription instructions, which generally leads to pain undertreatment. Patients reflected on experiencing shame and fear surrounding their prescription opioid use and feeling uncomfortable communicating with their healthcare providers on these topics. Our findings indicate that future work is required to educate patients and providers in order to de-stigmatize opioid use. Through alleviating stigma, patients may be better able to make decisions regarding their pain management which lead to freedom from cancer-related pain and improved QoL.

Modification of Behavioral Habits in Prehabilitation Programs

OBJECTIVES

To review the evidence supporting the modification of behavioral habits and substance use management during cancer treatment and how to implement them as part of a multimodal optimization intervention.

DATA SOURCES

A literature review of the association between cancer and behavioral habits, their impact on oncological treatment outcomes, and substance use management guidelines.

CONCLUSION

There is an association between harmful habits, such as smoking and alcohol consumption, and cancer. The continuation of poor behavioral habits throughout oncological treatments is associated with poor oncological outcomes and increased complications. Prehabilitation could be an ideal setting to screen, assess, and modify these harmful habits. Prehabilitation programs should be equipped with professionals and resources to help patients achieve harmful habit cessation.

IMPLICATIONS FOR NURSING PRACTICE

This review puts into manifest the importance of a multidisciplinary approach to substance use management. It can serve as a framework to develop a harmful habit cessation intervention in the context of multimodal prehabilitation to improve surgical and oncological outcomes in the cancer population.

Opioid Analgesics Adverse Effects: The Other Side of the Coin

BACKGROUND

Opioids are the cornerstone of the management of cancer pain. However, the development of adverse effects may compromise the opioid response. They include nausea and vomiting, constipation, drowsiness, sleep disorders, cognitive dysfunction, myoclonus, pruritus, dysuria, dependence and the development of aberrant behaviors, respiratory depression, and some endocrine responses.

METHODS

The goal of this paper is to identify the most common opioid-related adverse effects, their pathophysiology, and proposing the possible treatments. This narrative review will describe how these adverse effects may develop and how to prevent or to treat.

CONCLUSION

Intensity of adverse effects tend to decrease with continuous use. However, they may be persistent and may require symptomatic treatment or more complex treatment including alternative strategies for pain management.

Stringent Control of Opioids: Sound Public Health Measures, but a Step Too Far in Palliative Care?

PURPOSE OF REVIEW

Opioids are the only class of drug with the proven ability to control severe pain. The introduction of stringent opioid prescribing restrictions has inevitably impacted upon the ability of those prescribing opioids for advanced life-limited disease to practice as previously and could limit the supply of adequate pain relief to patients with cancer. This review considers the evidence that symptom management of patients with advanced cancer contributes to the "opioid problem" and whether there is adequate recognition of the risks involved.

RECENT FINDINGS

The literature suggests that the risk of opioid abuse is low in the palliative care population as is the risk of legal consequences for doctors prescribing opioids at the end of life. However, as many patients with cancer are living longer or surviving with chronic pain, palliative care physicians must be cognisant not only of the risks of long term opioid use but also of the risk of opioid misuse. Adherence to evidence or consensus-based guidelines is necessary to avoid inappropriate prescribing. In palliative care, it is appropriate not only to exercise a reasonable degree of opioid control and surveillance, primarily for the good of society, but also to ensure that the ability to treat pain in patients with advanced malignant disease is not compromised.

Signature Informed Consent for Long-Term Opioid Therapy in Patients With Cancer: Perspectives of Patients and Providers

CONTEXT

Signature informed consent (SIC) is a part of a Veterans Health Administration ethics initiative for patient education and shared decision making with long-term opioid therapy (LTOT). Historically, patients with cancer-related pain receiving LTOT are exempt from this process.

OBJECTIVES

Our objective is to understand patients' and providers' perspectives on using SIC for LTOT in patients with cancer-related pain.

METHODS

Semistructured interviews with 20 opioid prescribers and 20 patients who were prescribed opioids at two large academically affiliated Veterans Health Administration Medical Centers. We used a combination of deductive and inductive approaches in content analysis to produce emergent themes.

RESULTS

Potential advantages of SIC are that it can clarify and help patients comprehend LTOT risks and benefits, provide clear upfront boundaries and expectations, and involve the patient in shared decision making. Potential disadvantages of SIC include time delay to treatment, discouragement from recommended opioid use, and impaired trust in the patient-provider relationship. Providers and patients have misconceptions about the definition of SIC. Providers and patients question if SIC for LTOT is really informed consent. Providers and patients advocate for strategies to improve comprehension of SIC content. Providers had divergent perspectives on exemptions from SIC. Oncologists want SIC for LTOT to be tailored for patients with cancer.

CONCLUSION

Provider and patient interviews highlight various aspects about the advantages and disadvantages of requiring SIC for LTOT in cancer-related pain. Tailoring SIC for LTOT to be specific to cancer-related concerns and to have an appropriate literacy level are important considerations.

Preoperative Stellate Ganglion Block for Perioperative Pain in Lateralized Head and Neck Cancer: Preliminary Results

Patients with head and neck cancer represent a vulnerable population at particular risk of opioid dependence due to frequent histories of substance abuse, requirement of extensive surgery, and the synergistic toxicity of multimodal therapy. Regional anesthetic techniques have been used by other surgical disciplines to facilitate early recovery after surgery and decrease postoperative patient narcotic requirements. This pilot study investigates the efficacy of a preoperative regional analgesia using stellate ganglion block in lateralized head and neck cancer surgery. From our early results, stellate ganglion blockade may hold promise as an effective preoperative intervention for controlling early postoperative pain, lessening narcotic requirements, and improving quality of life.

Opioid Prescribing Safety Measures in Medicaid Enrollees With and Without Cancer

INTRODUCTION

Opioid prescribing safety among individuals with cancer is poorly understood. This study estimates the prevalence of Pharmacy Quality Alliance opioid measures among individuals with cancer undergoing or not undergoing active treatment versus those without cancer.

METHODS

Pennsylvania Medicaid data (2016) were analyzed in 2018 to identify adults aged 18-64 years with and without cancer diagnoses who had 2 or more opioid prescriptions. Active cancer treatment, defined as having chemotherapy, radiotherapy, cancer surgery, or hospitalization with a primary diagnosis of cancer, was evaluated from October 2015 to December 2016 allowing a ≥3-month look-back period for cancer diagnoses observed in the first quarter of 2016. Opioid dosages (>120 morphine milligram equivalents for ≥90 consecutive days), multiple providers (4 or more prescribers and 4 or more pharmacies), and opioid and benzodiazepines overlapping ≥30 days were evaluated.

RESULTS

The sample with opioid prescriptions included 111,491 enrollees without cancer diagnoses and 12,819 with cancer, 58.8% of whom were not in active cancer treatment. Among enrollees undergoing cancer treatment, with cancer but not in active treatment, and without cancer, the prevalence of high morphine milligram equivalents was 7.1%, 6.0%, and 4.7% (p<0.001), respectively. The corresponding prevalence of multiple providers was 6.7%, 4.1%, and 3.4% (p<0.001). Concurrent opioid and benzodiazepine prescriptions occurred in 28.6%, 30.5%, and 26.8% (p<0.001), respectively.

CONCLUSIONS

Individuals with cancer, regardless of treatment status, had higher-risk opioid use based on Pharmacy Quality Alliance measures versus those without cancer. Their systematic exclusion from opioid quality surveillance could create missed opportunities to identify patients at high risk of adverse opioid-related outcomes.

Opioid addiction and misuse in adult and adolescent patients with cancer

In the context of a therapeutic opioid epidemic, particularly in the USA, where increasingly stringent screening for 'at risk' individuals and close monitoring of opioid prescription and use is strongly recommended, the issue of misuse within the cancer population must be addressed. Most patients with advanced cancer will have pain requiring opioid therapy at some stage during their disease course. In the majority, this will provide good pain relief with no short- or longer-term adverse sequelae. A subset will present with substance misuse issues that will influence management and prescribing practice. The potential ethical issues of limiting effective analgesia on the basis of addiction risk or history must be acknowledged. Both a judgemental or 'relaxed' approach to such patients is problematic. Ignoring the situation will not be in the patient's best interest, but an undue focus on this aspect may damage therapeutic relationships with clinicians and adversely affect a holistic approach to care. Clinical practitioners must be aware of the risk factors for opioid misuse and in patients who are not under palliative care consider screening prior to commencing opioids. Clinicians must be able to manage and monitor those identified as having an opioid misuse problem.

Opioids in Cancer Pain: Right or Privilege?

Opioid analgesia is a mainstay of the treatment of cancer pain. Treatment of pain in patients with cancer with an ongoing substance abuse disorder can be difficult. We report the ethical challenges of treating a patient with cancer with a concomitant substance abuse disorder in an outpatient palliative care setting. We present an analysis of ethical considerations for the palliative care physician and strategies to aid in the successful treatment of such patients. We argue that there are select patients with cancer for whom exclusion from treatment with opioid therapy is warranted if their health is endangered by prescription of these medications.

Brief review: pain management for cancer survivors: challenges and opportunities

PURPOSE

As the number of cancer survivors continues to increase due to advances in medicine, many cancer survivors remain on their same pain management regimen long after their cancer treatment has been completed. Thus, the purpose of this review is to encourage awareness of the challenges and opportunities of pain management in cancer survivorship. It is our expectation that these patients will be referred to pain medicine specialists so their pain management can be optimized during the period of survivorship and ultimately improve their quality of life.

PRINCIPAL FINDINGS

Cancer and its treatment can cause significant pain which requires multidrug therapy, including strong analgesics such as opioids. Optimal pain management has been shown to improve the quality of life of cancer patients, and that is also true for cancer survivors. Nevertheless, the appropriate use of pain medications, especially opioids, must be re-evaluated and adjusted during treatment as the patient transitions into survivorship care and thereafter. This may otherwise result in unnecessary opioid use or may even lead to abuse. Fortunately, as cancer treatment is completed and the survivorship period begins, pain improves gradually and the need for pain medication should decrease. Unfortunately, some patients continue to take their potent analgesics during the period of survivorship although it may not be necessary. It is a challenge for pain practitioners who do not see these patients early in their disease or in the recovery period. Nevertheless, this challenge presents an opportunity for pain management providers to educate oncologists to refer cancer survivors to pain centres early during the period of their survivorship. Cancer survivors could then receive optimal care and maintain a better quality of life without having to take unnecessary pain medications.

CONCLUSIONS

It is clear that there is a need to improve pain management in cancer patients, particularly in cancer survivors. Pain physicians should play a critical role as part of a multidisciplinary team that cares not only for cancer patients but also for cancer survivors. Optimizing pain management during the cancer survivorship period results in a better quality of life.

[Dependency syndrome and hyperalgesia due to an opioid therapy for curative treatable pain. Case report of an apparent palliative patient]

Opioids are an essential part of cancer pain management but particularly in this patient group physicians could misinterpret opioid-induced potentially life-threatening side effects within the central nervous system (CNS) or hyperalgesia as a consequence of tumor progression. In this case increasing the opioid dose or switching to rapidly acting opioids may trigger a vicious circle. We describe a case report of a male patient who was treated with high doses of transdermal and endonasal fentanyl 2 years after pancreatomy due to cancer. The patient was referred to the palliative care unit presenting with delirious behavior and 30-40 severe abdominal pain attacks/day. After withdrawal of the opioid medication all CNS symptoms disappeared. Further diagnostics revealed multiple incisional hernia as the reason of the pain syndrome. The patient recovered after herniotomy and has now been pain free without any pain medication for more than 16 months. This case report underlines again the necessity of pain diagnostics also in assumed palliative patients with the risks of high dose opioid treatment.

Screening for substance abuse and diversion in Virginia hospices

BACKGROUND

Although inadequate treatment of pain is a problem for hospice patients, increases in the medical use of opioids have been accompanied by increasing levels of abuse and diversion in the community. Balancing pain relief with concerns about abuse and diversion is a difficult issue for hospices.

OBJECTIVES

The aim of this study was to determine policies and practices in Virginia hospices regarding substance abuse and diversion in patients and their families.

METHODS

A survey was conducted of Virginia hospices about policies, perceptions, and training regarding substance abuse and diversion.

RESULTS

Twenty-three of 63 hospice agencies responded (36.5%). Less than half (43.8%) required mandatory substance abuse training. Only 43.5% had policies regarding screening for substance abuse in patients; 30.4% had a policy regarding screening for substance abuse in family members. Policies regarding screening for diversion in patients (21.7%), and families (17.4%) were rare. Policies regarding opioid use in patients with a history of substance abuse or diversion were uncommon (33.3%, 30.4%, respectively); 30.4% had policies regarding use of opioids in patients whose family members had a history of diversion or abuse. Thirty-eight percent of hospices agreed that substance abuse and diversion was a problem for their agency, and these agencies were more likely to have written policies or mandatory training.

CONCLUSION

Most Virginia hospices lack mandatory training and policies regarding substance abuse and diversion in patients and family members. More than one-third felt that abuse and diversion were problems in their agencies. A national conversation regarding policies toward substance abuse and diversion in hospice agencies is needed.

Pain and Opioid Dependence: Is it a Matter of Concern

Opioids are extremely effective in managing cancer pain, and now are utilized for longer periods of time in cancer patients as the treatment for malignancies has become more successful.[1] The goals in cancer pain treatment includes maintaining function in patients with cancer pain (especially in earlier stage disease), and palliation in advanced disease.[1] The perception of the lay public and inexperienced clinicians that addiction is inevitable, often leads to an inappropriate fear to utilize opioids to appropriately manage pain; resulting in persistent under-treatment of cancer pain internationally.[23] There is much confusion about the phenomenon of physical dependence and how this can be differentiated from the maladaptive behaviors that constitute a diagnosis of substance abuse. The burden of cancer and associated cancer pain is projected to continue to rise, and is often at an advanced stage at diagnosis in less developed countries.[4] To be able to provide quality care for this patient population availability of opioids and skilled clinicians in pain management is paramount. In the majority of cases, the main concern is to abate concerns about risks of opioid addiction; to allow adequate pain relief. To understand the infrequent phenomenon of substance abuse in the setting of cancer pain management clear definitions are needed, and review of the epidemiology of occurrence in cancer populations is needed. It is also important to clearly separate the issues of substance abuse at the patient level and diversion of prescribed opioids. There are principles of managing cancer pain in the rare clinical scenario when the risk of substance abuse is high, which can still allow safe management of cancer pain with opioids.

The management of cancer pain

The experience of pain in cancer is widely accepted as a major threat to quality of life, and the relief of pain has emerged as a priority in oncology care. Pain is associated with both the disease as well as treatment, and management is essential from the onset of early disease through long-term survivorship or end-of-life care. Effective relief of pain is contingent upon a comprehensive assessment to identify physical, psychological, social, and spiritual aspects and as a foundation for multidisciplinary interventions. Fortunately, advances in pain treatment and in the field of palliative care have provided effective treatments encompassing pharmacological, cognitive-behavioral, and other approaches. The field of palliative care has emphasized that attention to symptoms such as pain is integral to quality cancer care.

Under-treatment of cancer pain

PURPOSE OF REVIEW

Cancer pain remains inadequately treated, despite internationally accepted management guidelines and a myriad of treatment options. Risk factors for undertreatment are reviewed, along with possible explanations. Recent studies documenting the scope of the problem as well as investigating solutions are discussed with clinical-practice recommendations outlined.

RECENT FINDINGS

Women over 65 years of age representative of a cultural minority, with earlier stage disease, cared for at home, and with high-school education or less are at highest risk of having uncontrolled cancer pain. Optimal treatment is impeded by patients' maladaptive beliefs, nonadherence, underreporting or miscommunication with caregivers; from a healthcare provider perspective, it may be due to inadequate assessment, documentation, knowledge, and communication. Emerging data support the vital influence of lay caregivers on appropriate pain management. Although home-education programs may decrease pain and improve quality of life, there are also less intensive approaches deliverable by individuals to holistically address pain.

SUMMARY

Prospective study of barriers to both delivery and receipt of adequate pain management is needed, as the majority of published literature is based on survey studies. Treatment must be individualized based on clinical circumstances and patient wishes, with the goal of maximizing function and quality of life.

Trends in long-term opioid therapy for chronic non-cancer pain

OBJECTIVE

To report trends and characteristics of long-term opioid use for non-cancer pain.

METHODS

CONSORT (CONsortium to Study Opioid Risks and Trends) includes adult enrollees of two health plans serving over 1 per cent of the US population. Using automated data, we constructed episodes of opioid use between 1997 and 2005. We estimated age-sex standardized rates of opioid use episodes beginning in each year (incident) and on-going in each year (prevalent), and the per cent change in rates annualized (PCA) over the 9-year period. Long-term episodes were defined as > 90 days with 120+ days supply or 10+ opioid prescriptions in a given year.

RESULTS

Over the study period, incident long-term use increased from 8.5 to 12.1 per 1000 at Group Health (GH) (6.0% PCA), and 6.3 to 8.6 per 1000 at Kaiser Permanente of Northern California (KPNC) (5.5% PCA). Prevalent long-term use doubled from 23.9 to 46.8 per 1000 at GH (8.5% PCA), and 21.5 to 39.2 per 1000 at KPNC (8.1% PCA). Non-Schedule II opioids were the most commonly used opioid among patients engaged in long-term opioid therapy, particularly at KPNC. Long-term use of Schedule II opioids also increased substantially at both health plans. Among prevalent long-term users in 2005, 28.6% at GH and 30.2% at KPNC were also regular users of sedative hypnotics.

CONCLUSION

Long-term opioid therapy for non-cancer pain is increasingly prevalent, but the benefits and risks associated with such therapy are inadequately understood. Concurrent use of opioids and sedative-hypnotics was unexpectedly common and deserves further study.

Management of chronic pain in cancer survivors

Chronic pain is a frequent complication of cancer and its treatments and is often underreported, underdiagnosed, and undertreated. Pain in cancer survivors is caused by residual tissue damage from the cancer and/or the cancer therapy. This pain can be divided into 3 pathophysiologic categories: somatic, visceral, and neuropathic. The most common treatment-induced chronic pain syndromes are neuropathies secondary to surgery, radiation therapy, and chemotherapy. Comfort and function are optimized in cancer survivors by a multidisciplinary approach using an individually tailored combination of opioids, coanalgesics, physical therapy, interventional procedures, psychosocial interventions, and complementary and alternative modalities. Management of chronic pain must be integrated into comprehensive cancer care so that cancer patients can fully enjoy their survival.

Addressing the intersecting problems of opioid misuse and chronic pain treatment

Misuse of prescription opioid medications has continued as a major public health problem in the United States. Review of major epidemiologic databases shows that the prevalence of opioid misuse rose markedly through the 1990s and the early part of the current decade. In this same period of time, the number of prescriptions for chronic noncancer pain increased markedly, and the intersection of these two public health problems remains a concern. Further, despite some leveling off of the overall rate of prescription opioid misuse in the past several years, surveillance data show high and increasing mortality associated with these drugs. Analysis of the 2006 National Survey of Drug Use and Health indicates the increasing prevalence of prescription opioid misuse is associated more with an increase in the general availability of these medications than misuse of the medications by those who were directly prescribed them. National Institute on Drug Abuse initiatives to address the prescription opioid problem include programs to stimulate research in the basic and clinical sciences, and to educate physicians and other health personnel.