Hollywood, FL—Achieving balance in the appropriate use of opioids to treat cancer pain requires skill and compassion. Strategies for safely and effectively prescribing opioids while reducing the risk of drug misuse and abuse were offered by Judith Paice, PhD, RN, FAAN, at the National Comprehensive Cancer Network 21st Annual Conference.
Best practices for the management of chronic pain is a timely issue, given the recent federal proposal to address prescription opioid abuse and the heroin use epidemic.
"We've learned to use opioids a little more judiciously, but the pendulum maybe swung a little bit too far in the direction of using them in people who maybe aren't the best candidates, or using doses higher than we should," said Dr Paice, Director, Cancer Pain Program, Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL. "We're starting to reevaluate…; our goal is truly a balance between analgesia, function, and safety. We need to think of those 3 components when we're providing good pain control."
Another way to think of the challenge is the safety of the patient, prescriber, and community, she said. The concept of no pain for 24 hours a day, 7 days a week is now considered unrealistic.
In addition to understanding the characteristics of the pain, the providers should also assess the effect the pain is having on the patient's life. Response to interventions for past pain episodes, including the types of adverse effects, is part of this assessment. Comorbid conditions should be considered as well, since these may place the patient at risk for misuse of pain medicines. The patient's functional goals should also be determined.
Medication choice should match the type of pain. For somatic pain, rely on nonopioids, advised Dr Paice, whereas neuropathic pain may require opioids at higher doses, along with adjuvant analgesics. Visceral pain is less well understood, but opioids and corticosteroids are reasonable choices.
Less well-known adverse effects of opioids include hormonal changes (suppression of testosterone), which may impact libido, fertility, bone health, and fatigue.
"I don't want to lose track of the fact that we still have people who are undermanaged with pain control," she said. Those at risk for undertreatment include infants and children, patients >65 years of age, long-term survivors, cognitively impaired persons, economically disadvantaged patients, and non–English-speaking patients.
The oncology patient can likewise suffer from overtreatment of pain. As with undertreatment, long-term survivors are at risk of overtreatment. Others at similar risk are patients with comorbid mental health conditions (ie, anxiety, depression, sleep disorders). "We need to be very clear with patients that you can't take these medicines to treat your anxiety…or to help you sleep," said Dr Paice. Patients with limited financial resources may be at risk of overtreatment with opioids because they have limited access to physical therapy and mental health counseling.
While the long-term benefits of opioid therapy have not been documented, since the duration of most studies has been 12 weeks, adverse effects of long-term opioid use include cognitive difficulties and depression; respiratory depression is also related to opioid use.
An increasing rate of opioid prescriptions correlates with increasing rates of opioid abuse and opioid-related deaths, she pointed out. The differential diagnosis of aberrant drug-taking behavior includes pseudo-addiction, in which the amount of drug ordered is insufficient, possibly because of insurance limits. Some patients, however, do have an opioid addiction while others attempt to obtain the drug with criminal intent (diversion). Smoking is a risk factor for addiction as are a personal history of sexual abuse and a family history of substance abuse.
Urine drug-toxicology testing can help discern whether patients are taking the drug as prescribed or are diverting it. Prescription drug–monitoring programs are available to screen for aberrant behaviors and to verify medication dose and refill dates.
When opioids are no longer beneficial, physicians should provide a strategy to wean the patient off the drug. A slow downward titration, about a 10% reduction in dose per week, is recommended.
To ensure a safe community, educate patients and their families about safe medication practices, including keeping pain medicines locked away, Dr Paice advised.
Paice J. Cancer pain management: strategies for safe and effective opioid prescribing. Presented at: National Comprehensive Cancer Network 21st Annual Conference; March 31-April 2, 2016; Hollywood, FL.