Interdisciplinary Approach to Managing Opioid Use at The University of Texas M.D. Anderson Cancer Center

For the past 29 years, The University of Texas M.D. Anderson Cancer Center, Houston, has consistently been ranked as one of the premier cancer hospitals in the United States by US News & World Report. The center focuses on the patient, and offers state-of-the-art cancer care from diagnosis through treatment, to survivorship-related issues, innovative treatments based on groundbreaking research, and leadership in cancer prevention. It also has more nurses per patient than any other cancer hospital.

The Oncology Nurse-APN/PA (TON) spoke with Tonya Edwards, MS, RN, MSN, FNP-C, Nurse Practitioner, Palliative Care and Rehabilitation Medicine, about how patient support and education are hallmarks of The University of Texas M.D. Anderson Cancer Center. In this article, Ms Edwards discusses the institution’s focus on counseling and support, educational resources, and the management of patients with cancer who receive opioids for pain relief.

TON: Can you tell us about your role at The University of Texas M.D. Anderson Cancer Center?

Ms Edwards: I started out as a registered nurse 21 years ago and have worked at The University of Texas M.D. Anderson Cancer Center for the past 12 years in the outpatient setting. Now, I am a family nurse practitioner on the inpatient side, working with acutely ill patients with cancer. For the past few months, I have been part of a mobile team that offers palliative care and support for symptomatic patients with cancer. We help to control pain, constipation, nausea, fatigue, depression, anxiety, and other symptoms that these patients may have. We also follow up on former inpatients who are now in our outpatient clinic, to make sure that their symptoms continue to be managed well.

TON: How did you get involved with combating opioid abuse among patients with cancer?

Ms Edwards: While I was working in the outpatient setting, I noticed a lot of “red flags” among patients who were on opioids for pain control (eg, pill counts that did not match what was prescribed; requests for frequent refills; avoidance of clinic visits; aggressive behavior; and prescriptions from other providers). Although these patients were being managed by standard protocols and we were following up on them monthly, some of them tried to get around our management efforts by calling physicians at night for more opioids.

I felt it was necessary to streamline the process related to our opioid prescriptions and patient management. I developed a PowerPoint presentation illustrating how we could improve the process for our nurses in the supportive care clinic. Before presenting it to the nurses, I showed it to the physicians who worked with us. The physicians loved my ideas, and even though I had received outside help to develop the presentation, Eduardo Bruera, MD, Chair, Palliative Medicine, said, “Let’s try this plan.”

I also developed a Compassionate High Alert Team with Suresh Reddy, MD, Professor, Palliative Care and Rehabilitation Medicine, Division of Cancer Medicine, The University of Texas M.D. Anderson Cancer Center, to help manage patients when any aberrant behaviors appeared, and this is now part of our interdisciplinary team approach in both the outpatient and inpatient settings.

TON: Is your program and approach unique?

Ms Edwards: When we published our data in February 2018 (Arthur J, et al. Oncologist. 2018;23:263-270), we did a literature search and could not find any other reports on managing opioid abuse in patients with cancer.

TON: What does the Compassionate High Alert Team approach involve?

Ms Edwards: When we identify a red flag (ie, nonmedical opioid use) in a patient, we invite the patient to come to the clinic and meet with a team, which typically includes a physician, nurse, pharmacist, patient advocate, and occasionally, a counselor. We let the patient know we have concerns about his or her opioid use. For example, we may have noticed that the patient has seen 3 different physicians for opioid prescriptions within the past few months, the patient frequently reports stolen pills, or the patient says a family member is responsible for taking the pills.

This interdisciplinary approach has proved to be effective for our patients and staff.

TON: What is the biggest challenge of managing patients with cancer?

Ms Edwards: Our patients come to M.D. Anderson Cancer Center from all over the United States and the world. It can be challenging to get them to continue on their symptom management medications—in particular opioids—because the rules differ from one country to the next. Opioid misuse is an emergent issue, requiring more research to classify the clinical effectiveness of our interventions.

TON: How do you encourage appropriate opioid use in patients who require pain control?

Ms Edwards: Patients must be assessed physically, and be given updated opioid education, including information that opioids can be addictive. Education is the most powerful tool we provide to our nursing staff and patients.

TON: What is your biggest reward at work?

Ms Edwards: For both inpatient and outpatient work, my biggest reward is seeing patients achieve symptom control and have good quality of life, knowing that we have given them comprehensive education and have managed their symptoms so that they are able to function—to play with their children, to go to work, to socialize.

There are many patients we have been following for years, and it is an honor for me to spend time with patients who are able to achieve relief from palliative care. Even if these patients go on to hospice—and not all patients do—it is gratifying to be a helpful part of their cancer journey.