Opioid Epidemic Response May Restrict Cancer-Related Pain Management
An estimated 4 in 10 cancer survivors live in some degree of pain, and 5% to 10% have severe chronic pain.
The Centers for Disease Control and Prevention (CDC) estimates that since 1999 the number of overdose deaths involving prescription opioids has quadrupled and that approximately 91 Americans die each day from an opioid overdose.1
In response to what many are calling an opioid epidemic, the CDC issued guidelines for limiting prescribing of opioids and many state legislatures have passed or are in the process of passing laws limiting opioid prescriptions. Although much of the response to the opioid epidemic exempts treatment for cancer-related pain, a recent Oncology Nurse Advisor online survey showed that more than 80% of respondents were concerned about how current restrictions set up to manage the opioid crisis are affecting cancer patient pain management.
“What we are seeing is more and more difficulty for our patients in getting their pain medicine,” said Ann Brady, MSN, RN-BC, CHPN, a symptom management care coordinator at Cancer Center Huntington Hospital in Pasadena, California. “In the past, a physician could write an order for an opioid and the patient could fill it. Now there are a lot more hoops to jump through.”
The International Agency for Research on Cancer, estimated that in 2012 there were more than 32 million people worldwide living with cancer and that number is expected to increase to more than 52 million by 2030.2
As the number of people with cancer increases so too will the number of people living with cancer-related pain. An estimated 4 in 10 cancer survivors live in some degree of pain, and 5% to 10% have severe chronic pain.3,4
Pain related to cancer is dynamic. Patients with cancer can experience pain related to the tumor itself. A tumor growing in an organ may stretch the part of the organ, causing pain. Tumors that metastasize to bone or to the spinal cord or a nerve can also cause pain. However, cancer-related pain can also be due to cancer treatment. Patients undergoing surgery, radiation therapy, chemotherapy, bone marrow transplant, or hormonal therapy can experience a variety of types and degrees of pain that may be long-lasting.5
“The management and care of cancer-related pain is quite complex and requires multiple disciplines to help cancer patients get control of their pain,” said Jiajoyce Conway, DNP, CRNP, AOCNP, an oncology nurse at Cancer Care Associates of York in York, Pennsylvania.
According to Dr Conway, opioids may be considered for cancer-related pain in several settings including short-term use in patients with pain due to treatment, and for the treatment of patients with advanced disease who are experiencing significant pain.
Unfortunately, since the recognition of and response to the growing opioid epidemic both Dr Conway and Ms Brady have begun to face difficulties in getting their patients their pain medication.
Opioid Epidemic Response
In 2016, several things happened to signal a growing recognition of the opioid epidemic in the United States. First, the Comprehensive Addiction and Recovery Act was signed into law. The legislation was a comprehensive attempt to address the opioid epidemic and authorized more than $180 million each year in funding to address 6 areas necessary for a coordinated response to the opioid epidemic: prevention, treatment, recovery, law enforcement, criminal justice reform, and overdose reversal.
In addition, the CDC released its “Guideline for Prescribing Opioids for Chronic Pain.”6 The guideline outlined voluntary, evidence-based recommendations for prescribing opioids in patients aged 18 years or older in a primary care setting. The guideline suggested starting with the lowest effective dose possible and prescribing only what is needed for the expected duration of pain. Specifically, it noted that a prescription for 3 days or less will often be enough to manage acute pain and a prescription for more than 7 days will rarely be needed. The CDC guideline recommendations are for the prescribing of opioid pain medications in outpatient settings outside of active cancer treatment, palliative care, and end-of-life care.
In recent years many states have also passed legislation limiting opioid prescriptions. According to the National Conference of State Legislatures, 24 states have enacted legislation limiting opioid prescribing or giving guidance related to opioid prescribing.7 Legislation in Minnesota and Kentucky limits first-time opioid prescriptions to a limit of 3 to 4 days; Hawaii, Alaska, Utah, Louisiana, Pennsylvania, New York, Massachusetts, Connecticut, Indiana, and Maine all limit first-time prescriptions to 7 days. Approximately half of the states with legislation specify that prescriptions must be for the treatment of acute pain. Similar to the CDC guidelines, most of these laws exempt treatment for cancer and palliative care.
“These opioid restrictions are supposed to carve out for cancer pain, and I think technically they do, but on a practical level it does not always work that way,” Ms Brady said. “Most people's understanding of opioids is related to the crisis and often doesn't distinguish between cancer pain and other pain.”
Ms Brady has seen these effects in her day-to-day care for patients. For example, some insurance companies and pharmacies are responding to the opioid crisis by being more restrictive with pain medications, she said. Brady will often have to call insurance companies and speak with several rounds of representatives in order to obtain insurance coverage for a patient to receive the type, strength, or length of opioid prescription necessary for their pain.
“This can be very frustrating and time consuming because sometimes we are making changes to pain management treatment on a day-to-day basis,” she said.
Dr Conway has also encountered these issues, adding that some insurance carriers will not authorize coverage beyond emergency 3-day or 7-day prescriptions.
Ms Brady has also heard from patients that even once an opioid prescription is approved by their insurance carrier, they may still run into issues when they go to a pharmacy to fill the prescription. “If a physician writes for 90 pills and the pharmacy says they only have 30 pills in stock, the patient may only get 30 pills and will not be able to come back to get the remainder of those pills,” she said.
“That is inadequate pain control,” Dr Conway points out. “This can lead to patients rationing out their pain medication, and in between pills they are suffering.”
Ms Brady said she has also heard of pharmacies requiring that opioid prescriptions be picked up in person by the patient. “For some patients with cancer that is a huge burden.”
Opioid addiction is still a concern in patients with cancer, especially as more and more patients continue to survive beyond 10 years. According to Dr Conway, that means the prescribers must carefully weigh the pros and cons of these medications.
“If I am treating a patient with advanced, terminal disease, and I know that patient is likely addicted to the medication, am I going to fight the patient knowing that their time is limited and they have no other way to survive but on pain medication? No,” Dr Conway said.
However, there are rare situations where patients with cancer or cancer survivors begin to seek opioid medications from multiple providers, and that should be recognized as drug-seeking behavior, she said.
“Although it is only a small subset of patients, these patients have to be held accountable for such behavior,” Dr Conway said. “If I have any concern that a patient is receiving opioids from multiple providers I will hold them accountable to a pain contract, and if they violate that contract we will no longer prescribe for that patient.”
Non-Opioid Pain Management
Of course, there are management options for treating cancer-related pain outside of the use of opioids. Mild to moderate pain can be controlled with the use of acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). Other drugs may be used in conjunction or in place of opioids to help relieve cancer-related pain. These include antidepressants, which can treat tingling or burning pain from damaged nerves, antihistamines, which can help control nausea and itching, anti-anxiety drugs, which can treat muscle spasms, or anticonvulsants, which help control nerve pain.8
Ms Brady is also a big proponent of integrative therapy. “The clinic where I work has an acupuncturist, a massage therapist, and someone who does classes on mindfulness, and while patients are in the hospital there is music therapy, pet therapy, and a variety of other things available,” she said. “However, a lot of times these things may help, but will not be a complete fix.”
According to Dr Conway, oncology nurses, advance practitioners, and physicians have a responsibility to provide all types of supportive services for patients with cancer experiencing pain.
“That starts with assessing patients individually and not grouping everyone into one category,” Dr Conway said. “An individualized approach to care means understanding what type of pain they have, their goal of management, and what long-term outcomes we are seeking.”
- Understanding the Epidemic. Drug overdose deaths in the United States continue to increase in 2015. Centers for Disease Control and Prevention website. https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed November 29, 2017.
- GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012. International Agency for Research on Cancer World Health Organization website. http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx. Accessed November 29, 2017.
- van den Beuken-van Everdingen M. Chronic pain in cancer survivors: a growing issue. J Pain Palliat Care Pharmacother. 2012;26(4):385-387.
- Glare PA, Davies PS, Finlay E, et al. Pain in cancer survivors. J Clin Oncol. 2014;32(16):1739-1747.
- ASCO Answers Managing Cancer-Related Pain: A Guide for Patients, Families, and Caregivers. Alexandria, VA: American Society of Clinical Oncology; 2017. https://www.cancer.net/sites/cancer.net/files/managing_pain_booklet.pdf. Accessed November 29, 2017.
- Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-49.
- Prescribing Policies: States Confront Opioid Overdose Epidemic. National Conference of State Legislatures website. http://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx. Accessed November 29, 2017.
- Non-opioids and other drugs used to treat cancer pain. American Cancer Society website. https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/pain/non-opioids-and-other-drugs-to-treat-cancer-pain.html. Accessed November 29, 2017.