The opioid crisis, although not new to the United States, has gained significant attention since the government recognition and subsequent announcement of the problem in 2017. With the increased public and legislative awareness of this issue there is new concern about the prescriptive practices of pain management for patients as well as discussion within the oncology community of how to best manage malignant pain. The cancer patient can present very specific challenges to symptom and pain management based on a number of characteristics. The obvious issues focus around the disease; however, more subtle issues arise around existential suffering, social conditions, family and patient expectations associated with a cancer diagnosis, as well as the societal view of the cancer patient. With all of these variables, the question arises: What should we consider in managing pain for the oncology patient? And how do we best provide safe but effective symptom control to allow this vulnerable patient population to be successful in pursuing their goals of care? The oncology navigator is in a key position to maximize the opportunities for effective pain management for these patients because of the close relationship that develops with the patients and their families. This not only allows the patients to be more successful in meeting their goals but also enables more effective management and treatment from the medical team.
The History of Opioids
Opioid products are a derivative of the poppy plant and have been documented in history back to the time of the Mesopotamian empires for both recreational and medicinal purposes. The Sumerians referred to poppy as “Joy Plant,” and other ancient cultures used it for sedative purposes. In the early 1800s, chemists were able to isolate a portion of the poppy plant that became known as morphine. The pain control effects of morphine became a valuable tool in the treatment of patients and became more widely used in the United States during the Civil War. During this conflict and in the years shortly following, the addictive nature of opioids became more apparent. In the late 1800s, morphine began to be used in medical procedures, and from there the medical uses grew.
Over the same period, opium was being marketed in the form of laudanum for basic management of everything from cough suppression and headaches to treatment of menstrual symptoms. This resulted in overuse of the product and the predisposition of physicians at the time to prescribe this agent to women, making the typical opioid addict a middle-aged affluent female. The production of opioid-based products was well recognized as a potential money-making business, and Bayer entered the market, initially manufacturing heroin for purchase. As the addictive nature of these products became more recognized, the US government began to pass legislation to ban heroin and opioids to protect the public from addiction. The first legislation, the Opium Exclusion Act, was passed in 1909, quickly followed in 1914 by the Harrison Narcotics Tax, and in 1924, the Anti-Heroin Act. From there, legislation continued to develop in relation to the regulation and restricted use of opioids in the United States. In response to worldwide concerns of the addictive issues with opioids and heroin, oxycodone was developed in 1916 and approved in the United States in 1939. The intent was to improve control of opioids along with the hope of less addictive issues compared with traditional heroin and morphine.
The Consumerism of America
The current issues with opioids are recognized as having developed during the 1990s and into the 2000s. It was during this time that the concepts of pain as a measurable vital statistic became popular. In the early 2000s, even The Joint Commission began the requirement of recognizing pain and addressing pain in all patients. This is thought to have strongly influenced and contributed to the current crisis we face. By acknowledging the issues around pain and tying it to factors such as patient satisfaction, the focus of treatment teams changed to begin ensuring a patient’s pain was treated aggressively, in the hope of bolstering patient satisfaction. This included treating pain quickly with medications that were highly effective, such as opioids, but with this came the risk of addiction, which was often overlooked or downplayed due to the ever-influential patient satisfaction rating. Adding additional fuel to consumerism, the United States and New Zealand are the only countries that allow direct-to-consumer pharmaceutical advertising. This certainly influences the problem of medication demand and potential abuse among the consumers. With direct marketing, persons at risk then pursue medications by requesting them from their provider after seeing specific products advertised that they feel would be appropriate for their treatment. With satisfaction driving practice ratings and scores, the patient’s requests would often be met.
Statistics released by the National Institute on Drug Abuse in 2015 indicate there were approximately 33,000 deaths related to opioid drug overdose. That number rose alarmingly through 2016, and increases in overdose rates occurred from 30% to 70% based on regional characteristics in the United States in 2017. In response to consumerism, provider practice patterns, and social expectations, hospitals and healthcare survey companies have removed pain as the fifth vital sign. It is now recognized that surveying pain management as a primary point of patient satisfaction has contributed to the opioid crisis. The American Medical Association has also reviewed physician practice and passed a resolution removing pain as a recognized vital sign. This was intended to encourage physicians to address pain in a light other than satisfaction. State and federal agencies also began creating and updating policies around the prescribing of medications, as well as developing state monitoring programs engineered to track not only patient use but provider practice, thus holding providers accountable for their management of patients requiring opioid medications.
How to Approach Pain in the Cancer Patient
As a navigator, what is important to consider when approaching the cancer patient with pain? When a patient presents with cancer pain, it is a priority to identify what is important to the patient in relation to their preferences for treatment. Pain is not only a physical symptom; it has strong psychosomatic and emotional components. When the patient is suffering with pain, often the family may be suffering as well. Pain is a complex symptom, and it is critical to address all aspects and dimensions of pain to provide successful management. This means it is important to listen to what the patient is saying, but it is more important to hear the patient. It is common to get into the flow of the clinical day, appointment times, and the rush of a schedule, which can limit what is truly heard, but it is critical to understand the patient, not just the complaint. When engaging a patient and family, reassure them that they are being heard, and that the team is working to address what is important. With this approach, the patient will begin to demonstrate improvement in pain symptoms just from the feeling of support. Reassuring patients that you will work with them to develop the best plan to address their pain in keeping with their goals will help in improving the patient situation, reduce anxiety, and still enhance satisfaction and experience. In addition to identifying these key concerns for the patient, it is necessary to explore expectations of the patient and family, as well as those of the care team. If the expectations of care and pain management are not clearly identified up front, the situation is ripe for failure. I always discuss with patients and families that cancer pain is there because of a significant problem within the body. It is unlikely that the care team will get the patient “pain free.” Instead, the expectation should be that the patient’s pain will be manageable to support ongoing activities and function. I often refer to getting the patients to a pain level of 3 to 4 on a scale of 1 to 10. This will allow them to be comfortable, yet allow them to continue with treatments or maintain their lifestyle. Given the dynamic nature of cancer and treatments for the patient, this can be an ever-changing presentation that requires frequent readdressing of the expectations. Cancer navigators have a unique opportunity to provide this support and help define these expectations given their close and intimate role working with patients and families.
Once rapport has been developed with the patient, the next step is to obtain a detailed and accurate history about the pain complaints. Again, the cancer navigator is in a unique position to take the time to obtain this information. This information will allow the team to look at the patient’s pain complaint and assess the interventions the patient has tried. The traditional approach of evaluating Provocation, Quality, Region, Severity, and Timing is sound in nature. This includes items such as: How and when did the pain start? Is this sharp or dull, achy pain? What part of the body is involved? How bad is the pain on a scale of 1 to 10 or FACES scale? And how long has this been occurring or is there a pattern related to the pain? Depending on how basic or detailed and extensive the evaluation is, it can set the stage for successful treatment moving forward. This provides the treatment team a “picture” of what a patient is experiencing and how it is impacting the function and quality of life. This step is the most important component of the patient interaction, but it is often the most common step that is rushed through. This is demonstrated by the intake process, which is often scripted and completed by office or medical intake personnel based on a computer or written intake sheet. As a cancer navigator continues to work with the patient, there is the opportunity to obtain a more detailed history, and it is possible to identify areas for basic pain management that may defer the addition of narcotic pain medication. It is during this assessment that the patient’s medical history, as well as the specific nature of the cancer, must be considered. If the patient has renal or liver disease, or if the patient’s cancer is affecting those organs, there may be limits to the type of adjunctive therapy that could be considered.
It is not uncommon during this portion of the history that you hear the patient state, “I have tried everything” to help the pain. It is rare that patients have truly exhausted all options for self-care and treatment. I do not say this to doubt or mistrust patients but because the self-care treatments they may try are often utilized the wrong way or for too short a duration. An example of this is patients who come in stating they have tried ibuprofen for the pain. When a more detailed history is taken, it might be revealed that they tried 200 mg of ibuprofen perhaps 2 times a day. This does not leverage the maximum benefit that an anti-inflammatory can provide and does not mean that ibuprofen for this patient will not be effective if timed and dosed at appropriate strength. The same concepts can be applied to ice, heat, elevation, and other interventions. Looking at the timing, duration, and schedule of the interventions and ensuring the appropriate application of these interventions, as well as the willingness of the patient to utilize the interventions, redefine the opportunity to treat pain with non-narcotic management techniques.
This evaluation and history also provide the opportunity for the navigator or other clinical personnel to begin to think outside the box. Rather than escalating to narcotic pain management, explore the idea of complementary and alternative medicine (CAM) such as massage, healing touch, acupuncture, guided imagery, hypnotism, and other techniques. Often these methods of intervention can be effective, if for no other reason than decreasing anxiety and providing some distraction. This is not to say that all patients will be open to this approach, or that they even have the resources to pursue CAM, as insurance traditionally does not cover this cost, but it should be explored. I would encourage all cancer centers to develop a CAM resource list or volunteer list to assist with treating patients. The cancer center at the facility where I work has used hypnotherapy quite effectively for patients undergoing bone marrow biopsy and thereby reduced the need for both narcotics and benzodiazepine use both during and following the procedure.
In recent years, with patient satisfaction driving practice, it was quick and easy to escalate to opioid management of pain, particularly in a patient with cancer. However, basic concepts of management should always be incorporated into the treatment plan. Reflecting on the World Health Organization’s pain management ladder, start at the bottom of the ladder with non-opioids plus adjunctive therapies (as above) and escalate care up the ladder as needed for continued pain control. Each step you take up the ladder does not mean you ignore or discard the previous attempts in therapy, but rather that you incorporate them in the escalation of care. It is essential to maximize non-narcotic options prior to initiating narcotic pain management. If moving to narcotic pain management, it should be mandatory to continue to attempt adjunctive and supplemental therapies, and most importantly to document the process of working through each of these considerations.
Escalation to Opioid Pain Management in the Current Environment of the Opioid Crisis
Cancer pain can be relentless and will often require escalation to narcotic pain management. How do we move to that level of management in a safe and effective way while navigating the current culture and crisis surrounding narcotics and the stigma associated with these drugs? When escalating to narcotic pain management, it is necessary to use the history component of a pain assessment as previously discussed, but also to attempt to identify patients who may have special considerations or may be at risk of addiction based on their personality. Patients with a known past illicit or prescription drug history may be identified as likely requiring higher-dose opioids for pain management compared with their counterpart with no such history. Evaluation of past controlled substance use through state-driven drug monitoring programs is another useful tool in these situations and is recommended by national and most state guidelines. This may also give the navigator or clinician an opportunity to discuss identified concerns or even specific patient or family concerns about a pain management plan and expectations. If it is identified that patients are using street drugs for pain management, it becomes necessary to put safety checks and boundaries in place to protect not only the patients but also the care team. This can be done using several techniques. Consideration could be given to a pain contract. I am not a fan of pain contracts, but I do use them in patient scenarios in which there are high-dose narcotics being used with a history of narcotic abuse, illicit drug use, or compliance concerns. These contracts are intended to outline expectations for both patients and the care team. They traditionally include how much medication will be prescribed, how often, consequences of using the medicine outside of directions, single pharmacy dispensing, and even random drug testing to ensure appropriate use of medications and no illegal substances. The benefit is that clear expectations are set for the treating relationship. The challenge with these is they are often used to provide a reason for a care team to stop treating the patient. When patients are released from care for violations, they are often left without resources to continue their care. Contracts are often overutilized by surgical or orthopedic teams as well, and tend to become more of a protective document for the teams than a true tool to support a patient. In addition, some patients or families may view a contract as a lack of trust from the care team. Other methods include providing limited days of prescription drug or dispensing systems to be utilized in the home.
As opioids are initiated, it is important to consider the current crisis as well as federal and state guidelines for the use of opioids. Although it is not the traditional role of the navigator, being familiar with these guidelines may make the development of patient treatment plans safer and easier and provide the opportunity to identify other means for treatment of patients with cancer-related pain. The CDC has guidelines available online (www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm) for review. It is important to remember that a majority of opioid guidelines are aimed at noncancer pain management, specifically for noncancer-related chronic pain. The challenge for the navigator and care team is that interpretation of these guidelines could be viewed as not applicable to the cancer patient based on language as well as legislation related to the opioid crisis. The societal obligation that we have as a treatment team is to recognize that with current therapies for cancer, the treatment of cancer as well as management of a patient’s symptom burden have transitioned from a past state of crisis and acute intervention to a state of chronic disease management. This obligates us as the medical team to ensure judicial but effective use of opioids in the treatment of oncologic and malignant pain.
The guidelines and legislation currently being generated serve 2 purposes. The first is to ensure a reduction in opioid prescriptions and thus a reduction in related deaths. The second is to hold providers and care teams accountable for responsible practices while treating patients. Although every person, both patient and care provider, will feel the impact of this crisis, it remains possible to provide excellent and appropriate care to our patients with cancer. Through close relationships, excellent understanding of the patient’s goals and expectations, and familiarization of current guidelines and standards, the cancer navigator has the privilege of walking alongside the patient during this journey. This relationship enhances the care team’s ability to provide excellent and safe pain management for the patient regardless of opioid use and the current national crisis.