At the 2018 AONN+ Annual Conference, attendees heard a rapid-fire rundown of some of the most newsworthy, and sometimes controversial, topics in cancer care.
At the meeting, Elizabeth Franklin, LGSW, ACSW, educated the crowd on Trump-era healthcare policy changes; Carey S. Clark, PhD, RN, AHN-BC, urged conference goers to embrace medicinal cannabis and break the stigma; and Tonya Edwards, MS, MSN, RN, FNP-C, encouraged a compassionate approach to the opioid crisis.
Policy Changes on the Horizon
As part of the Trump administration’s plan to combat drug pricing in the United States, the US Department of Health & Human Services has proposed shifting coverage of some Medicare Part B drugs to Medicare Part D, which could increase out-of-pocket chemotherapy costs for patients.
According to Ms Franklin, Executive Director of the Cancer Policy Institute at the Cancer Support Community, out-of-pocket costs are typically about 33% higher in Part D than in Part B. “A great example is oral drugs versus infusion drugs,” she noted. “Patients pay a lot more for oral, right? This change could make everything look like that.”
Currently, Medicare Part D plans are required to cover all drugs in 6 categories known as “protected classes,” including all cancer drugs, antidepressants, antipsychotics, and HIV drugs. But in an effort to lower drug costs, coverage may soon be scaled back substantially, to as little as 1 or 2 drugs in each class, Ms Franklin reported.
“Because of the complex nature of cancer, ‘all or substantially all’ [antineoplastic drugs] have to be covered, but that could change. This is very, very serious for patients,” she said. “I know policy can be challenging to understand, but I think it’s the responsibility of everyone working in the healthcare system to stay engaged on this.”
Ending the Stigma Around Medical Cannabis
According to the National Cancer Institute, cannabis can provide symptom relief for patients going through cancer treatment by stimulating appetite, improving sleep, and relieving pain and nausea. It can also induce tumor growth inhibition while protecting normal cells. But despite this, there is still a stigma attached to patients who use cannabis.
“We really need to end the stigma around medicinal use of cannabis, supporting our patients and being nonjudgmental, compassionate, and patient-centered,” said Dr Clark, Associate Professor of Nursing at the University of Maine at Augusta and President of the American Cannabis Nurses Association. “We need to get over this idea that palliation is about end of life and hospice; it’s not. It’s about helping to manage symptoms, and it needs to start with diagnosis.”
The National Council of State Boards of Nursing (NCSBN) recently published the NCSBN National Nursing Guidelines for Medical Marijuana, which outlines 6 principles of essential nursing knowledge as they relate to the use of medical cannabis. These principles encompass various facets of dealing with medical cannabis and mandate that nurses should have a working knowledge of the current state of legalization of medical and recreational cannabis use, an understanding of the endocannabinoid system (the body’s largest receptor system), knowledge of safety issues related to cannabis use, and should approach patients without judgment regarding their treatment preferences, to name just a few.
“This ties in really well with policy,” said Dr Clark. “You need to be aware of the policies in your state concerning what your patients can and cannot legally do around the use of medical cannabis.”
She encourages nurses and navigators to learn about the endocannabinoid system, as well as ingestion methods, dosing/self-titration, and safety considerations, and to become familiar with their state practice act. “Patients are using medical marijuana, and we want to support them the best that we can,” she said. “If you’re in a state where it’s not legal, find a legislator and start writing some legislation with them, so that your patients can have access to medicine that is safe and tested, and so they don’t have to go out on the black market.”
Assess patients’ past cannabis use, and clarify their goals for its medical use, she said. Focus on education and coaching, and advise patients to “start low, go slow,” with gradual increases until their symptoms are managed. “Patients don’t have to get high to achieve palliation,” she noted. Cannabinoid products high in THC can cause a euphoric high but can also lead to side effects like dry mouth, dizziness, anxiety, or even paranoia.
There is still debate over whether cannabis is an “entry drug,” but according to Dr Clark, “there are some good data to show that it can actually be an exit drug to get people off of opiates.”
A Nonjudgmental Approach to the Opioid Crisis
The United States is in the core of an emergent and hazardous epidemic of opioid overdose, with known abuse of opioids and heroin, according to the CDC.
According to Tonya Edwards, from the Department of Palliative Care and Rehabilitation Medicine at MD Anderson, addressing this epidemic requires an all-hands-on-deck approach, and nurses are on the front line.
“If a patient comes in with cancer, regardless if they came in with existing issues with cocaine or heroin, we still want to treat them with dignity and respect and let today be day 1 of opioid education,” she said.
If aberrant behavior such as drug hoarding is established, conduct a thorough assessment, begin an open and nonjudgmental conversation with the patients while communicating concerns about their safety, and review chart documentation for any potential explanations for deviant behavior. If members of the team, including nurses, physicians, pharmacists, social workers, and psychologists, are not using a consistent documentation method, remedy that. “We need to be documenting in the same way. We need to join forces,” she said.
In her clinic at MD Anderson, television screens in every room play opioid educational materials on a loop, addressing such issues as what to do about constipation or pain, and how to contact a provider for a prescription adjustment. “There’s opioid education in every angle in that clinic,” she said. “If they see us once a month for a year, they’re going to get that opioid handout sheet every time, to the point that they say, ‘Yeah, yeah, I know. You do random urine drug screens. Don’t sell, don’t share.’”
“But that’s what we want!” she emphasized. “We want them to understand what’s going on; we want to disclose everything.”
Ms Edwards designed a streamlined system to guarantee cohesive and uniform documentation among all team members, and to ensure providers don’t deny payment because of inaccurate documentation. These prepopulated templates allow nurses and other providers to simply erase what they did not complete, rather than describing what they did. “You do so much every day, but do you document it well? Probably not, because it’s easy for you to forget,” she explained. “This way our documentation is spot on.”
To address opioid abuse, she advises decreasing the time interval between follow-ups for refills and limiting the opioid quantity and dose at each visit. Set boundaries and limitations, and taper patients off strong analgesics if possible. Consider referral to specialist clinicians when necessary, and continue to be vigilant. If a patient loses a prescription twice in a month, try to figure out what’s going on to keep the patient safe, but do so without name-calling, she encouraged. According to Ms Edwards, a change from adherence to aberrancy may be subtle, but duration is the strongest predictor of misuse.