The majority of patients with cancer pain need opioids. But in the midst of an ongoing opioid crisis in the United States, how do providers safely prescribe them to their patients? According to Jeannine Brant, PhD, APRN, AOCN, FAAN, this requires a safe and balanced approach to pain and symptom management.
For decades, opioids have been the mainstay of pain—particularly cancer pain—management. Opioids have fewer systemic side effects than most treatment modalities, with no end-organ toxicity. Their side effect profile shows that they are actually very safe in most patients and lead to improved quality of life and improved functional outcomes in many individuals.
“They’re still a very useful tool in cancer care,” said Dr Brant at the 2020 Oncology Nursing Society Bridge Virtual Conference. “So what happened?”
According to Dr Brant, an oncology clinical nurse specialist, director, and lead scientist at the Billings Clinic Department of Collaborative Science and Innovation, opioids began excessively spilling out into communities due to a lack of proper patient selection; a lack of appropriate assessments for pain/functioning and aberrant behaviors; overprescribing for postsurgical pain, dental pain, and acute pain; and borrowed/stolen prescriptions.
The Scope of the Problem
From 1999 to 2016, more than 200,000 people died in the United States of overdoses related to prescription opioids, and overdose deaths involving prescription opioids were 5 times higher in 2016 than in 1999.
Additionally, more than 11.5 million Americans older than 12 years reported misusing prescription opioids in 2016, an alarming statistic considering the fact that overdoses are the leading cause of death in people younger than 50 years.
The CDC guideline for prescribing opioids does not actually apply to cancer pain, palliative care, or end-of-life care but advises that opioids should not be used as a first-line treatment for chronic pain.
“We know that the use of opioids in our populations is definitely still warranted, but even in cancer survivors with chronic pain syndromes, we want to try other options first,” she said. “We also want to make sure we establish goals (ie, function/pain), make sure that the benefits outweigh the risks, and start low and go slow.” She added that in these populations, she avoids prescribing benzodiazepines and instead opts for antidepressants to treat both depression and anxiety.
According to Dr Brant, one of the biggest challenges faced by providers early on in the opioid crisis was the “knee-jerk reaction.” Providers experienced Drug Enforcement Administration fears, leading to a refusal to prescribe and a rapid tapering of opioid availability around the country. Any aberrant behavior resulted in opioid discontinuation, and patients who used marijuana were dismissed from practices (even though marijuana use has been associated with curbed use of opioids in some populations). The FDA also decreased opioid production, resulting in an increased burden on palliative care teams.
The 10 Steps to Universal Precautions
When it comes to prescribing opioids, Dr Brant recommends following the standard universal precautions approach, the goals of which are as follows:
- Protect patients (from harm, opioid abuse disorders, etc)
- Protect practitioners (from losing the privilege to prescribe)
- Protect access (to valuable therapies)
- Protect the community (by not excessively spilling opioids out into communities)
- Promote cost-effective use of resources
This approach entails 10 steps, which Dr Brant described in detail:
- Differential diagnosis: the provider should take social and family histories (any use disorders?), evaluate comorbidities and any past psychiatric or cancer diagnoses, in particular those associated with a history of chronic pain.
- Psychological risk assessment: conduct a mental health screening and urine drug testing; use risk-assessment tools (eg, Opioid Risk Tool, Screener and Opioid Assessment for Patients in Pain), initiate a sensitive and respectful conversation, and utilize a prescription drug monitoring program.
- Informed consent: conduct a discussion regarding benefits and risks (ie, side effects, addiction vs physical dependence), set therapeutic expectations with the patient and goals of treatment.
- Treatment agreement: this sets behavioral expectations (ie, the patient should not “shop around” to other prescribers). “The treatment agreement is not all inclusive, but it does provide a conversation so that the patient knows it is a privilege to use opioids,” she noted.
- Pre- and postintervention assessment: focus on functioning and pain response before and after the intervention, and ensure continuity of care with the team (provider, nurse, pharmacist, social worker, counselor, etc).
- Trial of opioid: explain to patients that all opioid prescriptions are trials. Use rational polypharmacy (ie, coanalgesics), set a goal for the next visit and have an exit strategy.
- Reassessment: reassess function using objective information (ie, HbA1c in diabetic patients, pay stubs, gym or physical therapy attendance records, patient’s partner’s report), evaluate adherence to other aspects of treatment (ie, counseling), look at prescription drug monitoring plan, conduct urine drug test (screening assay and confirmatory testing). Dr Brant noted that a patient’s risk stratification should be considered prior to urine drug testing. The guidelines recommend testing every 6 to 12 months for low-risk patients, every 3 to 6 months for moderate-risk patients, and every 1 to 3 months for those in the high-risk category.
- The Six A’s: evaluate the patient’s Analgesia, Activities of Daily Living, Adverse Events, Aberrant Behaviors (behavioral changes [eg, possibly more manipulative or demanding, slurring words]), Affect, and Adjuvants.
- Review diagnosis and comorbidities: review disease progression/evolution, comorbidities (ie, depression, anxiety, insomnia), and evaluate for addiction or substance use disorder. “Notice that step 9 wasn’t step 1,” she said. “You have to work with these patients for quite some time before establishing a diagnosis. We have to watch patients all the time, we have to watch their comorbidities evolve, and a lot of times we have dual diagnoses.” Dr Brant pointed out the difference between an addicted patient and a “chemical coper,” a patient who often uses opioids to cope with psychosocial or spiritual distress. These patients need structure, psychiatric input, and drug treatments that decentralize the pain medicine to their coping by reducing its meaning, undoing conditioning, and undoing socialization.
- Documentation: document everything, including a patient’s initial assessment and plan, their treatment adherence, education provided, action plans, outcomes, monitoring, “Six As,” etc. In the case of a provider being “blamed” for a patient’s addiction, documentation can be a lifesaver, she said.
Creating an Exit Strategy and Preserving Hard-Earned Gains
Creating an exit strategy for a patient who is misusing opioids involves disengaging with the opioid, not discharging the patient, she said.
Promote shared decision-making with the patient and begin opioid disengagement by tapering the dose (refer to a specialist for tapering and provide adjuvants for pain and symptoms), but continue general medical care even if opioids can no longer be safely prescribed for that particular patient.
According to Dr Brant, substance use disorders can be prevented by assessing risk and providing safe pain care. As oncology practices are likely to see an increased number of patients with a current or past substance use disorder, better opioid-prescribing guidelines are needed, and modified prescribing practices—along with the education of patients and families—are warranted to prevent the exposure of these medications to unintended populations.
“We have worked so hard to provide good care for patients with cancer pain, but we’re still not doing a great job at managing it,” she said. “We still have a lot of work to do, but to preserve some of these gains, we really have to try to prevent use disorders and safeguard pain care. Advocacy on behalf of patients with cancer pain is imperative to avoid losing access to essential therapies.”