Managing cancer pain in the throes of the opioid crisis

For the Gazette
Published: 1/3/2017 6:16:07 PM

Last month, U.S. Surgeon General Dr. Vivek Murthy released a report on the substance addiction crisis. Similar to the 1964 version that raised the alarm on tobacco, it too did not reveal much new research but rather serves as a compilation of previous studies. Almost 21 million of our citizens suffer from some sort of substance abuse problem, a number 50 percent greater than those who have any type of cancer combined.

Between 1999 and 2015, yearly deaths attributed to narcotic use increased more than five times, to more than 20,000.

Over the past year, significant state restrictions on narcotic prescribing — dosages, amount of drug to be dispensed, prescription tracking — have been reinforced by health insurance companies with significantly increased paperwork (and invariable delays) and still lower dosing limits and dispensed pill counts. These efforts are properly intended to both reduce the amount of drugs that might be diverted to illegal or inappropriate uses and decrease the number of patients treated with opiates unnecessarily, thus lessening the number of people at risk for addiction.

As with any action, there are unintended consequences. Increasing the challenges and burdens of pain management for patients with either advanced cancer or for those receiving cancer treatment that is very painful appears to be one of them.

Cancer patients are, of course, still able to obtain opiates for the effective relief of their pain, and more easily than patients with pain that is not cancer related, but the trials cancer patients face in obtaining needed relief have significantly increased.

Smaller prescriptions and frequent insurance pre-authorization requirements often result in delays and gaps in pain management. Patient and physician concerns regarding addiction are likely to lead to both delays in starting and inadequate dosing of pain medication.

It has been accepted for decades that effective cancer pain relief has been hampered by the concerns of patients, and their physicians, of addiction. Over the past 20 years, physician-led organizations concerned with cancer pain management have produced guidelines and education to relieve concerns of addiction among those with advanced cancer, and have urged a more suitable dosing approach aimed at reducing or eliminating pain. A common statement among them: Addiction in cancer patients is rare.

Has anything changed?

A recent study evaluated over 600 cancer patients for known risks for addiction development, as well as actual addiction behaviors — rapidly escalating doses, diversion of drug for sale or other uses, obtaining prescriptions from more than one physician. Less than nine percent of patients had in their medical history a recognized risk factor for addiction, but when looking at behaviors that define addiction, only four percent of patients met that definition, and many of those because they used alcohol to some degree with their opiate medication.

We can quibble about whether or not four percent is rare, but I think we can agree that four percent could be considered quite uncommon. Indeed, there is literature on cancer pain pseudo-addiction: patients who exhibit behaviors of addiction not because they are addicted to pain medications, but because their cancer pain is not adequately managed and they are simply seeking relief of their symptoms.

We recognize that cancer patients can and do exhibit addictive behaviors, and as physicians we need to prescribe opiates in a fashion that both is effective in managing their pain while limiting the risk, however slight, that we might foster narcotic dependence. Oncologists and palliative care physicians are trained to evaluate pain and its causes — tumor infiltration into organs, damaged nerves and nerve endings, cancer treatment-associated pain, and pain that is not directly cancer- or cancer treatment-related, such as constipation. Each scenario is different, and many may respond to treatment without using opiates. But opiate treatment will remain critically important, because it works well, and may be the only effective treatment for cancer pain.

What can we do?

Use opiate medications when truly needed and at appropriate doses.

Encourage the pharmaceutical industry to produce medications that enhance pain relief while reducing the risk of addition and discourage this industry from its past marketing practices

Have physicians work with their patients to establish realistic and acceptable goals for pain relief and patient function.

Explore other approaches to pain relief — physiotherapy, acupuncture, hypnosis.

Urge our legislators to modify their current opiate crisis approach to achieve the goals of both reducing opiate usage while avoiding placing cancer patients at risk for poorer symptom control.

Dr. Wilson Mertens is Medical Director and Vice President, Cancer Services Baystate Regional Cancer Program, based in Springfield. This column, in which health professionals from Baystate address issues related to cancer, runs monthly.

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