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Preventing Opioid Dependence in Cancer Patients

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January 15, 2021

Opioids For Cancer Pain Management

The opioid epidemic is one of the greatest public health crises of our times and is currently the leading cause of accidental death in the US. (1) This epidemic can largely be traced to opioid prescriptions written by physicians to help patients manage their pain. In fact, in 2012, health care providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills. (2)

As our country has begun to realize how these prescribing patterns fueled the opioid epidemic, health care providers are increasing their efforts to limit prescribing and prescribe in a safe and thoughtful manner.

But, what about patients who suffer from cancer?  Because of our advances in cancer treatments, there are more than 14 million cancer survivors in the US, and an estimated 40% of  these cancer survivors will continue to experience persistent pain, either as a result of  the cancer itself, the treatment of the cancer, and/or other pain not related to the cancer. (3,4)

Should these cancer patients be getting opioids?  Can they develop an opioid addiction?  Would limiting opioids prescriptions be harsh and worsen their pain? 

These are all great questions that patients and their families should be asking when someone is diagnosed with cancer. Many patients with cancer diagnosis may need to be on opioid medications to manage their pain.  Patients should not feel like they have to suffer with pain to avoid developing an addiction to opioids. Their pain should be addressed.

At the same time, just because a person has developed cancer does not make them any less likely to develop an addiction than the general population.  Just like anyone else who is prescribed opioids, 20% of patients with cancer are at risk for developing an addiction. (5) Addiction can affect anyone and does not discriminate based on age, gender, race, ethnicity, socioeconomic status, or even diagnosis- such as cancer.

So how do doctors and patients approach pain management for patients with cancer in a safe way?

“What is important in addressing someone’s pain is to first recognize the underlying cause of the pain,”  says Dr. Talia Lewis,  a Palliative Care physician who works in Boston, Massachusetts, and helps patients and their families make treatment decisions based on the patient’s goals of care. “For some cancer conditions, opioids may help alleviate pain alongside other strategies.  For other conditions, opioids are often not needed.”

For patients who have a cancer diagnosis and are not at end of life care, opioids might help in the following situation: (6)

  • Pain directly to the cancer spreading (such as spreading to bone or the bowels, causing constipation)
  • Pain that occurs after a surgical operation
  • Pain that occurs as a result of chemo or radiation-therapy based treatments (this does not include nerve pain)

For each of these conditions, the pain is “acute,” meaning it will last only a certain period of time and should resolve. Opioids may help during this period of time.  Unfortunately, oftentimes patients will be started on opioids to manage these conditions but when their condition resolves, the opioids are not stopped, putting them at higher risk for developing an addiction.

Then, there are conditions that rarely require the need for opioids to manage pain, such as: (7)

  • Peripheral neuropathy (“pins and needle”/nerve pain sensations) related to cancer treatments such as chemotherapy and radiation therapy
  • Chronic pain NOT related to cancer
  • Acute pain in the soft tissues, like the muscles, tendons, or ligaments (like back pain or shoulder pain)
  • Minor procedures (like dental procedures)

Alternatives to Opioids For Pain Management

For these type of conditions, patients should focus on other medications or strategies (and not opioids) that can help manage their pain.

As Dr. Lewis describes, “Regardless of the condition, we know that there are a LOT of strategies that help manage patient’s pain that work very well and are safe for patients.  We should start with these options before considering opioids.”

Medication options that can provide relief from various types of pain include:

  • Non-steroidal anti-inflammatory medications (NSAIDs): ibuprofen, naproxen, advil, aleve
  • Acetaminophen (tylenol)
  • Topical products: voltaren gel (a topical anti-inflammatory gel), lidocaine patches or ointments (that provide localized numbing to an area of pain)

Other classes of medications that are NOT opioids and can provide pain relief for nerve pain and chronic pain in general:

  • Selective norepinephrine receptor inhibitors (SNRIs), including duloxetine and venlafaxine
  • Nerve medications, like gabapentin and lyrica
  • Tricyclic antidepressants (TCAs), like amitriptyline and nortriptyline

NON- medication options that can provide relief from various types of pain include:

  • Physical therapy
  • Acqua therapy (water-based)
  • Acupuncture
  • Steroid injections
  • Exercises like yoga and tai chi
  • Heat & Ice

With all of these strategies, it is important for the patient to understand that the goal is NOT to try to eliminate pain.  As Dr. Lewis explains “That is usually not a realistic goal.  Rather, the goal should be to help patients live with their pain in a way that allows them to meet their functional goals-- such as being able to walk their dog, do housework, or sit for two hours to watch their son’s baseball game.”

Another important component to treating pain, regardless if it is related to cancer or not, is addressing patients’ mental health.  Patients often struggle with anxiety or depression and all of this can be exacerbated when they have a diagnosis of cancer, are undergoing treatment, and when uncertainties about their prognosis can take their toll. Talking to a therapist and learning how to cope in healthy ways is an important part of their overall health plan.

Dr. Lewis, and others who take care of patients with cancer diagnosis, advocate for a team-based approach, which often includes the patient’s primary care physician, their cancer doctor, palliative care doctor, therapist and/or psychiatrist, physical therapist, pharmacist and social workers or case managers.  Physician providers should work together to understand the cause of the patient’s pain and choose the right treatment approaches, and the larger team can help patients address their mood, obtain non-pharmacological pain treatment services, and coordinate their care. 

How To Safely Manage Pain With Opioids

If opioids are chosen, there are several things that can be done to maximize benefits and minimize harms:

  1. It should be clear who is prescribing the opioid medications and for how long, based on the source of the pain.
  2. Patients should be continually re-evaluated to determine if and when to stop the opioid medication. 
  3. Patients should be monitored and treated for opioid-related side effects, such as constipation, changes in breathing, mental clouding, and increased risk for falls. 
  4. Patients should be monitored for safety and appropriate use of the medication through urine drug testing, the prescription drug monitoring program, and signing and adhering to pain treatment agreements. 
  5. The  opioid medication should also be stored in a safe and secure setting.   
  6. Patients at higher risk for developing addiction, such as those who have a personal or family history of addiction and mental health conditions, might need greater support, monitoring, and treatment if an opioid addiction develops (with medications like buprenorphine/naloxone (Suboxone), methadone, or naltrexone). 

For cancer patients who are at the end of their life, they may need opioids to help manage symptoms, such as  pain, shortness of breath, and cough. Under these circumstances, the approach shifts from addiction monitoring to instead focus on making the patient as comfortable as possible.  In these cases, the patient and their family should work with Palliative Care and Hospice Services to honor the patients’ wishes and goals and hence provide an appropriate treatment plan.

In summary:

  • Patients with cancer often have pain.
  • A multidisciplinary treatment team should work together in conjunction with the patient to identify the patient’s underlying cause of pain and provide a comprehensive treatment plan that includes medication and non-medication options.
  • First line treatments include medications and non-medication options that do not involve opioids.
  • Sometimes, for specific conditions, patients with cancer may need opioids to adequately address their pain.  The duration of treatment should be based on the underlying cause of their pain, and the medication should be stopped once the condition resolves.
  • Patients with cancer can develop an addiction to opioids so it is important that patients’ safety is carefully monitored.
  • For patients with cancer at the end of their life, the management plan will likely shift to comfort measures based on the patients goals of care, which may include liberal use  of opioid medications.  A Hospice Service can be helpful in guiding these decisions and the treatment plan.

Bicycle Health

Bicycle Health is a telehealth company that provides treatment for opioid addiction with buprenorphine/naloxone (Suboxone) to patients across the country.

To learn more about the success rates and safety of Bicycle Health’s telemedicine addiction treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment here.

Header Photo by Ivan Samkov from Pexels

Citations

(1) Rudd R, et al. Increases in drug and opioid overdose deaths—United States, 2000–2014. Morbidity and mortality weekly report. 2016.

(2) Paulozzi LJ, Mack KA, Hockenberry JM. Vital signs: variation among states in prescribing of opioid pain relievers and benzodiazepines—United States, 2012. MMWR Morb Mortal Wkly Rep 2014;63:563–8.

(3) Finucane TE, Nirmalasari O, Graham A. Palliative care in the ambulatory geriatric practice. Clin Geriatr Med. 2015;31(2):193-206. doi:10.1016/j.cger.2015.01.008

(4) U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Retrieved from U. S. Department of Health and Human Services website: https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html

(5) Nguyen LM, Rhondali W, De la Cruz M, et al. Frequency and predictors of patient deviation from prescribed opioids and barriers to opioid pain management in patients with advanced cancer. J Pain Symptom Manage. 2013;45:506-516.

(6) Burera E, Del Fabbro E. Patient and Survivor Care Pain Management in the Era of the Opioid Crisis.Society of Clinical Oncology Educational Book 38 (May 23, 2018) 807-812.

(7) Burera E, Del Fabbro E. Patient and Survivor Care Pain Management in the Era of the Opioid Crisis.Society of Clinical Oncology Educational Book 38 (May 23, 2018) 807-812.

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