Anaheim, CA—The United States may be in the midst of an opioid epidemic, but the undertreatment of pain remains an issue for patients with cancer. US healthcare providers wrote 259 million prescriptions for opioids in 2012, enough for every adult in the country, but approximately 50% of patients with cancer continue to report pain (van den Beuken-van Everdingen MH, et al. Ann Oncol. 2007;18:1437-1449), said Julie Waldfogel, PharmD, CPE, Clinical Pharmacy Specialist, Pain and Palliative Care, Johns Hopkins Hospital, Baltimore, MD, at the 2017 Hematology/Oncology Pharmacy Association Annual Conference, who cited a 2007 study by van den Beuken-van Everdingen and colleagues.
This pain does not end with the disease. In the same study, 33% of cancer survivors reported dealing with constant pain after curative treatment.
To help grapple with these contradictions, Dr Waldfogel focused on the recent Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain. The CDC guidelines specifically exclude patients with cancer who are receiving active treatment, palliative care, or end-of-life care. Only cancer survivors with chronic pain who have completed treatment, who are in clinical remission, or who are under cancer surveillance are included in the guidelines.
Educate Patients on Risks and Benefits of Therapy
It is important to educate patients about the risks and benefits of opioid use before starting opioid therapy, but provider responsibilities should be considered as well, said Dr Waldfogel. For patients receiving long-term opioid therapy, multiple groups recommend the use of treatment agreements—a document signed by the patient and the clinician that outlines the responsibilities and expectations of both parties.
However, the effectiveness of these agreements is equivocal, said Dr Waldfogel. Although primary care providers report improved satisfaction and comfort in managing patients with chronic pain when using treatment agreements, a systematic review revealed weak evidence supporting the effectiveness of opioid treatment agreements in reducing opioid misuse (Starrels JL, et al. Ann Intern Med. 2010;152:712-720).
“Most studies that have evaluated effectiveness say they simply make providers feel better about themselves,” said Dr Waldfogel. “Don’t ask patients to sign a treatment agreement as part of general paperwork. Instead, talk to patients separately about the contract, and use it as an opportunity to provide education,” she advised.
Risk Screening Tools
The CDC also recommends that providers evaluate risk factors for opioid-related harms and mitigate such risk. There are several risk screening tools available to screen patients before and during opioid treatment.
“These tools are not time-consuming, ranging from 3 minutes to 15 minutes or less, but can be useful as a part of risk stratification,” said Dr Waldfogel, who stressed that the point of risk stratifying is to “do something different based on which strata your patients are in.”
“Reassessment is essential as a patient’s risk stratification can change over time,” she added.
In addition, the CDC recommends reviewing prescriptions with Prescription Drug Monitoring Programs, which are statewide electronic databases on controlled substance dispensing. These are only state-specific, said Dr Waldfogel, but legislation is progressing for states to share these data.
Finally, per the CDC, providers should use urine drug testing before starting opioids and at least annually, she said.
“You don’t need to apply all of these ideas, but be open to the idea that some of these will apply,” concluded Dr Waldfogel.