Opioid Prescribing in an Opioid Crisis: What Basic Skills Should an Oncologist Have Regarding Opioid Therapy?
Although clinical evidence supports the use of opioids for cancer-related pain, doing so amidst the current opioid crisis remains a challenge. A proportion of opioid-related deaths in the USA are attributable to prescription opioids, which implicates health care providers as one of the major contributors. It is therefore even more important now for all clinicians to follow safe and effective opioid prescribing practices. Oncologists are often in the frontline of cancer pain management. They are encouraged to use validated tools to screen all patients receiving opioids for high risk behaviors. Those identified as high risk for potential abuse of opioids should be monitored closely. When aberrant behavior is detected, the clinician will need to openly discuss the issue and its possible implications. Oncologists may then implement measures such as limiting the dose and quantity of opioids prescribed, shortening interval between follow-ups for refills to allow for increased monitoring, setting boundaries/limitations, weaning off opioid analgesics, or/and referring to a pain or palliative medicine or drug addiction expert for co-management when necessary. These efforts may aid oncologists in safely managing cancer pain in the environment of national opioid crisis.
KeywordsOpioid crisis Pain Aberrant
Compliance With Ethical Standards
Conflict of Interest
Joseph Arthur and Akhila Reddy declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 2.•• Arthur J, Bruera E. Balancing opioid analgesia with the risk of nonmedical opioid use in patients with cancer. Nat Rev Clin Oncol 2018. Gives an up-to-date in-depth description of the topic.Google Scholar
- 3.•• CDC NCfHS. Wide-ranging online data for epidemiologic research (WONDER). 2017; http://wonder.cdc.gov. Accessed May 7, 2018. Provides relevant current data on the epidemiology of the opioid crisis.
- 5.Report of the President’s Commission on Combating Drug Addiction and the Opioid Crisis. November 1, 2017. 2017; https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf. Accessed 01/18/2019.
- 6.Drug Enforcement Administration DoJ. Schedules of controlled substances: rescheduling of hydrocodone combination products from schedule III to schedule II. Final rule. Fed Regist. 2014;79(163):49661–82.Google Scholar
- 7.ASCO Policy Statement on Opioid Therapy: Protecting access to treatment for cancer-related pain. 2016:16. http://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/2016_ASCO%20Policy%20Statement%20on%20Opioid%20Therapy.pdf. Accessed 01/24/2017.
- 8.Commision TJ. Pain management 2018; https://www.jointcommission.org/topics/pain_management.aspx. Accessed May 28, 2018.
- 10.Lipari RN, Hughes A. How people obtain the prescription pain relievers they misuse. The CBHSQ report. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013;1–7.Google Scholar
- 12.Hughes A, Williams, M. R., Lipari., R. N., Bose, J., Copello, E. A. P., & Kroutil, L. A. Prescription drug use and misuse in the United States: results from the 2015 National Survey on Drug Use and Health. 2015; http://www.samhsa.gov/data/sites/default/files/NSDUH-FFR2-2015/NSDUH-FFR2-2015.htm. Accessed 5/12, 2018.
- 13.Schroeder AR, Dehghan M, Newman TB, Bentley JP, Park KT. Association of opioid prescriptions from Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA Intern Med. 2018.Google Scholar
- 14.Howard R, Fry B, Gunaseelan V, et al. Association of Opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg. 2018:e184234.Google Scholar
- 17.Prevention CfDCa. Annual surveillance report of drug-related risks and outcomes — United States, 2017. 2017; https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf. Accessed 06/25, 2018.
- 19.•• Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. JAMA. 2016;315(15):1624–45. A very useful opioid prescribing guideline for clinicians.Google Scholar
- 22.Passik SD, Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 1: prevalence and diagnosis. Oncology (Williston Park). 1998;12(4):517–21 524.Google Scholar
- 23.• Arthur JA, Edwards T, Lu Z, et al. Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic. Cancer. 2016;122(23):3732–9 Provides current information about aberrant opioid use in cancer patients.CrossRefGoogle Scholar
- 25.Carmichael AN, Morgan L, Del Fabbro E. Identifying and assessing the risk of opioid abuse in patients with cancer: an integrative review. Subst Abus Rehabil. 2016;7:71–9.Google Scholar
- 28.Koyyalagunta D, Bruera E, Engle MP, et al. Compliance with opioid therapy: distinguishing clinical characteristics and demographics among patients with cancer pain. Pain Med. 2018;19(7):1469–77.Google Scholar
- 33.American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Washington: American Psychiatric Association; 2013.Google Scholar
- 36.• Scholten W, Simon O, Maremmani I, et al. Access to treatment with controlled medicines rationale and recommendations for neutral, precise, and respectful language. Public Health. 2017;153:147–53 Provides alternative suggestions to common terminologies in describing the problem.CrossRefGoogle Scholar
- 40.•• de la Cruz M, Reddy A, Balankari V, Epner M, Frisbee-Hume S, Wu J, et al. The impact of an educational program on patient practices for safe use, storage, and disposal of opioids at a comprehensive cancer center. Oncologist. 2017;22(1):115–21 Demonstrates the importance of opioid education.CrossRefGoogle Scholar
- 62.Prescription drug monitoring program training and technical assistance center. http://www.pdmpassist.org/content/state-pdmp-websites. Accessed 10/01, 2017.
- 70.Defense USDoVAUSDo. VA/DoD clinical practice guideline for opioid therapy for chronic pain 2017; www.healthquality.va.gov/guidelines/Pain/cot/. Accessed May 9, 2018.
- 77.•• Gomes T, Juurlink DN, Antoniou T, Mamdani MM, Paterson JM, van den Brink W. Gabapentin, opioids, and the risk of opioid-related death: a population-based nested case-control study. PLoS Med. 2017;14(10):e1002396 Provides new and relevant data on the concurrent use of gabapentin and opioids.CrossRefGoogle Scholar
- 80.• Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245–52 One of the very few recent studies demonstrating the benefits of naloxone use in opioid prescribing practice.CrossRefGoogle Scholar
- 83.Mishra SI, Scherer RW, Snyder C, et al. Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database Syst Rev. 2012(8). https://doi.org/10.1002/14651858.CD008465.pub2.
- 85.Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni PA. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database Syst Rev. 2011;3:CD007519.Google Scholar
- 87.•• Arthur J, Edwards T, Reddy S, et al. Outcomes of a specialized interdisciplinary approach for patients with cancer with aberrant opioid-related behavior. Oncologist. 2018;23(2):263–70. This article describes a novel way of addressing aberrant opioid behavior in cancer patients.Google Scholar