Cancer Pain and New Opioid Policies

Dr Bob Twillman Discusses Opioid Risk Assessment in Cancer Pain and New Opioid Policies – April 12, 2018 – Laura Joszt

Typically, cancer pain management is carved out of policies that try to restrict opioid prescribing in an effort to combat the opioid epidemic, but with more and more patients surviving their cancer, there is some uncertainty regarding who is affected by these policies, explained Bob Twillman, PhD, executive director for the Academy of Integrative Pain Management.

The American Journal of Managed Care® (AJMC®):

How does pain management with cancer maybe differ from pain management in patients with other diseases?  

Bob Twillman, PhD (BT):

In many ways, cancer pain management is similar to treating pain in people who don’t have cancer.

There are a few key differences, though.

I think when we’re treating cancer pain, we more often know what is causing the pain than we do in people who have what we call chronic non-cancer pain.

And in a lot of chronic non-cancer pain cases, it’s hard to tell exactly what’s causing the problem from a physical standpoint. And that’s not so true in cancer.

So, there may be a few little differences, but, for the most part, the same principles apply: We still have to identify what the specific type of pain is and tailor our treatment to that type of pain.


With more and more patients surviving cancer, has there needed to be a change in how pain is managed in this population?


Pain in cancer survivors is something that’s really gained more attention over the past few years as survival has increased in people with cancer.

When I began doing cancer pain management 20 years ago, most patients didn’t survive their cancers, and so they had entirely different goals of care.

Now that most patients are actually surviving their cancer experience, we have to look at what’s going to be the best for the long term.

So, we do have to pay greater attention to issues related to substance use disorder.

We also have to pay greater attention to the long-term pain that patients experience as a result of those very treatments that are helping them survive.

Many patients are surviving longer because they’re getting chemotherapies and other treatments that are more neurotoxic, and as a result, they’re winding up with long-term neuropathic pain syndromes that we have to be able to treat effectively.

So as that has been something that’s emerged, the need to treat that pain appropriately and over the long term has really emerged, as well.


How do new policies to combat the opioid epidemic have unintended consequences for patients dealing with chronic pain?


The primary way in which policy makers have so far attempted to deal with the opioid problem in our society is to restrict the prescribing of opioids.

Now, generally, when they’ve instituted policies to do that, they have carved out people who have cancer, they have carved out people who are getting palliative care or hospice or end-of-life care.

So, to some extent, that really shouldn’t be a problem for them, these new policies.

However, what we know is that the way those policies are perceived by prescribers is such that it could have an unintended consequence of causing them to pull back on prescribing for everyone, not just those who may have a predisposition to addiction, but for every patient who gets opioids.

I’m getting tired of hearing about all these horrible and entirely foreseeable, yet supposedly “unintentional”, consequences of the CDC Opioid Prescribing Guideline.

Most pain patients realized right away that these “suggestions” would become codified rules, no matter how little evidence supported them – and we were even more right than we ever imagined.

Now even the United States Congress wants to control our individual medical care by setting standard medication doses for every single US citizen, regardless of age, size, and genetics. There have been bills proposed to enforce the 90MME limit at the national level.

I’ve read all kinds of views supported only by ignorant opinion, financial interests, and the zeal of crusaders, but I can still be shocked by such an appalling idea.

So, we’re concerned that there may be a generalized pull back in prescribing that could unintentionally harm people who really need these medications.

Considering the stated positions of PROP and many of those the guideline authors, the intention was clear to anyone who knew about the fervent anti-opioid beliefs and opinions of the carefully selected people who were allowed to virtually dictate the guideline.

We certainly seeing that happen in people who have non-cancer pain. We get reports all the time from patients who had been doing well on long-term opioid therapy and are having that therapy withdrawn as a result of some of the new policies that have come out. So, we’re concerned that that same thing can happen for people who have cancer, and we’re keeping a close eye on that.

In all pain and opioid discussions and policies, “cancer pain” is endowed with almost sacred status and explicitly granted immunity from all opioid limits – even though there’s no difference between cancer and non-cancer pain.

Without evidence, pain from this particular disease is ranked as far more significant and severe than other pains, which can include spinal injuries, sickle cell disease, cluster headaches, trigeminal neuralgia and countless other grotesquely painful chronic conditions.

And the other thing to consider is: while many of these policies carve out treatment of pain in people who are on active cancer treatment, many of them don’t specifically mention treatment of pain in cancer survivors.

And it’s a little bit unclear at what point treatment of pain in cancer survivors ceases to be cancer pain management and becomes non-cancer pain management.

So, there’s some things we still have to work out in terms of who the policies really do apply to.

Rather than “working out” the details of these grossly biased guidelines, which would just heap convoluted and imprecise conditions onto what is already scientific garbage, let’s throw them out and start over.

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