Opioid Epidemic Response May Restrict Cancer-Related Pain Management – January 2018 by Leah Lawrence
In response to what many are calling an opioid epidemic, the CDC issued guidelines for limiting prescribing of opioids and many state legislatures have passed or are in the process of passing laws limiting opioid prescriptions.
Although much of the response to the opioid epidemic exempts treatment for cancer-related pain, a recent Oncology Nurse Advisor online survey showed that more than 80% of respondents were concerned about how current restrictions set up to manage the opioid crisis are affecting cancer patient pain management.
“What we are seeing is more and more difficulty for our patients in getting their pain medicine,” said Ann Brady, MSN, RN-BC, CHPN, a symptom management care coordinator at Cancer Center Huntington Hospital in Pasadena, California. “In the past, a physician could write an order for an opioid and the patient could fill it. Now there are a lot more hoops to jump through.”
As the number of people with cancer increases so too will the number of people living with cancer-related pain. An estimated 4 in 10 cancer survivors live in some degree of pain, and 5% to 10% have severe chronic pain.
Pain related to cancer is dynamic. Patients with cancer can experience pain related to the tumor itself. A tumor growing in an organ may stretch the part of the organ, causing pain. Tumors that metastasize to bone or to the spinal cord or a nerve can also cause pain.
However, cancer-related pain can also be due to cancer treatment. Patients undergoing surgery, radiation therapy, chemotherapy, bone marrow transplant, or hormonal therapy can experience a variety of types and degrees of pain that may be long-lasting.
According to Dr. Conway, opioids may be considered for cancer-related pain in several settings including short-term use in patients with pain due to treatment, and for the treatment of patients with advanced disease who are experiencing significant pain.
Unfortunately, since the recognition of and response to the growing opioid epidemic, both Dr. Conway and Ms. Brady have begun to face difficulties in getting their patients their pain medication.
Opioid Epidemic Response
“These opioid restrictions are supposed to carve out for cancer pain, and I think technically they do, but on a practical level it does not always work that way,” Ms. Brady said.
“Most people’s understanding of opioids is related to the crisis and often doesn’t distinguish between cancer pain and other pain.”
Ms. Brady has seen these effects in her day-to-day care for patients. For example, some insurance companies and pharmacies are responding to the opioid crisis by being more restrictive with pain medications, she said. Brady will often have to call insurance companies and speak with several rounds of representatives in order to obtain insurance coverage for a patient to receive the type, strength, or length of opioid prescription necessary for their pain.
“This can be very frustrating and time-consuming because sometimes we are making changes to pain management treatment on a day-to-day basis,” she said.
Dr. Conway has also encountered these issues, adding that some insurance carriers will not authorize coverage beyond emergency 3-day or 7-day prescriptions.
Ms. Brady has also heard from patients that even once an opioid prescription is approved by their insurance carrier, they may still run into issues when they go to a pharmacy to fill the prescription.
“If a physician writes for 90 pills and the pharmacy says they only have 30 pills in stock, the patient may only get 30 pills and will not be able to come back to get the remainder of those pills,” she said.
“That is inadequate pain control,” Dr. Conway points out. “This can lead to patients rationing out their pain medication, and in between pills they are suffering.”
He speaks as though only cancer patients suffer from untreated pain. What about all the rest of chronic pain patients now desperately rationing out their own pain medication? Why is it OK for them to suffer between pills?
Ms. Brady said she has also heard of pharmacies requiring that opioid prescriptions be picked up in person by the patient. “For some patients with cancer that is a huge burden.”
Opioid addiction is still a concern in patients with cancer, especially as more and more patients continue to survive beyond 10 years. According to Dr. Conway, that means the prescribers must carefully weigh the pros and cons of these medications.
“If I am treating a patient with advanced, terminal disease, and I know that patient is likely addicted to the medication, am I going to fight the patient knowing that their time is limited and they have no other way to survive but on pain medication? No,” Dr. Conway said.
Non-Opioid Pain Management
Ms. Brady is also a big proponent of integrative therapy. “The clinic where I work has an acupuncturist, a massage therapist, and someone who does classes on mindfulness, and while patients are in the hospital there is music therapy, pet therapy, and a variety of other things available,” she said.
“However, a lot of times these things may help, but will not be a complete fix.”
According to Dr. Conway, oncology nurses, advanced practitioners, and physicians have a responsibility to provide all types of supportive services for patients with cancer experiencing pain.
“That starts with assessing patients individually and not grouping everyone into one category,” Dr Conway said.
“An individualized approach to care means
- understanding what type of pain they have,
- their goal of management, and
- what long-term outcomes we are seeking.”