Addressing Opioid Misuse in Cancer Pain Management

Opioids are powerful pain medications that are also associated with misuse, addiction and overdose. In the U.S., the opioid epidemic has claimed more than 1 million lives to date, and the majority of misused opioids (90%) originate from health care provider prescriptions.

Despite increased regulations on opioid prescriptions, many situations, such as post-surgical pain and cancer-related pain, still require opioids for effective pain management. Unfortunately, any opioid prescription puts patients and their communities at risk for opioid-related complications, such as misuse and diversion.

Two new studies from Columbia University cancer researchers highlight the increased risk that cancer patients face for persistent opioid use. One study measured rates of new and prolonged opioid use in adolescents and young adults with cancer, while the other tested an intervention to reduce the risk for prolonged opioid use following cancer-related surgery and treatment. The studies were led by Dawn L. Hershman, MD, deputy director for Cancer Care Delivery and Research at the Herbert Irving Comprehensive Cancer Center (HICCC) and director of the Breast Oncology program at Columbia University Irving Medical Center, along with first authors Melissa Beauchemin, PhD, MSN, CPNP, and Jacob Cogan, MD. 

The first study, co-led by Dr. Beauchemin, identified the need to better monitor adolescent and young adult (AYA) cancer patients for post-treatment opioid use given the potential negative impact of long-term opioid use for this demographic. The study examined insurance claims data across the U.S. and found that more than half of AYAs with sarcoma, cancer of the bone or soft tissues, were prescribed opioids during their cancer treatment, and nearly one-quarter of these patients continued to use opioids after treatment was completed. The study appeared May 23 in the journal, Cancer.

One of the drivers of opioid misuse is that the majority of opioids prescribed to patients to manage post-operative pain go unused, and the pills that are not used are also not disposed of correctly. The second study, co-led by Dr. Cogan, demonstrated that use of an inexpensive pill-dispensing device with mail-return capacity increased rates of disposal of unused opioids after cancer surgery. The study results will be presented at the annual meeting of the American Association for Clinical Oncology (ASCO) in Chicago, held June 3 to 7.

Dr. Melissa Beauchemin (MB), assistant professor of nursing at Columbia’s School of Nursing, and Dr. Jacob Cogan (JC), postdoctoral clinical fellow of hematology-oncology at Columbia’s Vagelos College of Physicians and Surgeons, discuss the slippery slope of managing pain for cancer patients following surgery or treatment and their increased risk of persistent opioid use.

Why are cancer patients at an increased risk for opioid misuse or addiction?

JC: There have been many efforts to limit opioid use in patients in general because of the opioid epidemic. Cancer patients are one of the remaining populations that are somewhat of an exception—they typically get what they need for pain management, and understandably so because if somebody has metastatic cancer and they're in horrible pain, sometimes only opioids can manage that pain. But this can also lead to some patients with early-stage, curable cancers getting more than they need after a cancer-related surgery.

MB: It’s important to note that there are no clinical practice guidelines that outline pain management for children, adolescents and young adults with cancer. There are adult practice guidelines for pain management, but for younger patients, available guidelines focus on palliative care pain management. In pediatrics, we do not know what the prescribing patterns are like for children and adolescents with cancer. Dr. Cogan did a recent study that found 17% of patients became persistent opioid users after mastectomy (surgical removal of one or both breasts) and reconstruction. That study and others signal this is a potential problem. On the other hand, with this hyper-awareness that opioids are addictive we don't want to under treat pain either. Figuring out what that sweet spot is for high-quality pain management, but high-quality safe pain management is what we’re striving for. 

Are you finding that patients are hesitant to take opioids for their pain?

MB: It varies. There are a lot of patients and/or their families, who don’t want to take opioids and who are terrified of opioids. They might’ve seen a bad outcome or they’re just aware of the dangers of opioid use. I think it's our job to treat the pain but then to make sure that we stop the pain medicine as safely and early as we can, which is exactly what pain specialists do for patients who are in the hospital. This becomes trickier when patients are out of the hospital because there is less support for them, like handling post-surgical pain at home or other treatment-related pain like mucositis, a sore and inflamed mouth or gut and a common side effect to chemotherapy and radiotherapy.

JC: Opioids are a huge problem but at the same time, they are really effective to treat pain, especially severe, short-lived post-surgical pain. We believe that some patients have pain that they suffer with unnecessarily because they're so scared of opioids. So that's what makes this such a difficult balance to strike. How do you encourage someone to take what they need, but also ensure they're not taking so much that they start to get dependent and potentially addicted? 

Are oncologists more aware of how to limit or monitor opioids for their patients’ pain management?

MB: Yes. There's a real trend toward awareness. Even just with our recent paper in Cancer and Dr. Cogan’s upcoming ASCO presentation, there is much more discussion around how we manage pain and not over prescribing or under prescribing. The awareness is there but I think exactly what to do is the challenge.

One of your solutions involves a new pill-dispensing device. Can you tell us more?

JC: It's amazing to think that opioid medications are still prescribed in the same type of pill bottles as any other medication. We have been studying a password-protected pill dispenser that is simple to use, works in tandem with a smartphone app that provides clinical guidance, and overall, creates a more secure, sophisticated way for patients to use this dangerous type of medication. The majority of patients we piloted this device with said having the various safeguards in place made them feel like they weren’t alone; they felt more secure taking the medication because they felt they were being monitored by their doctor. The app helps the patient stick to the right schedule. Hopefully this solution helps patients to better navigate post-operative pain management, especially the ones who are apprehensive about taking opioids in the first place. 

The second piece of this solution is that it addresses the safe return of unused opioids, which is a big contributor to the overall opioid problem.

JC: All the data says that over 90% of the pills that are misused are obtained from a leftover prescription or from a friend or relative. So the idea is basically that these unused pills are really dangerous in the community. When patients are done with the [pill-dispensing] device, and if there's still some pills left, we give them a mailer, and they just drop it in the mailbox and send it back for safe disposal. That gives them a very easy way to get it out of the house and get them disposed of responsibly.

What’s unique about the adolescent and young adult (AYA) demographic when it comes to potential opioid misuse?

MB: They are disproportionately at higher risk of opioid misuse and overdose death than older adults. In the cancer setting, these patients typically receive intensive and multimodal treatment—surgeries, radiation and chemotherapy. With kids, there’s a higher cure rate and they can take higher doses of something like chemotherapy, but they also then experience higher toxicities, ranging from physical symptoms to psychosocial and financial issues from the cost of treatment and care. 

The important thing to think about is how we can develop both provider-facing solutions, such as limiting prescriptions and better pain management guidelines for AYAs, and on the patient-facing side, how can we better educate them about potential substance abuse. We need to focus on how to engage with our younger patients and be better about laying out a plan together so that we can set them up to do as well as possible if they have to take this medication.

What is needed near-term, and long-term, to help cancer patients overall navigate this dangerous terrain?

JC: Pain is such a hard thing to solve. It’s not like blood pressure, it’s sort of subjective and it's hard to measure. I think that's where the issues with opioids come from—it’s difficult to know exactly what pain is for everyone and it's hard for providers to know the right amount of medicine to give people. The way that we deliver this type of care needs to be reformed. We need to reimagine the way that we give pain medicine to people, and provide more support and guidance. It's not really just about using less opioids, it's about using them in a way that is both effective and safe for patients.

MB: As we figure out the strategies and how to potentially support patients, we should think about the precision oncology model, providing individualized care. Let’s take a minute and understand better where the patient is, what their pain is and what is their history of pain. There's a lot of data in addiction medicine and in chronic pain management about how to do this in oncology; we haven't always done this as well but it's there. So if we can just learn how to be better, smarter about prescribing opioids and about pain management and do it more efficiently, effectively and individualized, hopefully then we can set people up for better outcomes. Shame on us if we cure someone of their cancer, but then they become addicted to opioids. There has to be a better way.