William Dale, MD, PhD
It wasn't too many years ago that the primary concerns related to pain management for patients with cancer revolved around whether they were getting adequate relief. Now, with the United States in the throes of an opioid epidemic, the use of these powerful and addictive pain relievers for patients with cancer is coming under unprecedented scrutiny.
Major cancer centers are examining their current protocols to develop new ways to manage pain with shorter courses of opioids— or, if appropriate, with nonopioid approaches. Oncologists are increasingly being advised to assess patients for their risk of developing opioid dependence and monitor them for signs of abuse.
As more patients achieve long-term survivorship, the need for better management of pain medication will become more pressing, Alison Wakoff Loren, MD, MSCE, noted recently in a perspective for the New England Journal of Medicine
“Oncologists are accustomed to giving opioids, but we must also be comfortable taking them away and sometimes giving them in limited doses or not at all,” wrote Loren, an associate professor of medicine in the Division of Hematology/Oncology at the Hospital of the University of Pennsylvania in Philadelphia. “We need to be aware of risk factors for substance use disorders and tools for preventing and addressing them… Although many cancer survivors live with chronic health issues caused by their treatment, opioid addiction should not be one of them.”
Dimensions of the Epidemic
The emphasis on opioid prescribing practices in cancer care comes amid a grim litany of statistics about the nation’s drug abuse problems. Prescription opioids have been identified as significant contributors to the overdose epidemic. The Centers for Disease Control and Prevention (CDC) reports that more than 35% of all US opioid overdose deaths in 2017 involved a prescription.2
In 2018, JAMA Network Open
published a serial cross-sectional study that found that the percentage of deaths in the United States attributed to opioids rose 292% between 2001 and 2016.2
That increase, from 0.4% (1 in 255) to 1.5% (1 in 65), represents 1.68 million years of life lost. During the same period, the rate of US opioid-related deaths increased from 3.3 to 13.1 deaths per 100,000.3
The age group bearing the highest burden was adults aged 25 to 34 years; in this age group, 1 in 5 deaths in the United States is now opioid related. However, adults aged 55 to 64 years, the most likely age group to be coping with cancer, experienced the largest relative increase in the proportion of deaths attributable to opioods, with an increase of 754%, from 0.2% to 1.7%.3
But what about opioid-related deaths and addiction among patients with cancer? Several medicines commonly used to treat cancer pain, including fentanyl, hydrocodone, methadone, morphine, and oxycodone, were among the drugs most frequently involved in fatal overdoses in the United States from 2011 to 2016, according to the CDC’s National Center for Health Statistics.4
However, there are few statistics on the incidence and impact of opioid abuse among patients with cancer. Findings from a study presented at the American Society of Clinical Oncology (ASCO) 2018 Quality Care Symposium showed that patients with cancer were less likely to die of an opioid overdose than the general population. Nevertheless, the incidence of these deaths rose over a 10-year period.5
Meanwhile, results from other studies indicate that many patients with cancer face a high risk of misusing prescription opioids. Investigators at The University of Texas MD Anderson Cancer Center in Houston found that 29% of 522 patients whose charts they reviewed were at high risk for opioid misuse. Patients with scores ≥4 on the Screener and Opioid Assessment for Patients with Pain-Short Form were more likely to be younger than 55 years, have a higher morphine-equivalent daily dose, and report more feelings of pain, depression, and anxiety.6