As opioid abuse in the face of chronic pain becomes a major health concern, pain management for people with cancer is a challenge for providers.
On April 2, 2016, Judith Paice, PhD, RN, FAAN, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, presented safe and effective opioid prescribing, discussing safety concerns, as well as best practices in oncology, during the National Comprehensive Cancer Network® (NCCN®) 21st Annual Conference: Advancing the Standard of Cancer Care™. Dr. Paice is a member of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Panel for Adult Cancer Pain.
The goal of pain control is balance -- balance of pain relief, enhanced function, and safety of the patient, prescriber, and community, explained Dr. Paice. Proper assessment of the patient is the ideal way to ensure safety for all three parties, she said.
Patient assessment not only includes the physical aspects of the pain, but also the effect of the pain on the patient's quality of life; other medications that the patient takes on a regular basis; previous treatments and outcomes; co-morbid conditions, including biopsychosocial, spiritual, and financial conditions; risk for misuse; and the patient's goals for pain care, she said.
Many times, complete pain relief is not possible; however, it is important to work with patients to identify a measureable and attainable goal for progress, such as being able to walk around the block or playing with their grandchildren, she added.
Overtreatment & Undertreatment
As part of the overall balance required for safe opioid prescribing, there is the consideration of two distinct populations: those at risk of overtreatment, as well as those at risk for undertreatment, she said.
"We do not want to lose sight of the need for pain control," she said, noting that there are several populations most at risk for undertreatment for pain including, but not limited to infants and children, the elderly, cognitively impaired patients, non-verbal individuals, and those with good performance status.
On the other hand, patient groups most at risk for overtreatment are long-term survivors; patients with a lack of financial resources; patients with pre-existing substance abuse disorders; and those with co-morbid mental health conditions, such as anxiety, depression, and sleep disorders. The threats of overtreatment include cognitive difficulty, depression, sexual dysfunction, and risk of overdose, said Dr. Paice.
Safe Community & Responsible Assessment
According to the Centers for Disease Control and Prevention, for every one death due to opioid abuse, there are 10 treatment admissions, 32 emergency department visits for misuse or abuse, 130 people who abuse or are dependent, and 825 non-medical users.
Dr. Paice noted that responsible assessment, proper opioid prescribing, and patient counseling can lead to lower abuse within the community itself. Patients must understand the responsibility that accompanies opioids including that these medications should, ideally, be locked up to prevent theft and illegal distribution. Safe disposal is also key, she explained, noting options such as take-back programs.
Responsible assessment includes differential diagnosis of non-compliance and aberrant drug taking behavior, which Dr. Paice separated into five distinct groups:
• Pseudo-addiction, in which the amount of drug ordered is too low or patients have insurance limitations. These patients, she said, tend to display behaviors that are misunderstood as drug-seeking, although they are following dosage allowances.
• Psychiatric disorders, including chemical coping or mood disorders
• Inability to follow a treatment plan due to low literacy, use of pain medication for other symptoms such as sleep deprivation, or anxiety
• Criminal intent
According to Dr. Paice, a number of factors are "red flags" for patients who are at high-risk for addiction, such as current and past misuse of prescription or other street drugs, alcohol use, smoking, family or friends with substance abuse disorder, and sexual abuse, particularly as a child or preteen.
With all groups, she added, there are precautions that prescribers can take to monitor adherence, including urine drug testing, pill counts, and prescription drug monitoring programs.
Treating the Whole Patient
Dr. Paice noted the importance of ensuring that patients with substance abuse disorder are treated not only for their pain, but also for any psychosocial conditions that put them at risk for abuse. In order to do so, Dr. Paice suggested ongoing assessment of the patient with consistent differentiation of misuse and abuse behavior from undertreatment. Finally, she said, it's important to discuss concerns openly with the patient.
A multidisciplinary approach to care following risk stratification is ideal for this patient group; however, there should be one prescriber. This multidisciplinary approach helps ensure that patients are treated for the underlying psychiatric disorders and have treatment tailored to their physical needs. For instance, patients with opioid misuse history may require higher doses of drug, she said.
Clinicians should also consider support systems for this patient population, including family and friends of the patient, increased outpatient visits, or even inpatient or outpatient treatment for addiction, Dr. Paice added.
Measures for Success
When a patient moves from active treatment for addiction to long-term recovery and sobriety, consistent monitoring is essential. Dr. Paice suggested tactics for both clinicians and patients that will help ensure success in the transition period.
Clinicians, she said, should encourage patients to maintain ongoing participation in their recovery through including open communication to help identify stressors for relapse. Also important is to access a support system such as a 12-step program, seek psychiatric support, and an active sponsor, maintain stability in the home and get regular sleep and exercise.
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