With nearly 16 million long-term cancer survivors, the treatment and care of patients with cancer has changed. But long-term cancer survivors may be plagued by chronic pain sequelae. To help these patients, researchers have identified the potential of strong opioid analgesics when they have advanced cancer and pain. [1]

Although opioids, when used responsibly for cancer associated pain, are beneficial to help vulnerable patient population cope, over 40,000 Americans died due to opioid overdose in 2016.

Hence, in the midst of the national opioid epidemic, it’s good to revisit what can be done to limit opioid abuse.

Two new studies explore opioid use in cancer care. The studies compared opioid deaths among cancer patients to the general population and looked at an initiative to reduced opioid use after oncology surgeries.

The findings of these studies will be presented at the American Society of Clinical Oncology?s (ASCO) upcoming Quality Care Symposium, taking place September 28?29, 2018 in at the JW Marriott Phoenix Desert Ridge in Phoenix, Arizona.

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In the first study, the authors find that cancer patients were 10-times less likely to have deaths attributed to opioid use than the general population.

The data come from a retrospective study from researchers at Duke University conducted between 2006 and 2016. This is the first study to comprehensively explore the risks associated with opioid use among cancer patients.[2]

“Patients with cancer often rely on opioids to help manage their pain during treatment and to live comfortably with the disease. Without adequate pain management, patients can be forced to take breaks from lifesaving therapy or become hospitalized due to the side effects of treatment,” said Fumiko Chino, MD, lead author of the study and a radiation oncologist with the Duke Cancer Institute.

“This study should provide both oncologists and patients with some reassurance that opioids can be a safe and effective option for managing cancer-related pain.”

Statistical data
To determine the number of opioid deaths among patients with cancer, researchers evaluated death certificates from the National Center for Health Statistics where opioids were listed as the primary cause of death and cancer was noted as a contributing cause.

For the general population, they reviewed certificates where opioids were listed as the primary cause but cancer was not mentioned. Chino notes that a limitation of this study is that the certificates did not provide any indication of the stage of cancer or treatment status at death. In addition, recent evidence suggests that opioid-related overdose deaths may be under-reported on death certificates because of incomplete cause-of-death reporting, indicating that the actual number of opioid-related deaths may be higher than they appear.

Cancer patients vs. general population
According to the death certificates, from 2006-2016, there were 895 deaths caused by opioids in cancer patients, compared to 193,500 in the general population. Researchers found that the incidence of opioid deaths increased significantly in the general population (from 5.33 to 8.97 per 100,000 people) but only slightly among patients with cancer (from 0.52 to 0.66 per 100,000). Deaths from opioid use were highest in patients with lung (22%), gastrointestinal (21%), head and neck (12%), hematological (11%), and genitourinary (10%) cancers.

Chino and colleagues noted that further research should explore how regulations to address the opioid crisis are affecting access to opioids for patients with cancer and the ability of their physicians to prescribe these medications to help manage cancer-related pain.

Reduced Opioid Use
In a second study, conducted by a team of Stanford Health Care, researchers achieved a 46% reduction in opioid use among 443 patients with cancer who underwent a range of urologic surgeries without increasing their pain or anxiety. [3]

The researchers succeeded this reduction through a two-pillared approach which includes: maximizing the use of over-the counter (OTC) non-opioid therapies, and changing the nature of post-surgery discussions with patients.

Risk of addiction
“While opioids can be an effective pain management tool for cancer patients, there is a risk of addiction, particularly for people who have recently undergone surgery,” said lead author Kerri Stevenson, a nurse practitioner at Stanford Health Care.

“We found that when you have conversations with patients about pain control, including non-opioid therapies available and the potential risks associated with opioids, they appreciate being involved in their own care, and, subsequently, have a reduced need for opioid medications.”

Acute Pain Management
Many patients first encounter opioids when they are prescribed for acute pain management after surgery, and an estimated 6% of patients who are not regular opioid users become newly addicted to these medications post-surgery.

Non-opioid medications
The first pillar of the researchers? strategy entailed developing care pathways for post-operative pain control utilizing non-opioid medications and therapies as first line. This included educating providers and nurses about the availability and efficacy of the treatment plans. Patients were still prescribed opioids but at lower doses and only escalated if necessary.

The second pillar involved changing postoperative conversations with patients.

Rather than having nurses routinely asking patients whether they wanted any pain medication, referring to opioids, they discussed the current non-opioid medications patients were receiving for pain, along with their frequency and dosage, and asked whether those medications were sufficient.

In addition, the care team was trained to discuss the potential side effects of opioids of which patients may not be aware.

The authors developed these processes after reviewing daily opioid use, pain scores, and anxiety scores for patients recovering from surgery for urologic cancers over a four-month period (from November 2017 to March 2018) and analyzing the factors contributing to excessive opioid use.

They also designed pain regimens using varying combinations of non-opioid medication using varying combinations of acetaminophen, ketorolac, gabapentin, and local anesthetics.

Noteworthy is that this reduction in opioid requirements was successfully achieved across multiple surgery types ranging from robotic prostatectomy (55.1 morphine equivalent daily dose or MEDD) to open radical cystectomy (50.6 MEDD).

Researchers found that after the new processes were put in place, there was no increase in pain and anxiety among patients in the 24- and 48-hour window post-operation, compared to the previous approach.

“With the new approach, opioids were never withheld, but they were no longer the automatic default for patients and providers,” Stevenson said.

However, over the course of study, which involved 443 patients, the median opioid use per patient decreased 46% from 95.1 to 51.5 MEDD.

“Our study shows that it?s possible to decrease patients? reliance on opioids after surgery, and that healthcare providers have an important role to play in the nationwide effort to combat the opioid epidemic,” she added.

The authors believe their approach could be applicable to other types of surgeries in various diseases, but that it would need to be tested under different circumstances and with a greater number of patients.

Solid evidence
“There?s now solid evidence to suggest that people with cancer are at a lower risk of death related to opioid use than the general population, which is important information for physicians to have as they prescribe pain treatment for their patients,” noted William Dale, MD, PhD, and ASCO expert and member of the Quality Care Symposium Team.

“At the same time, opioids can be addictive, so we should find alternatives and welcome new approaches to reduce their use, especially immediately after surgery. Essentially, we need to balance the need for opioids in patients with cancer that have high symptom burdens with the dangers of overdosing when we consider policies and use them thoughtfully.”

[1] Driver L. Opioid Prescribing and Cancer Pain ? Contemporary Challenges. OncoZine. September 3, 2018.
[2] Chino FL, Kamal A, Chino JP. Opioid-associated deaths in patients with cancer: A population study of the opioid epidemic over the past 10 years. J Clin Oncol 36, 2018 (suppl 30; abstr 230).
[3] Stevenson K, Kee J, Van Zyl E, Dugala A, Shah JB Reducing opioid utilization after urologic oncology surgery. J Clin Oncol 36, 2018 (suppl 30; abstr 269)

Last Editorial Review: September 25, 2018

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