Since 1999, the opioid epidemic has claimed the lives of more than half a million people in the United States.1
Laws have been passed to limit the public’s access to opioids, but these laws may inadvertently affect patients who rely on prescription opioids to manage pain, particularly patients with cancer.2,3
“Opioids are often the mainstay of cancer pain management,” said Mamta Bhatnagar, MD, of UPMC Hillman Cancer Center in Pennsylvania, who noted that pain is common among cancer patients and survivors.
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Several recent studies have explored patterns of opioid use and misuse in these patients.
Opioid Use in Cancer Patients
In a study published earlier this year, Sabik et al analyzed cancer registry data and electronic health records to determine predictors of and trends in opioid prescribing for patients with cancer during the 12 months after diagnosis.4
The sample included 5649 patients with breast cancer, 2083 with colorectal cancer, and 2654 with lung cancer. These diagnoses collectively comprised more than 36% of new cancer cases in the United States in 2020.
The results demonstrated variable opioid prescription rates by cancer type: 35% in breast cancer, 37% in colorectal cancer, and 47% in lung cancer.
Patients with a history of opioid use before diagnosis were up to 5 times more likely to receive opioids after diagnosis, which suggests that “pain among patients with cancer may commonly include non-cancer-related pain,” the authors wrote.
In a study published in 2020, Jairam et al observed higher rates of prescription opioid use among cancer survivors than among patients without cancer.5 However, rates of opioid misuse were comparable between more recent survivors (3.5%), less recent survivors (3.0%), and participants without cancer (4.3%).
A 2020 study by Vitzthum et al revealed opioid abuse or dependence in 2.9% of more than 100,000 cancer survivors who were military veterans.6
Another study from 2020 by Jairam et al revealed trends in opioid overdose among patients with cancer.7 The results showed a 2-fold increase in the incidence of emergency department visits for opioid overdose between 2006 and 2015.
Predictors of Chronic Use and Misuse
“As much as we don’t like to think about it, opioid misuse is real in this vulnerable and sick population,” Dr Bhatnagar said. “Misuse can include taking too much medicine, taking someone else’s medicine, taking it in a different way than prescribed, or taking the medicine to get high.”
Multiple factors have been linked to an increased risk for chronic use and misuse of opioids in the cancer population. Jairam et al found that younger age, alcohol use disorder, and nonopioid drug use disorder were associated with prescription opioid misuse among cancer survivors.5
A study by Check et al revealed predictors of chronic opioid use in the second year after cancer diagnosis, which included younger age, baseline depression, substance use, and Medicaid coverage vs private insurance.8
Factors associated with an opioid-related emergency department visit included comorbid chronic pain, substance use disorder, and mood disorder.7 Head and neck cancer and multiple myeloma were found to be risk factors for overdose.
Dr Bhatnagar noted that several opioid risk assessment tools have been developed. However, they are not well validated in patients with cancer, may be biased against certain populations, and can be difficult to implement in practice.
Preventing and Addressing Opioid Misuse
“Patients with cancer may have high requirements for opioids for medical reasons, but it is certainly possible to work closely with them to minimize misuse and to use even high doses of chronic opioids in an appropriate fashion,” said Henry S. Park, MD, of Yale School of Medicine in New Haven, Connecticut.
Dr Park noted that even high-risk patients should receive treatment for cancer-related pain when appropriate, and providers should not overlook the potential for opioid misuse in patients with a lower risk profile.
Patients should be advised to avoid sharing medications or visiting multiple physicians for prescriptions, and they should be informed of the office policy on early refills of controlled substances, Dr Bhatnagar said.
“Careful discussions and longitudinal follow-ups with every patient are essential to ensure they are receiving and taking an appropriate amount of opioids for their situation, which may change over time,” Dr Park said. “Regularly scheduled urine toxicology screenings and opioid contracts may be helpful when chronic opioid prescriptions are necessary.”
When a toxicology screen yields a positive result, providers must weigh the risks and benefits of continuing therapy. If a patient screens positive for an illegal substance such as cocaine or heroin, clinicians should discuss the risks of such use and refer the individual for substance abuse treatment, Dr Bhatnagar recommended. Clinicians should discuss findings and concerns regarding drug misuse with patients and their loved ones.
If opioid misuse is detected and opioid tapering is deemed appropriate, the “decision must be made while keeping in mind the disease course, prognosis, and whether all mental health issues have been adequately addressed,” Dr Bhatnagar said. “One can continue to manage pain using nonopioid strategies such as nerve blocks where appropriate and the use of adjuvants for neuropathic and musculoskeletal pains.”
In some cases, patients believed to be misusing opioids do not have an adequate response to nonopioid therapies. For these patients, clinicians should consider weekly prescriptions of opioids and frequent urine drug screenings, according to Dr Park. The use of buprenorphine-naloxone, with or without a pure mu receptor agonist, represents an additional option.9
Challenges and Unmet Needs
Dr Bhatnagar acknowledged the practical challenges involved in detecting and acting on opioid misuse.
“Cancer and its treatment can be devastating, and our instinct is to do everything we can to help patients have a decent quality of life,” she said. However, to allow them to “engage in opioid misuse behaviors as they go through treatment is not the right care for these patients.”
Dr Bhatnagar pointed to the need for improved screening tools for opioid misuse in this population, increased research on and payment for complementary pain management strategies, and further study of pain management approaches for patients with cancer pain and comorbid substance use disorders.
Dr Park emphasized the need to determine whether recent legislation to limit access to opioids is adversely affecting access for patients with cancer-related pain.
“If restrictions are too strict and broad, then policies that minimize opioid use in patients without cancer may affect those who do have cancer,” he said. “Much more nuanced research is needed to determine how these policy changes can affect appropriateness of opioid prescribing among patients in different clinical subgroups.”
Disclosures: Dr Park disclosed receipt of honoraria from RadOnc Questions LLC. Dr Bhatnagar had no relevant disclosures.
References
1. US Centers for Disease Control and Prevention. Understanding the epidemic. Updated March 17, 2021. Accessed June 23, 2022. https://www.cdc.gov/drugoverdose/epidemic/index.html
2. Davis CS, Lieberman AJ. Laws limiting prescribing and dispensing of opioids in the United States, 1989-2019. Addiction. 2021;116(7):1817-1827. doi:10.1111/add.15359
3. Page R, Blanchard E. Opioids and cancer pain: Patients’ needs and access challenges. J Oncol Pract. 2019;15(5):229-231. doi:10.1200/JOP.19.00081
4. Sabik LM, Eom KY, Sun Z, et al. Patterns and trends in receipt of opioids among patients receiving treatment for cancer in a large health system. J Natl Compr Canc Netw. 2022;1-8. doi:10.6004/jnccn.2021.7104
5. Jairam V, Yang DX, Verma V, Yu JB, Park HS. National patterns in prescription opioid use and misuse among cancer survivors in the United States. JAMA Netw Open. 2020;3(8):e2013605. doi:10.1001/jamanetworkopen.2020.13605
6. Vitzthum LK, Riviere P, Sheridan P, et al. Predicting persistent opioid use, abuse, and toxicity among cancer survivors. J Natl Cancer Inst. 2020;112(7):720-727. doi:10.1093/jnci/djz200
7. Jairam V, Yang DX, Yu JB, Park HS. Emergency department visits for opioid overdoses among patients with cancer. J Natl Cancer Inst. 2020;112(9):938-943. doi:10.1093/jnci/djz233
8. Check DK, Baggett CD, Kim K, et al. Predictors of chronic opioid use: A population-level analysis of North Carolina cancer survivors using multi-payer claims. J Natl Cancer Inst. 2021;113(11):1581-1589. doi:10.1093/jnci/djab082
9. Merlin JS, Khodyakov D, Arnold R, et al. Expert panel consensus on management of advanced cancer-related pain in individuals with opioid use disorder. JAMA Netw Open. 2021;4(12):e2139968. doi:10.1001/jamanetworkopen.2021.39968
This article originally appeared on Cancer Therapy Advisor
