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.
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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
