Opioid Dependence In Cancer Patients: What Can Be Done?

The Use of Opioids in the Treatment of Cancer Pain

The opioid crisis is one of the most serious public health issues of our day, and it is now the top cause of unintentional death in the United States. Opioid prescriptions provided by doctors to help patients manage their pain are mostly to blame for the crisis. In fact, 259 million prescriptions for opioid pain medication were written in 2012, enough for every adult in the United States to have a bottle of pills. Health care providers are increasing their efforts to limit prescribing and prescribe in a safe and conscientious manner as our country begins to grasp how these prescribing behaviors fostered the opioid epidemic. But what about those who are afflicted with cancer? There are more than 14 million cancer survivors in the United States as a result of advances in cancer treatment, and an estimated 40% of these cancer survivors will continue to experience persistent pain, either as a result of the cancer itself, the cancer treatment, or other pain unrelated to the cancer. Is it OK for these cancer patients to be given opioids? Is it possible for them to become addicted to opioids? Is it possible that limiting opioid prescriptions would be cruel and make their misery worse? When a person is diagnosed with cancer, patients and their families should ask all of these questions. Many individuals who have been diagnosed with cancer may require opioid drugs to help them manage their discomfort. Patients should not feel compelled to endure discomfort in order to prevent developing an opiate addiction. Their suffering must be addressed.

At the same hand, just because a person has cancer does not mean they are any less prone than the general population to acquire an addiction. 20 percent of cancer patients, like everyone else who is administered opioids, are at risk of developing an addiction. Addiction can impact everyone, regardless of age, gender, race, ethnicity, socioeconomic level, or even a diagnosis like cancer.

So, how do doctors and patients approach cancer pain management in a safe manner? "Recognize the underlying cause of the pain first," says Dr. Talia Lewis, a Palliative Care physician in Boston who helps patients and their families make treatment options based on the patient's goals of care. "Opioids, in combination with other treatments, may help relieve pain in some cancer patients. Opioids are frequently unnecessary for other illnesses." Opioids may be helpful in the following situations for individuals who have been diagnosed with cancer but are not in need of end-of-life care:

• Directly related to the spread of cancer is pain (such as spreading to bone or the bowels, causing constipation)

• Pain that develops as a result of a surgical procedure

• Pain experienced as a result of chemo or radiation therapy treatments (this does not include nerve pain)

The pain in each of these illnesses is "acute," which means it will only last a short time and then go away. Opioids may be beneficial during this time. Unfortunately, patients are frequently started on opioids to manage these diseases, but the opioids are not withdrawn when the condition improves, putting them at a higher risk of developing an addiction.

Then there are conditions that only require opioids to treat pain on a rare occasion, such as: (7)

• Cancer therapies such as chemotherapy and radiation therapy can cause peripheral neuropathy ("pins and needles"/nerve pain sensations).

• Chronic pain that isn't caused by cancer

• Acute soft-tissue pain, such as in the muscles, tendons, or ligaments (like back pain or shoulder pain)

• Procedures that are minor (like dental procedures)

Pain Management Alternatives to Opioids

Patients should focus on other medications or tactics (rather than opioids) to assist control their pain in these situations. "Regardless of the disease, we know that there are a LOT of ways that assist patients control their pain that work extremely well and are safe for patients," Dr. Lewis says. Before turning to narcotics, we should investigate these alternatives."

There are a number of medications that can help with various forms of pain, including:

• Ibuprofen, naproxen, advil, and aleve are examples of non-steroidal anti-inflammatory drugs (NSAIDs).

• Acetaminophen is a pain reliever (tylenol)

• Voltaren gel (a topical anti-inflammatory gel), lidocaine patches or ointments are examples of topical products (that provide localized numbing to an area of pain)

Other types of drugs that aren't opioids but can help with nerve pain and chronic pain in general include:

• Duloxetine and venlafaxine are examples of selective norepinephrine receptor inhibitors (SNRIs).

• Gabapentin and lyrica are two examples of nerve medicines.

• TCAs, such as amitriptyline and nortriptyline, are tricyclic antidepressants.

Non-pharmaceutical treatments that can help with various forms of pain include:

• Physical therapy is a type of treatment that is used

• Using water as a therapeutic (water-based)

• Acupuncture

• Injections of steroid

• Yoga and tai chi are two examples of exercises.

• Ice & Heat

It is critical for the patient to understand that the purpose of all of these techniques is NOT to eradicate pain. "That is usually not a realistic aim," says Dr. Lewis. Rather, the goal should be to help patients manage their pain in a way that allows them to achieve their functional goals, such as walking their dog, doing chores, or sitting for two hours to watch their son play baseball."

Addressing patients' mental health is also a crucial part of treating pain, whether or not it is related to cancer. Patients frequently suffer from anxiety or depression, which can be exacerbated when they have been diagnosed with cancer, are having treatment, and are uncertain about their prognosis. Talking to a therapist and adopting good coping mechanisms are critical components of their overall health plan. Dr. Lewis and others who care for cancer patients urge for a multidisciplinary approach that includes the patient's main care physician, cancer doctor, palliative care doctor, therapist and/or psychiatrist, physical therapist, pharmacist, and social workers or case managers, among others. The broader team can assist patients manage their mood, acquire non-pharmacological pain treatment services, and coordinate their care by working together to determine the origin of the patient's pain and choose the best treatment options.

How To Use Opioids Safely To Manage Pain

If opioids are chosen, there are a number of things that can be done to optimize benefits while minimizing side effects:

Based on the etiology of the pain, it should be obvious who is providing opioid drugs and for how long.

Patients should be re-evaluated on a regular basis to see if and when they should discontinue using opioid medications.

Opioid-related adverse effects, such as constipation, respiratory changes, mental clouding, and an increased risk of falling, should be monitored and addressed. Urine drug testing, the prescription drug monitoring program, and signing and adhering to pain treatment agreements should all be used to ensure patient safety and appropriate medication use.

In addition, the opioid medication should be kept in a safe and secure location. If an opioid addiction develops (with medications like buprenorphine/naloxone (Suboxone), methadone, or naltrexone), patients at higher risk for developing addiction, such as those with a personal or family history of addiction and mental health conditions, may require more support, monitoring, and treatment.

Patients with advanced cancer who are nearing the end of their lives may require opioids to help manage symptoms like discomfort, shortness of breath, and cough. When this happens, the attention turns away from addiction monitoring and toward keeping the patient as comfortable as possible. In these situations, the patient and their family should collaborate with Palliative Care and Hospice Services to honor the patients' preferences and aspirations and, as a result, develop an appropriate care plan.

In conclusion:

Cancer patients are frequently in discomfort.

A multidisciplinary treatment team should collaborate with the patient to determine the underlying cause of pain and develop a thorough treatment plan that incorporates both drug and non-pharmaceutical approaches. Medication and non-medication approaches that do not require opioids are used as first-line therapies. Patients with cancer may require opioids to appropriately handle their pain in certain circumstances. The length of treatment should be determined by the underlying reason of their discomfort, and medication should be discontinued after the problem has been resolved. Patients with cancer are at risk of developing an addiction to opioids, thus their safety must be closely monitored. The management plan for cancer patients towards the end of their lives would most likely change to comfort measures based on the patients' goals of care, which may include the liberal use of opioid drugs.