Opioids are the go-to treatment for cancer-related pain. But is this mainstay poised to change as the opioid crisis continues to grow?
Opioids are top of mind for many oncology nurses when it comes to managing patients’ cancer-related pain. However, as the opioid epidemic continues to sweep the nation—claiming an average of 130 American lives every day1— healthcare providers must be aware of the risks of these popular painkillers, knowing when to use them, when not to, and how to identify biases, as well as recognizing the warning signs of potential misuse. Armed with thorough documentation and patient communication tools, nurses can be key players in the safe administration of opioids and other analgesics to patients with cancer.
“It’s our moral obligation to treat pain, and suffering is not a desired response at all,” said Tonya Edwards, MSN, MS, RN, FNP-C, a palliative care nurse at The University of Texas MD Anderson Cancer Center in Houston, in an interview with Oncology Nursing News®. “But there is a cascade of issues out there, especially with so many opioid-related deaths.”
Many individuals have biases against opioids and the patients who use them, and oncology nurses certainly are not the exception to this rule. But Edwards stressed that healthcare workers need to put their patients’ pasts aside and always provide the best and most appropriate care.
“It’s unfortunate that patients might have had an addiction issue before, but now they have cancer. So it’s a double whammy,” she said. “We are not here to judge them on whatever happened in the past. They are human. They walk through the door with cancer, and we need to gain their trust and, of course, use our ethical concerns if we have to have an exit strategy and get them off the medicine later.”
Edwards noted that if patients have a history of opioid misuse, healthcare providers will not treat them with opioids in the cancer setting. But regardless of an individual’s history, each patient deserves to be treated with compassionate care, she explained.
Gretchen McNally, PhD, ANP-BC, AOCNP, agrees and says that the language oncology nurses use can have a major impact on perceptions as well as patient care. “For example, someone with an opioid use disorder, is the correct terminology, versus ‘an addict’ or ‘a junkie,’” said McNally, a nurse practitioner at Arthur G. James Cancer Hospital, part of The Ohio State University Comprehensive Cancer Center, in Columbus, in an interview with Oncology Nursing News®. “The first step is just recognizing and [trying] to use different terminology that is more respectful. Try to reframe your perception, which will then influence your practices.”
Improved education is also key in caring for this patient population. “Healthcare providers know that substance use disorders are a medical diagnosis, but I really don’t know that we all understand how much of a chronic brain disease it is,” McNally said. “People can’t really control that at all. So that [recognition] is the first step.”
Oncology nurses can look for specific signs of drug misuse, Edwards said. These include asking for more opioids before a prescription is finished, repetitively stating that opioids were stolen or lost, not attending oncology visits, and calling the clinic or heading to the emergency department only for more opioids.
The majority of opioid misuse starts with a prescription, “either that a doctor gave patients or that wound up in the wrong hands,” Patrick I. Borgen, MD, chair of the Department of Surgery and director of the Breast Center Program at Maimonides Medical Center in Brooklyn, New York, said in an interview with Oncology Nursing News®. “So the healthcare profession is directly at the center of this.”
Edwards said that she and her team at MD Anderson tell all their patients to lock up their medications to reduce the risk that another individual will take them. Additionally, providers at the institution make it a point to educate patients and their caregivers about proper opioid use and even host annual Opioid Crisis Seminar events to spread the goal of safe use. “Opioid education is one of the most powerful lessons that anyone can always share and build upon in their own clinic or inpatient area,” Edwards said. “Everyone in the community is welcome to come. We have people coming from all over the United States, and we are more than happy to let them see the system that we have.”
McNally’s team focuses on harm reduction for at-risk patients. She established a multidisciplinary committee within the lymphoma department of her hospital, comprising inpatient and outpatient nurse practitioners, pharmacists, patient care resource managers, social workers, and other nurses. After reviewing literature on the topic, they realized that harm reduction would be the best strategy to address opioid misuse in the cancer clinic.
Harm reduction does not treat addiction or disease. Rather, as its name suggests, the strategy focuses on minimizing harm and is not abstinence-based. “We can use safer prescribing practices or maybe be more aware of red flags that may come up—for example, patients losing their prescription, having it stolen, asking for early refills, and things like that,” McNally said, echoing Edwards’ advice. “We’re providing education to patients for different strategies to minimize their use or their risk.”
Harm reduction strategies at Wexner Medical Center, also part of The Ohio State University, included safer prescribing practices, such as asking every patient about their current or past substance use or addiction; consideration of complementary or nonopioid therapy; using the Prescription Drug Monitoring Program and employing a controlled medicine management form; pain diaries for patients; urine toxicology screenings; pill quantity limits; and other initiatives.2
Many patients with cancer may not even need opioids, especially because safer alternatives with similar efficacy are available, explained Borgen. After witnessing a growing number of opioid-related hospitalizations and deaths at its institution, Maimonides formed a group to determine how the healthcare staff could decrease the amount of opioids prescribed.
The group created the Enhanced Recovery After Surgery protocol, which it initially employed in the colorectal surgery space but then altered and applied to other areas of the
hospital, including breast cancer surgery. The protocol is focused on mitigating opioid use but still effectively treating patients’ pain.
“We did a pilot study. We had some surgeons who were naysayers, and they stayed out of it, but that gave us a control group. We were able to show dramatically better pain scores and really [use] zero opioids,” Borgen said. “So if you fast-forward now to 2019, we’ve just submitted a paper tracking 700 women who we’ve treated consecutively for their breast cancer without a single milligram of opioids being dispensed. I’m incredibly proud of that accomplishment." Borgen has found alternatives to opioids for his patients, such as liposomal bupivacaine (Exparel), which he describes as a “workhorse of a local anesthetic.” The bupivacaine is encased in liposomal microspheres that break over time, resulting in an operative field that is bathed in local anesthetic over days instead of just hours, giving patients who underwent breast cancer surgery about 72 hours of pain relief.
The team at Maimonides sets the expectation with patients that their pain will be managed but without the use of opioids. To put patients at ease—because this notion can make some appre- hensive, said Borgen—clinical staff members are available for patients by phone 24 hours a day, 7 days a week, if they need better pain manage- ment. But they almost never call. “I do think that these patients need peace of mind knowing that these pills are just a phone call away if they’re in pain. But it’s much better than our old mind-set, which was ‘Here are 50 pills. I hope you don’t need them,’” Borgen noted.
Edwards also cited alternatives to opioid use for pain management, such as referring patients to integrative medicine. “[The rehab team] can teach them certainexercises, or maybe they even need to walk in a different way to take the pressure off a painful area,” Edwards said. “They have tricks and aids in their field that are able to help them minimize pain or discomfort and be more functional. That’s the whole point of it: restoring functional recovery for everyone to continue on and be able to fight their cancer, go to their kid’s soccer game, or just have a good night’s sleep.”
McNally added that pain is not only physical but can be emotional, too, so having a psychol- ogist, in addition to physical and occupational therapists, on the treatment team can be helpful.
“Really before the whole ‘pain is the fifth vital sign’ campaign, they were looking at these multimodality clinics to treat pain, but those are expensive. Then they started coming out with opioids, and it was much easier to take a pill, and it cost less. Going back to that [kind of care] isn’t easy, but things like psychosocial therapy, phys- ical therapy, and occupational therapy can really help,” McNally said.
The courts are beginning to push back against manufacturers of these painkillers, too. In August, Johnson & Johnson and its subsidiaries were ordered by an Oklahoma judge to pay $572 million for their contributions to the opioid crisis in the state. This is after 2 other rulings stating that Purdue Pharma and Teva Pharmaceutical Industries Ltd. were ordered to pay $270 million and $85 million, respectively.
Despite promising alternatives, some patients ultimately will need opioids. “I think that there are going to be times, maybe for trauma patients or patients under- going large, radical surgery, when we do have to use opioids. But our choice of opioid matters,” Borgen said.
Borgen noted an underused opioid called buprenorphine that controls pain but does not elicit the same euphoric feeling that other drugs such as oxycodone and morphine do, making it less likely to lead to addiction. Overall, he expressed optimism that through patient and provider education, the opioid crisis can improve. “We’ve got to change the mind-set, and I think that’s happening,” Borgen said. “I think being honest and transparent about these drugs, offering alternatives, is what is going to make a change.”