Ask Tonya Edwards how frequently she encounters cancer patients addicted to prescription painkillers, and she offers a weary reply.
“Every day,” she sighs.
Edwards is a nurse in MD Anderson’s Supportive Care Center, where health care providers help patients deal with pain caused not only by their disease, but also their treatment.
“Not everyone with cancer will have pain, but more than half will,” Edwards says. “Our mission is to lessen their suffering.”
Prescription opioids, with brand names such as Vicodin, Oxycontin, Percocet and Fentanyl, have long proven superior to other drugs for easing cancer-related discomfort.
“These drugs interact with receptors in the brain to produce a powerful, pain-numbing effect,” says Eduardo Bruera, M.D., chair of Palliative Care and Rehabilitation Medicine. “They also make some patients feel happy, relaxed, even euphoric.”
Such soothing and pleasurable effects can lead to addiction. Most people won’t run into trouble when taking opioids prescribed for pain, but some will.
“One in five people have a larger than average number of opioid receptors in the brain,” Bruera explains. “These are the individuals who are predisposed to getting hooked.”
The lure of addiction is the driving force behind an opioid epidemic that began slowly in the late 1990s and today has burgeoned into a public health crisis. Overdoses of prescription painkillers and the illegal opioid heroin are killing more than 27,000 people a year.
“No one is immune,” Bruera says. “Emergency rooms across the country are treating young and old, professional and blue-collar, urban and rural, all races and backgrounds.
The problem is seen everywhere, Bruera says, including MD Anderson.
“Opioids are essential to controlling cancer pain,” he says, “but those who fail to take the drugs strictly as prescribed may find themselves dealing with cancer and addiction.”
As a nurse, Edwards is on the front lines of the addiction crisis. She’s first to see patients who show up unannounced, demanding, cajoling or asking politely for more medication.
Some claim their pills have been lost or stolen, while others say they’ve run out of pills early, with no explanation. Then there are the “doctor shoppers” who seek opioids from multiple MD Anderson doctors in the hospital’s various departments. A few go so far as to visit emergency rooms at other hospitals.
“They use excuses — whiplash, back pain, toothache — anything they can think of, to get the drugs,” Edwards says.
A quick check of MD Anderson’s computerized patient records and Texas’ statewide drug dispensing registry reveals who’s been making the rounds in search of prescriptions.
Over time, Edwards has learned to sense when she’s being “gamed,” but she doesn’t judge. Her first concern always is for each patient’s safety.
“This is a chronic disease that patients didn’t choose,” she says. “No one wakes up one morning and says, ‘I want to get addicted to my opioid pills because it’ll be fun.’ This could happen to me, and it could happen to you.”
Realizing the magnitude of the problem, Edwards devised a plan to help patients at risk, with assistance from Bruera and Supportive Care Center colleagues.
Put simply, it works like this:
Every patient who’s newly admitted to the Palliative Care Center completes two written tests that reveal whether they’re susceptible to addiction and how much supervision they may need.
Those whose test scores raise a red flag for potential abuse are closely monitored by clinic staff. If their behavior suggests they’re already abusing drugs – for example, they ask for new prescriptions, claim their pills were lost, or request stronger opioids — they undergo a urine drug screen.
When drug misuse is detected, MD Anderson’s Opioid Safety Initiative squad pays the patient a visit. Team members include Edwards, as well as a doctor, patient advocate, pharmacist and psychologist. Only a handful of hospitals across the country have such a resource.
“This isn’t about playing detective, spying on patients, or reprimanding them,” says Suresh Reddy, M.D., professor of Palliative Care and Rehabilitation Medicine. “The team’s sole purpose is to provide compassionate care to those who need our help and to see them safely through their cancer journey.”
Together, patients, their families and team members agree upon a plan of action that includes rules, boundaries and interventions.
Almost always, the plan calls for more frequent clinic visits — perhaps twice a week instead of twice a month — to ensure opioids are being taken as prescribed. Patients meet regularly with an addiction counselor. Those on stronger pain pills are transitioned to weaker ones and offered other forms of pain management. Claims of lost or stolen medication must be backed up by a police report before a new prescription can be written.
And to prepare for a “worst-case” scenario, patients’ family members are provided with Narcan, a prescription nasal spray that blocks the effects of opioids and reverses an overdose.
All these measures can help, Edwards says, but patient cooperation is key.
“Our message to patients is, ‘We’ll control your pain. It’s up to you to control your behavior.’”
The program launched a year ago and is working, says Edwards, who for her efforts won this year’s Brown Foundation Award for Excellence in Oncology Nursing.
The award is MD Anderson’s highest nursing honor.
“Most patients do much better when they understand that certain behaviors are required,” she says. “A little extra attention makes a big difference.”