Opioid abuse has been described as a crisis by public health professionals, as thousands of Americans die of prescription drug overdoses each year. In response to this crisis, in 2016 the U.S. Centers for Disease Control and Prevention (CDC) updated their pain treatment guidelines to reduce the use of opioids for chronic pain. However, these guidelines specifically excluded cancer patients because of the unique nature of cancer-related pain and because substance abuse was not believed to be prevalent in that patient population. But opioid overdoses and substance abuse problems do occur in a small subset of cancer patients, and clinicians at The University of Texas MD Anderson Cancer Center have implemented a system for detecting and managing issues that might arise from opioid abuse in cancer patients with chronic pain.
“Recent studies from our group and others show that some cancer patients who have pain and receive opioids experience problems that put them in danger of accidental overdose,” said Joseph Arthur, M.D., an assistant professor in the Department of Palliative, Rehabilitation, and Integrative Medicine. These studies led to a multidisciplinary approach to screening and intervention aimed at avoiding such issues while ensuring that patients in MD Anderson’s Supportive Care Center receive adequate treatment for their chronic pain.
“Our goal is to keep our patients safe so they can focus on fighting their cancer,” said Tonya Edwards, M.S.N., R.N., an advanced practice nurse in the Department of Palliative, Rehabilitation, and Integrative Medicine.
Assessing patient risk
When a patient is referred to the Supportive Care Center for chronic pain that requires opioids, the staff uses several tools to assess the patient’s risk of developing an opioid use disorder. First, the clinicians note any personal or family history of alcohol or drug abuse in the patient’s medical record. Next, the patient is asked to fill out two short questionnaires, the CAGE-AID (the CAGE alcohol screening questionnaire adapted to include drugs) and the SOAPP-R (Screener and Opioid Assessment for Patients with Pain–Revised), both of which are validated screening tools for drug abuse risk.
If the patient appears to be at risk, the staff may check the prescription drug monitoring program in the patient’s state of residence to see whether the patient is currently receiving or has in the past received opioids.
“These screening tools together tell us whether the patient is likely to develop an opioid use disorder,” Dr. Arthur said. He emphasized that patients found to be at high risk still receive the opioids necessary to manage their pain, but extra measures are put in place to protect the patient.
Ensuring patient safety
Typically, when a patient requires an opioid—regardless of the patient’s risk of opioid use disorders—Supportive Care Center staff members first explain the benefits and possible adverse effects of the drug. The patient also receives information about appropriate storage and disposal of the drug. “Sometimes, especially for patients at risk of substance abuse, we use an opioid management plan,” Dr. Arthur said. “This lays out the goals and expectations of the pain therapy and what each party—the care team and the patient—has to do. For the patient, these expectations include getting opioid prescriptions from only one doctor and one pharmacy.”
Some patients—especially those who need high doses of opioids or receive medications such as benzodiazepines that have potentially lethal interactions with opioids—are given a prescription of naloxone nasal spray for use in case of an overdose. Dr. Arthur and his colleagues follow the CDC guidelines for prescribing naloxone.
Patients receiving opioids who are at low or average risk of developing opioid use disorders typically have monthly follow-up visits in the Supportive Care Center; those at high risk may be asked to come in more often. On follow-up visits, the staff assesses whether the medicine is controlling the pain and whether the medicine is affecting the patient’s ability to function or causing other adverse effects.
In rare cases, staff members notice signs, such as frequent requests for early refills, suggestive of opioid use disorders. Ms. Edwards and her colleagues developed a system for nurses to identify such warning signs and inform the physicians so that appropriate action can be taken to ensure the patient’s well-being.
Opioid use disorders are multifaceted, and a physician alone may lack the expertise to address all the patient’s needs. To ensure proper care for patients with signs of opioid use disorders, the Supportive Care Center established the compassionate high-alert team (CHAT). A CHAT is a multidisciplinary group whose members vary according to the patient’s needs. In addition to a physician and a nurse, the team typically includes one or more of the following: a psychologist or counselor, who may be needed if the patient is dealing with issues such as anxiety or depression; a social worker, who can help the patient access resources to manage a variety of personal or family issues; a pharmacist, who can answer the patient’s questions about medication; and a patient advocate, who makes sure that the patient understands his or her rights and doesn’t feel intimidated.
The team meets quickly to discuss the case and then, together, talks to the patient and discusses appropriate management options. “We provide options in a non-confrontational manner,” Ms. Edwards said.
“The team approach provides a comfortable environment in which the providers and patient can agree on a plan to move forward,” said Suresh Reddy, M.D., a professor in the Department of Palliative, Rehabilitation, and Integrative Medicine, who first developed the CHAT program together with Ms. Edwards. He added that the comfortable environment not only puts patients at ease but also helps avoid burnout issues for staff members.
A group led by Dr. Reddy documented improvements in a cohort of patients after the CHAT program was implemented. These findings were published in 2017 in The Oncologist.
Sharing lessons learned
“Our approach to opioid management has worked well for us, and we’ve shared the lessons we’ve learned by conducting presentations for other departments at MD Anderson and other institutions,” Ms. Edwards said. She added that MD Anderson will host a seminar on the effect of the opioid crisis on the management of cancer-related pain for community health care providers on April 27, 2018 (see “Interdisciplinary Opioid Crisis Seminar,” below).
“Physicians need to be informed about prescribing opioids because the landscape is changing,” Dr. Arthur said. “There is increasing state and federal regulatory scrutiny of opioid prescribing. It is now more important than ever for physicians to be cautious when prescribing opioids to their patients, including cancer patients.”
For more information, contact Dr. Joseph Arthur at 713-794-1649 or firstname.lastname@example.org, Ms. Tonya Edwards at 713-792-6977 or email@example.com, or Dr. Suresh Reddy at 713-794-5362 or firstname.lastname@example.org.
Arthur J, Edwards T, Lu Z, et al. Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic. Cancer, 2016;122:3732–3739.
Arthur J, Edwards T, Reddy S, et al. Outcomes of a specialized interdisciplinary approach for patients with cancer with aberrant opioid-related behavior. Oncologist. 2017. doi: 10.1634/theoncologist.2017-0248. [Epub ahead of print]
OncoLog, March 2018, Volume 63, Issue 3
Interdisciplinary Opioid Crisis Seminar
MD Anderson is hosting a 1-day seminar to educate community health care providers about safe opioid use in the management of cancer-related pain. The Interdisciplinary Opioid Crisis Seminar will be held on April 27, 2018. Topics will include safe opioid prescribing; the impact of state, federal, and global initiatives to curb the opioid crisis; dealing with aberrant opioid-related behavior in cancer survivors; and using urine drug screens and prescription monitoring programs in opioid therapy. Attendees can receive continuing medical education or nursing continuing education credit. To register online, go to http://bit.ly/2oVmdFb.