Opioid Stewardship: Strategies for Cancer Pain Management

Oncology pharmacists can effectively employ an opioid stewardship approach to pain management for patients with cancer.

In a session held virtually on Tuesday, April 13, during the Hematology/Oncology Pharmacy Association (HOPA) Annual Meeting 2021, a panel of experts convened to discuss best practices for opioid use in patients with cancer pain, as well as how to identify and respond to opioid misuse.

Opioids are a first-line treatment for cancer-related pain, so their use is often necessary in the cancer care setting. As opioids are high-risk medications, oncology pharmacists can play an important role in minimizing unintended consequences in this patient population through proper monitoring and assessment.

Addressing Hesitancy

Because of the opioid epidemic, some patients may express fear or hesitancy when starting a pain management regimen with opioids, even when it is indicated, according to Rabia Atayee, PharmD, BCPS, CPE, clinical pharmacy specialist at The Johns Hopkins Hospital.

“When addressing fear of opioids, your approach should be inquiry before advocacy,” she advised. Understanding the basis of fear is important. These fears are usually related to addiction or stigma, but that might not always be the case, Atayee said. She cautioned not to assume, but instead allow the opportunity for the patient to express their own reasons for apprehension. “Say ‘tell me more’, state what you’re seeing, and then let the patient provide the rest to you,” she said. 

Pharmacists can also allay a patient’s concern by communicating that this is a shared decision-making process.

“Verbalize that [this is] shared decision making in developing a plan,” Atayee said. “That our goal is to use the lowest effective opioid dose, that we’re going to monitor.”

As part of shared decision making, providers and patients can take the following steps when deciding on a pain regimen.

• Review monitoring parameters
• Give 1-time dose of the opioid and monitor at time to maximum concentration with patient, if feasible
• Consider using non-opioids or opioids that the patient may not fear as much
• Consider utilizing non-pharmacotherapy treatment plan

“Another key thing when starting an opioid is having a transitions of care plan in mind,” Atayee continued. This includes transitions of care plans for outpatient and inpatient situations, as well as for curative intent. Although a plan should be put in place to taper down or off opioids for patients whose cancer is cured or in remission, Atayee urged that “tapering off opioids does not mean ending support or addressing their other symptoms.”

Assessment and Monitoring

Cancer pain is a complex mix of different physiological pain generators, and can progress and change rapidly over time, according to Atayee. Harm reduction is important to ensure appropriate use, but how do providers avoid swinging the pendulum too far in either direction?

“Assessment and monitoring is key,” Atayee stressed. For pre- and periodic post-opioid assessment of pain, pharmacists should focus on the 5 A’s:

1. Analgesia
2. Activity (function)
3. Adverse effects
4. Aberrant behavior
5. Affect (mood)

Prior to opioid initiation, pharmacists should assess a patient’s likely benefit and risk. Part of this assessment involves understanding the patient’s knowledge and beliefs of pain medication, previous experiences with opioids, self and family history of any substance use disorder, the patient’s experience with pain, and setting expectations regarding pain functional goals.

When it comes to expectations, Atayee emphasized ensuring that these goals are feasible to achieve. A pain score of 0 is usually not realistic, she said. Instead, focus on a more tolerable pain score and goals to improve function.

Atayee also stressed that it’s important to remain self-aware and check your own implicit biases. Avoid making any assumptions based on appearance, level of education, or anything else. “We really need to be able to check ourselves, even ask our teammates to help with that, and just [have] a very standardized assessment and monitoring approach that we use for all patients,” she explained.

Moreover, distinguishing between chemical coping and undertreated pain can be a challenge for the palliative care team, Atayee said. She recommended using an interdisciplinary team of licensed clinical social workers and palliative psychiatrists to help differentiate.

Guidelines and National Perspective

Tanya Uritsky, PharmD, clinical pharmacy specialist, pain medication stewardship at Penn Medicine, discussed the current state of guidance in best practices for opioid prescribing, highlighting the main guidelines available for use across different patient populations:

• Cancer survivors: American Society of Clinical Oncology (ASCO) Guideline on Management of Chronic Pain; National Comprehensive Cancer Network (NCCN) Guidelines for Survivorship
• Cancer treatment: NCCN Guidelines for Adult Cancer Pain
• Chronic pain: CDC Guideline for Prescribing Opioids for Chronic Pain
• Sickle cell disease: National Heart, Lung, and Blood Institute Guidelines for Management of Sickle Cell Disease; American Society of Hematology Guidelines 2020

Although not all the guidelines are intended for cancer pain, Uritsky noted that there are common themes endorsed across the board that point to good prescribing practices overall.

These common themes include:

• Use of nonpharmacologic therapy and nonopioid pharmacologic therapy
• Assessment of patient’s benefit and risk
• Continuous monitoring and evaluation of effectiveness
• Patient education on goals of treatment and safe use
• Optimization of adjuvant analgesics, psychosocial supports, and interventional therapies in conjunction with opioid therapy
• Gradual opioid dose reduction, when indicated

There are also several issues surrounding access to opioids, Uritsky noted, which can create barriers to getting opioids to patients who really need them. “In our world…insurance dictates a lot of what we do,” she said. Prior authorizations (PAs) are sometimes needed for certain prescription lengths or quantities. Insurance can also require urine drug screens for PA renewals. Additionally, as opioids are a high-risk medication, a pain contract, or pain agreement, is often required. Uritsky noted that this is a good thing. “I like refer to [this] as informed consent,” Uritsky said. “Pain contracts should not be something that’s used against the patient, but used to inform them.”

However, these obstacles to access can result in some unintended consequences, such as delay in patient care, disruptions in treatment plans, and increased workload on providers.

“We have an entire department dedicated to controlled substance prior authorization,” Uritsky said. “If you can’t do that, you can imagine the amount of burnout this might lead to when you have to navigate all of this.”

Uritsky did stress that chemical coping is a real risk among patients receiving treatment for cancer-related pain. “At least 1 in 5 patients with active cancer is at risk for opioid use disorder [OUD],” she said. There’s also balancing these issues of risk with the issue of undertreated pain, which occurs in up to 75% of patients with advanced care, according to Uritsky.

“The best way to do that is with a multidisciplinary approach,” Uritsky said. “We need everybody at the table to help patients get access to the things they need and that they deserve.”

Management and Prevention of Opioid Use Disorder

Julie Waldfogel, PharmD, BCGP, CPE, clinical pharmacy specialist at The Johns Hopkins Hospital, discussed specific risk assessment tools for preventing OUD, as well as how to respond when an OUD is suspected.

Waldfogel pointed to risk assessment tools that focus on a patient’s risk for opioid misuse over time. She emphasized the importance of reassessment. “People are not static in their risk,” she said. Waldogel explained that different screening tools are used depending on the situation. These tools can assess substance use, identify current misuse, and predict future misuse, according to Waldfogel.

Once you’ve risk stratified the patient, there are several strategies to help maintain safety and continue to monitor for effectiveness and necessity.

To minimize risk of OUD, Waldfogel recommends the following strategies:

• Monitor: Frequency of monitoring can be based on risk stratification.
• Change modifiable risk factors
• Naloxone: Patients can get access through prescriptions, overdose response programs, or standing orders in some states.
• Education on safe use and disposal: Drug take back sites, disposal kits, and mixing with unwanted substances.

“Our risk stratification mostly helps us with monitoring and, more particularly, with the frequency of that monitoring,” she said. Waldfogel also suggested identifying the risks that an individual has and if there’s anything that can be done to modify that risk level. “It’s always worth evaluating as a clinician to see if that’s something we can modify,” she said.

Waldfogel explained that, according to the ASCO Guideline Risk Stratification, pharmacists can respond to identified opioid misuse by reconsidering treatment to determine if nonopioid therapies are preferred, changing the monitoring (smaller, more frequent prescriptions), or requesting additional consults, such as with an addiction medicine specialist. 

Specific to naloxone, Waldfogel noted that the CDC Guideline recommends offering naloxone when factors that increase the risk of opioid overdose are present. They include:

• History of overdose
• History of substance use disorder
• Opioid doses > 50 MME/day
• Concurrent benzodiazepine use

If a patient is suspected to have developed an OUD, pharmacists should respond by evaluating their medications for pain management and getting them into treatment for their OUD.

To do that, pharmacists can use the Screening, Brief Intervention and Referral to Treatment (SBIRT) approach to identify the issue and intervene. According to Waldfogel, pharmacists should identify their response to a specific behavior, approach with a nonjudgmental discussion, provide a statement of non-abandonment, and explain the purpose of referral to treatment. Waldfogel recommendeds establishing referral links to SUD and mental health services in your area ahead of time to prepare for this type of situation.

References

1. Uritsky T, Waldfogel J, Atayee R. Opioid management in cancer patients: Employing an opioid stewardship approach. Presented at: Hematology/Oncology Pharmacy Association 2021; virtual; April 16, 2021.