Cancer Survivors Are Not Immune to Opioid Addiction

It was a short piece in the December 2018 New England Journal of Medicine table of contents that read, “Harder to Treat than Leukemia — Opioid Use Disorder in Survivors of Cancer.”¹ Written by a medical oncologist specializing in transplantation, the article poignantly described a case of a young woman post-allogeneic hematopoietic transplant who developed both acute and chronic graft-versus-host disease (GVHD) characterized by unrelenting pain, which prompted the need for opioids. The physician chronicled the patient’s spiral into addiction with its classic signs on display: requesting opioid prescriptions from multiple doctors; avoiding evaluation by pain specialists; increasing her consumption pattern; refusing any titration and tapering of meds; refilling old prescriptions; and repeatedly denying she had a problem. Those type of actions became her norm, and ultimate outcome of this case study was not a good one.

I laud this oncologist for not only telling the story, but also for sharing her feelings during the trajectory of caring for this patient (i.e., “I felt like her dealer”; “The possibility that she made have overdosed haunts me”). Some key points in this article that need reiteration. First, there is no exclusionary indication for cancer patients to become addicted; they are vulnerable like anyone else. Because of this, there needs to be special concern about prescribing opioids in non-terminal scenarios. Should there be specific criteria and guidelines for managing pain early in the cancer trajectory? Second, the prevalence of prescribing limitations related to non-opioids within cancer care (i.e., avoiding acetaminophen and nonsteroidal anti-inflammatory drugs due to organ toxicity concerns) may support the use of opioids. Are management algorithms needed? Third, even when the cancer survivor with an opioid addiction accepts the need for rehabilitation, may programs limit admission to patients having ongoing medical problems. Finally, the availability of prescription-drug monitoring programs which require providers to cross-check for patient use of other controlled prescriptions, are not available in all states. This hampers awareness of the early recognition of this disorder in our patient population.

Currently, opioids are responsible for the deaths of 130 Americans daily.² These numbers are projected to steadily escalate in the coming years.³ The acknowledgment of opioid abuse as a national healthcare emergency has been in place since 2017, making it is a relatively new public health concern. ⁴ Yet in cancer care, the exponential growth of cancer survivors may prompt an escalation of this disorder which cannot wait for lengthy deliberations to determine best practices. The numerous oncology-specific professional organizations need to collaborate on ways to quantify this impediment to our survivors’ recovery and request help from colleagues specializing in addiction care. A rapid response is needed now.

References:

• Loren AW (2018). Harder to treat than leukemia — Opioid use disorder in survivors of cancer. NEJM, 379(26): 2485-2487.
• Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/epidemic/index.html.
• Trecki J (2019). A perspective regarding the current state of the opioid epidemic. JAMA Network Open, 2(1): e187104.doi: 10.1001/jamanetworkopen.2018.7104.
• Gostin LO, Hodge JG & Noe SA (2017). Reframing the opioid epidemic as a national emergency. http://jamanetwork.com 8/23/18; doi: 10.1001/jama.2017.13358.