Rapid Taper Plays Role in Suspected Opioid Misuse in Patients With Cancer

Tapering treatment with opioids for cancer-related pain can be a challenging process. However, when there is suspected opioid misuse, clinicians should consider faster tapering combined with non-opioid treatments to prevent harm to the patient or others, explained Heather J. Jackson, PhD, APRN, FNP-BC, NEA-BC, FAANP.

Jackson is the administrative director of advanced practice at Vanderbilt-Ingram Cancer Center and associate professor of Nursing and of Medicine in the Division of Hematology/Oncology

Vanderbilt University Medical Center. In a recent interview with Oncology Nursing News, she discussed safe opioid tapering and multimodal pain management for patients experiencing cancer-related pain. The process, she explained, may look different in situations of misuse, she said, noting that potential signs of opioid misuse include:

• Patients continuing to fill their prescription and request early refills, though no opioids are detected in urine samples (this can indicate that somebody else is taking the patient’s opioids or potential diversion)
• Odd interactions with patients or family members regarding opioid use
• Patients seeming to plan their daily schedule around taking opioids
• Patients indicating they are withdrawing from typical daily tasks or social activities with impacted relationships
• Changes in mood such as irritability, nervousness, or fluctuations in emotions
• Symptoms of physical withdrawal

“In a situation of misuse, we don’t want to put those drugs out there,” Jackson said. “We don’t want to harm the patient; we don’t want to harm other people. So we do have to do a rapid taper and offer alternative pain remedies as well as assess for substance use disorders.”

Transcript

If we come upon a situation where we do [suspect] misuse, we discuss our concerns with the patient. Often a warning and limited number of opioid medications are prescribed and if misuse is validated, we proceed with a rapid taper. Our goal and our objective would be to be slow about this, and even have pauses in a taper. I've been known to spend a year-and-a-half with a patient that came to me on very high, extended-release regimens, and then with a short-acting [opioid prescription] on top of that…. I’ve had to pause, and they'll say, “it's a rough month … going on. Heather, can we please just pause there?” And absolutely you can do that.

But in a situation of misuse, we can't put those drugs out there. We don't want to harm the patient. We don't want to harm other people. So we do have to do a rapid taper, and in that situation, we'd want to address the symptoms of withdrawal, knowing that they can certainly be uncomfortable, but it's not going to harm the patient medically. We can give medicines to help with those symptoms. So we would want to treat any diarrhea. We can give medications to help with that sympathetic response in the nervous system.