Unrelieved Pain Management Remains Critical Issue in Patients with Cancer

Pain management of those with cancer still remains a challenge, according to Judith A. Paice, PhD, RN.

“Unrelieved pain is a huge public health crisis,” said Paice, Division of Hematology, Northwestern University, Feinberg School of Medicine, during a recent presentation at the Oncology Nursing Society Bridge virtual meeting.¹ “Opioid misuse and overdose deaths are emergencies... [but]efforts to reduce the opioid overdoses have resulted in stigma and unrelieved pain for people who might use opioids to relieve their pain.”

Paice’s presentation “Safe and Effective Use of Opioids to Treat Cancer Pain” highlighted how the media attention surrounding opioids has made pain management potentially more difficult for patients with cancer, as well as effective ways to prescribe and titrate opioids, and how the COVID-19 pandemic has further affected pain management.

The Impact of Current CDC Opioid Guidelines

In 2016, the CDC released guidelines for prescribing opioids.²

“These were pretty controversial for many of us who were working in the world of significant pain, like people treating people with cancer-related pain,” explained Paice. When the guidelines came out, there was not an omission for people at end-of-life care or patients receiving active cancer treatment.

Eventually a caveat was added for these specific populations, but there were still 2 guidelines that concerned oncology health care workers. The first guidelines stated that only a 3 to 5 days’ supply should be dispensed at a given time, and the second advised only using a very small amount of drug-less than 50 milligrams.²

Paice explained the ramifications this had on her patients experiencing acute pain. “We met with significant problems with access; insurance would not allow us to give [our patient] the dose that was needed on there without pay for that amount, saying that the dose exceeds the CDC guidelines… This patient [with metastatic prostate cancer and a large tumor impacting his spinal cord] really became very anxious about his use of opioids [and] was very fearful and upset about the stigma when he would go to the retail pharmacies and not be given the medications that had been rightfully ordered for him. And he was extremely fearful of running out of the medication.”

Paice was not the only nurse observing these access barriers. “ASCO conducted a survey of oncology practices,” she shared. “And they found that 40% of U.S. oncology practices stated that their patients were having difficulty filling opioid prescriptions.” These barriers included pill limits, maximum dosages, and medications not being unbillable at local pharmacies.³

Opioid Prescriptions for Patients and Survivors

While there are different definitions, some literature defines survivorship as beginning at the moment of a patient’s diagnosis and continuing through the rest of their lives.⁴ By this definition, there are 16 million cancer survivors in the United States alone, and it has been demonstrated that pain in this population is 40% or higher.⁵

With so many advanced treatment options, more patients are viewing their cancer as more of a chronic illness, adding another challenge to developing clinical practice guidelines, she added.

Current guidelines emphasize the non-pharmacologic interventions. Paice highlighted physical interventions, such as physical therapy, occupational therapy, recreational therapy, orthotics, heat packs and ice, etc. Other therapies can include integrative therapies such as acupuncture, music, massage, and more, depending on the institution. “A wide array of professionals can deliver nerve blocks, kyphoplasty and different kinds of peripheral infusions, psychological approaches,” she added. “We still struggle with a shortage of mental health practitioners, particularly practitioners who have expertise in the special needs of those who are experiencing a malignancy, but cognitive behavioral therapies, mindfulness imagery, relaxation, all can be exquisitely helpful for that person with cancer related pain.”

Opioids are usually considered after describing and reminding patients about the non-pharmacologic techniques used to manage pain. Patients should be reminded that there are long-term adverse events (AEs) associated with opioids, such as constipation, upper GI symptoms, mental clouding, endocrinopathies, etc. and as well sexual side effects including reduced libido, infertility, and more.

One significant change in pain assessment has been a transition from number-related pain assessments to task-oriented pain rating. For example, nurses might now ask their patients “What is your pain preventing you from doing that you want to be doing?” Outcomes and goals are defined by the patient. This can include returning to work, or even just walking around the block, being able to sit at a hard chair in a restaurant for dinner, or holding a grandchild. This style of approach allows for a more structured and measurable evaluation of treatment efficacy.

Another important change is risk assessment for potential misuse. This includes conversations about current or past misuse of prescription or illicit drugs, alcohol, smoking, gambling, etc.

“I also ask about family,” Paice shared. “And this helps me to get a very crude measure of genetics, if we find that very large number of biologic family members have had substance use disorder, then there's likely a high risk for this patient.”

Some conversations can be a little more sensitive. “I usually give people a little bit of a warning shot,” said Paice. “[I’ll say] I need to ask you a difficult question, and I stop for a second so I really have their attention, [and ask] ‘Have you ever been abused?’ ... And I'll explain to them that we know that someone who has been abused, particularly as a child, or an early teen, has a very high risk of substance misuse or addiction.”

Some patients are worried about becoming addicted to their pain medications, she said, but there is a prescription drug monitoring program that is available in 49 out of 50 states that Paice finds useful. She does however recommend using systems like these universally to avoid falling into traps of implicit bias. Additional useful monitoring tools include urine toxicology, and verbal or written patient agreement contracts.

Weaning Patients Off of Opioid Use

“That’s another thing that most of us didn't learn in our basic training related to pain management or opioids,” Paice said, regarding how to help patients wean themselves off opioid use. “I use a very slow downward titration note, [but] I'm primarily working in an outpatient practice.”

Paice shared that she helps around 200 patients in the outpatient hematology oncology clinics and that nurses can reduce prescription as quickly as 10% per week, but that 10% per month is often her preferred method of titration. She emphasized offering lots of coaching, as well as psychosocial support and encouragement, and to remind patients about why this is important, as well as getting the assistance of cognitive behavior therapists. Her team uses antidepressants rather than benzodiazepine to treat irritability and prefers to give their patients clear verbal treatment plans so they can understand how the process will look.

“It's about 5% to 20% every month, and you know what, if it's a holiday, we'll pause, we'll plateau, if it's an important day, you know, this month, their child is getting married, and they really want to not be going through any kind of change in their pain management. I understand that. But we're going to then resume with our reduction.”

Paice also discussed talking to patients about safe use. She shared that despite the media attentions surrounding opioid misuse, many patients are surprised when she describes locking up their pain medicines.

She also discussed nasal naloxone. While nasal naloxone prescription varies by state, there remains to be a consensus on who needs it. “I'm feeling more comfortable now than I was 2 to 3 years ago, when many patients were having to pay out-of-pocket and it was about $150 for the nasal Naloxone.

“Now most insurance companies are paying for it I would say maybe about 10% of my patients are having to pay a pretty significant copay. Some recommendations [say] that if the patient is getting more than 50 milligrams per day of oral morphine equivalents, then we should be prescribing nasal Naloxone.”

The Effects of COVID-19 on Cancer-Related Pain Management

The COVID-19 pandemic has exacerbated preexisting issues in unrelieved pain, summarized Paice. “We're seeing additional symptoms, some of them pain. So, in one of the early papers that documented the symptoms seen in COVID-19 as you would imagine breathlessness, agitation, drowsiness, pain, and then after hospitalization, muscle pain was common in more than half of the population.”

Common symptoms seen in patients referred to palliative care have included breathlessness (67%), agitation (43%), drowsiness (36%), and pain (23%). Post hospitalization symptoms have included fatigue (55%), dyspnea (45%) and muscle pain (51%).

“Whether you are a primary palliative care nurse which all oncology nurses should be, or whether you are a specialty palliative care nurse. All of us have an enormous role, regardless of our settings of care in providing stellar care for people with COVID-19, and particularly for our patients with the additional serious illness of cancer,” said Paice, urging listeners to mobilize staff with pain and palliative care training, provide brief education related to symptom control and to engage allied health to provide emotional support to patients, families and staff impacted by the pandemic.

“Go out there and change the world of pain management for your patients,” she concluded.

Reference

1. Paice JA. Safe and effective use of opioids to treat cancer pain. Presented at: Virtual ONS Bridge; Sept 9-16

2. Dowell D. Haegerich TN, Chou R.CDC Guideline for Prescribing Opioids for Chronic Pain MMWR. CDC. 2016; 65:1-50

3. Opioids and cancer pain: patient needs and access challenges. ASCO. Accessed October 8, 2021. https://www.asco.org/sites/new-www.asco.org/files/content-files/blog-release/images/opioids-cancer-pain-infographic-%202137x2755.pdf

4. Mayer DK, Nasso SF, Earp JA. Defining cancer survivors, their needs, and perspectives on survivorship health care in the USA. Lancet Oncol. Accessed October 10, 2021. 2017: 18 e11-18. doi: 10.1016/S1470-2045(16)30573-3.

5. Van den Beuken-van Everdingen MH, et al. Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis. J Pain Symptom Manage. 51: 1070-1090, 2016. doi: 10.1016/j.jpainsymman.2015.12.340.