Today, US Surgeon General Vivek Murthy released a report on addiction and the abuse of chemical substances, calling on the public, policy makers, and healthcare professionals to better address these issues. Part of the report, the first ever released by a Surgeon General focusing on substance use disorders, highlights the alarming number of overdoses and deaths resulting from addiction to opioid-based drugs.
One issue of great concern is the inappropriate prescribing of opioid pain medications. According to the report, more people now use prescription opioids than use tobacco. The high number of prescriptions has opened the doors to widespread abuse — often by people for whom the drugs were not prescribed.
The report is part of an increased government effort to address this urgent issue. In March, the Centers for Disease Control and Prevention (CDC) issued new guidelines for prescribing opioids for chronic pain. Although they make an exception for cancer patients in active treatment, the guidelines exclude cancer survivors no longer being treated — many of whom endure severe, chronic pain.
The CDC recommends that doctors prescribe opioids only after other therapies have failed and suggests that prescriptions for acute pain be limited to seven days. In addition, many states and private insurers are implementing or proposing increased restrictions on how opioids may be prescribed. These can include limits on the number of pills a doctor may prescribe or a requirement of prior authorization for opioid-based medications such as such as hydrocodone (Vicodin®) or oxycodone (OxyContin®).
With the number of cancer survivors increasing every year, these restrictions raise the possibility that many people with cancer-related pain could be denied access to adequate pain control.
Memorial Sloan Kettering physician and pain specialist Natalie Moryl says that cancer survivors need access to painkillers; studies show that up to 40% may experience pain at some point. She and her MSK colleagues are adjusting their practices to follow the new recommendations while ensuring their patients are able to control their pain safely.
“It important that there are proper measures in place to prevent overdoses, but we in the cancer community place the highest priority on controlling the pain of our patients,” Dr. Moryl says.
Vigilant Care and Monitoring
According to Dr. Moryl, the doctors on MSK’s Palliative Medicine Service perform a thorough evaluation of patients to understand pain and assess risk factors for opioid misuse if chronic opioid treatment is considered.
“During the clinic visit, we discuss the treatment plan that often includes physical therapy, psychological counseling, patient’s coping and expectations,” she explains. “If we deem that opioids are necessary and safe for long-term use, we typically prescribe them once a month and can further adjust treatment over the phone. We have a very vigilant group of physicians and nurses who monitor the patients closely and are alert to red flags for side effects of opioids and possible signs of abuse.”
Dr. Moryl says that New York State recently implemented a prescription drug monitoring program mandating that any doctor prescribing a controlled substance must first consult an electronic database that provides prescription histories for their patients.
“We think this has been a very positive outcome from the increased awareness of the problems of painkiller addiction,” she says. “We hope that eventually this type of database will be nationwide to make it easier to keep track of opioid prescriptions and identify possible problems with opioid misuse in the rare occasions this happens.”
Hurdles Remain for Some People with Cancer
Access to medical opioids for people with cancer is critical. However, those with legitimate need for pain medication still face barriers — some of which are new, Dr. Moryl explains. She described a recent breast cancer patient — a young mother of a teenager — who had been receiving pain management from a local primary care physician.
“She was receiving a fentanyl patch that lasted three days and could be prescribed only one dose at a time,” Dr. Moryl says. “Every three days the patients had to contact her doctor’s office to get a three-day supply of the opioid e-prescribed, then go to the pharmacy and wait for the prescription to be filled — all while being very ill from the cancer and busy receiving radiation and chemotherapy as well as being a single parent for her teenage daughter.”
Dr. Moryl says that cases like these illustrate that restrictions on opioid medications for non-malignant pain pose a risk of inadvertently changing practices in prescribing opioids for cancer pain. She and other MSK physicians are playing a leadership role in improving the quality of care for people with cancer pain.
For example, Dr. Moryl serves on the Adult Cancer Pain Panel for the National Comprehensive Cancer Network, an alliance of leading cancer centers that develops evidence-based treatment guidelines for most cancers and cancer-related symptoms including pain. MSK clinicians work closely with pharmacies and insurance companies to educate them about the importance of cancer pain management as well as to advocate for patients.
Opioids Safe for Cancer Patients
Dr. Moryl emphasizes that cancer patients rarely become addicted to medications prescribed for cancer-related pain if they take the medication exactly as prescribed and follow the directions of the physician.
She explains that most deaths related to opioids are seen in the noncancer community. Usually the person abusing the drug is not even the person for whom the medication was prescribed. The drugs were stolen or borrowed from the patient, or willingly shared or sold by the patient.
One way to address the growing concerns about drug overdose and opioid addiction is to increase patients’ awareness of their own responsibility for safe use, storage, and making sure the drugs are not abused by others.
“In addition to underscoring the importance of taking the medication only as prescribed, my colleagues and I make a point of explaining why it’s essential not to share medications with family members or friends — or other cancer patients — and to store the drugs safely, preferably in a locked space where nobody can reach it,” she says. “Even disposing of the drugs properly is important if you no longer need them or have been switched to a different medication. You should not have leftovers from six months ago sitting around.”
Dr. Moryl adds that MSK doctors have increased efforts to help patients who complete cancer treatment to taper medications to the lowest effective dose as soon as possible.
“We try to ensure that as pain diminishes, opioid doses are decreased so that the patients are not automatically getting refills of the medication they were prescribed before,” she says. “Decreasing the amount of unused opioids stored in the medicine cabinets in the patients’ homes decreases the risk of someone else taking the pills. And of course, our main focus is caring for cancer survivors and getting them back to normal life as quickly as we can.”