Dr. Egidio Del Fabbro presented on the management of cancer-related pain and aberrant opioid use in patients. Below is the full transcript of the video.
Del Fabbro: We need to identify those patients who are in most need of specialized care. Particularly those who have a propensity or risk for opioid misuse I think need to be referred to specialized care, whether that be a Palliative Care program, a supportive care clinic or a chronic pain clinic. I think you need an interdisciplinary approach with these patients.
There was also discussion that some simple measures can help these patients_—_simple measures such as giving them a pamphlet outlining some of the risks related to opioid misuse. In fact, research has shown that patients behavior changes have to be given this information: they’re less likely to misuse opioids they’re also more likely to keep them in a safe place. So I think simple measures such as education are important.
I think the other thing that’s important is also adopting a multidisciplinary approach that includes a psychologist, counselor, or perhaps even a chaplain because these patients who have cancer-related pain and [are] combating opioid dependence have a really tough time with coping with depression, demoralization_—just the distress associated with cancer treatment—_and I think they derive a great deal of benefit from continued counseling by psychologists or even a chaplain.
Doximity: What does harm reduction and risk mitigation entail?
Del Fabbro: Using long-acting opioids, trying to avoid immediate release opioids, because there has been a study showing that that is associated with an increased risk of overdose and death in patients with cancer.
Other measures that oncologists can take is to avoid giving large doses of IV opioids while patients are being admitted, so avoiding the demand dose of that PCA button I think is important.
Then there was also discussion about the role of urine drug testing and also the prescription monitoring program in patients with cancer. There haven’t been a great deal of studies as far as urine drug testing is concerned in patients with cancer, but the few that have been done suggest that we may have a problem_—_that patients with cancer may be at risk even for diverting these medications.
I’ll give you an example at our institution: We had about a third of patients showing up with no opioids in their urine that we prescribed also another fair percentage not only had no opioids that we prescribed, but either had street drugs or opioids that we did not prescribed in their urine so I think we need to be vigilant and it seems unfortunately as though urine drug testing is going to be taking more of a role in future in management of our patients.
Doximity: Should opioid misuse be looked at differently for chronic pain versus cancer pain?
Del Fabbro: While there has been a great emphasis, and there should be, on identifying patients who had increased risk for opioid misuse, I think perhaps the pendulum has swung way too far to the other side and increasingly weary in Oncology and Palliative Care treating cancer patients are concerned that there may be being denied legitimate access to opioids and I think a lot of people are also misinterpreting the regulations and guidelines that are out there for chronic pain patients and applying it unfairly and inappropriately to patients with cancer.
For instance, we’ve had national chain pharmacies refuse to give our patients opioids because they not prescribed naloxone, and most state regulations state categorically that patients with cancer or Palliative Care patients are excluded from guidelines mandating naloxone, so that’s just one example.
Doximity: What do you want others to know about Palliative Care?
Del Fabbro: Palliative Care is appropriate for patients at any stage of their disease trajectory and often we’re able to do so much more if they referred to us earlier. I think Palliative Care shouldn’t be regarded as only end-of-life care, and that it should move upstream. There have been many studies to show that it is beneficial for patients, but I think people need to be reminded constantly.