Opioids and Cancer Pain: Patients’ Needs and Access Challenges
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Dr. Pennell talks with Dr. Ray Page about efforts to address the opioid crisis impact onthe care of patients, and what role oncologists can play on this issue.

Hello, and welcome to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consultant editor for the JOP. The opioid crisis continues to be a major public health issue, with increasing attention at both the state and national level. Efforts to address this issue are highly relevant to oncologists, because we treat a unique population of cancer patients for which opioid prescriptions are an established standard of care. So how will these efforts to address the opioid crisis impact the care of our patients? And what role can oncologists play on this issue? Today, we're going to be talking about this topic with Dr. Ray Page medical oncologist and hematologist at the Center for Cancer and Blood Disorders in Fort Worth, Texas, who currently serves as chair of ASCO's Clinical Practice Committee, is on the ASCO Government Relations Committee, and is the current ASCO delegate to the AMA House of Delegates, about his new editorial titled, "Opioids and Cancer Pain, Patients' Needs and Access Challenges," which will be published in the April 2019 JOP. Ray, thanks for joining me today. Thank you. So can you start out by giving our listeners a little background on the magnitude of the opioid problem in the US. Sure, Nate. Let me just first say, the opioid epidemic is real and is startling. The CBC reported that in 2017 that over 72,000 in the United States died from drug overdoses. And this included over 47,000 people who involved in drug overdoses of opioids. And most of us have heard from the media that the biggest increase in use is through that synthetic opioid fentanyl. And it's often laced with heroin. And the recent volumes that have confiscated at the US border are enough to kill ever single US citizen. And the escalation of opioid abuse is really complex societal issue. And it includes contribution from all of those social determinants of health and mental illness. And when policymakers sometimes they like to look at a one size fits all kind of solution, which means they oftentimes want to largely focus on physician prescribing habits and just regulating patient access to opioids. Is there evidence that this kind of solution of targeting opioid prescriptions is impacting opioid prescribing in cancer patients? There is a negative impact there. But let me just say that cancer pain is very real and it's very frightening. And we know that cancer pain is historically undertreated. 8 out of 10 advanced cancer patients experience moderate to severe pain. And about 55% of cancer patients and 40% of cancer survivors experience chronic cancer related pain. So upwards of 43% of cancer patients and 10% of survivors use opioids to manage chronic cancer pain. Because of the heightened media awareness about the opioid epidemic, cancer patients are really experiences a lot of fear firsthand. Many of my patients have expressed to me that they actually have a fear of dying from taking opioids. And there's also of addition. And then on the other hand, they also have a fear that they may not even be able to get their hands on pain medicines at all. That actually is a really interesting topic that I hadn't thought of because I have the same problem with my patients worrying about taking opioids. You think that this being so much in the public eye is really influencing cancer patients' ideas about whether they should be taking opioids or not. They feel like they're at risk for addiction and contributing to the problem. Our cancer patients I think do have those real concerns and they have fear over it. And we're actually seeing that about a 1/3 of cancer patients and survivors are actually having difficulty to getting access to their prescribed opioid medications. And that has continued to increase markedly since just a few years ago in 2016. And the vast US oncology practices are concerned that restrictions on opioid prescribing is going to ultimately result in undertreatment of cancer pain. So it's these kind of dynamics what makes it difficult for physicians to treat pain, particularly cancer and cancer survivors. And while judicious prescribing is important, patients with cancer and cancer related pain, they need to have consistent access to pain control. Well, I think we can all agree on that. Before we talk about how we can protect cancer patients' access to these drugs, can you talk a little bit about what is being done sort of at the state and national level to address the opioid crisis and sort of how that's impacting our cancer patients? Yeah, absolutely. The opioid epidemic will continue to be a bipartisan priority for both state and federal governments with currently over 100 state bills that are out there that are identified. In a lot of upcoming state legislative sessions, there will be consideration of bills that are related to such things prescription fill limits and prescription drug monitoring programs and opioid prescribing guidelines. And we're all expecting to see bills that are going to be related to the identification of outlier prescribers and bills that are promoting the utilization of opioid alternative therapies in the cases of both acute and chronic pain. Just on the federal level, you know in 2016, President Obama, he signed the first major federal addiction law in 40 years. And that was the Comprehensive Addiction Recovery Act. And that bipartisan legislation authorized evidence-based prevention and treatment programs and recovery programs and law enforcement initiatives to help prevent overdose death and proper prescriptions. And as you had asked, in 2017 when President Trump came into office, he announced that his administration was declaring an opioid crisis and made a national public health emergency under federal law. And as a result, the White House office of the national drug control policy directed numerous federal agencies to address the opioid problem. But that was largely within their current budgetary confinements. But I think actions by both administrations had positive impacts on the opioid problem primarily just by initiating activity in our government agencies. So when the various laws and policies are passed, do they have built in protections for vulnerable populations that need access to opioids, like cancer patients? Yeah, that's one thing that we've pushed a lot for. And in general, most of them do. And so President Trump signed a sweeping legislation in 2018 that was touted as the single largest bill to combat the drug crisis in our countries history. And there was a lot of efforts to do things like expanding access to treatment for substance abuse disorders and those kind of things. But, for example, January 1st of this year, as part of that law, it included new opioid prescribing policies that will impact Part D beneficiaries and the prescribers. And this includes such things as real-time safety alerts on pharmacy dispensing of opioids and drug management and utilization tools and the improvement of communications between the pharmacists and the physicians. But as you asked, one important note about this legislation that was passed is that residents of long-term care facilities and those that are in hospice care and patients receiving palliative care or end of life care, and patients being treated for active cancer related pain, they are exempt from a lot of these interventions. Well, it's good that at least someone is considering our patients in this. But I know that certainly-- I believe ASCO has quite a bit of concern about maintaining access to patients. So what role is ASCO playing in this issue? You know, Nate, ASCO is very sensitive to the needs, to address the opioid crisis and to support thoughtful and evidence-based interventions aimed at decreasing substance misuse and abuse and overdose death. However, ASCO really continues to advocate for appropriate access to pain medications for cancer patients, recognizing that that typical one size fits all solution risks oftentimes marginalizing our cancer patients and their needs. And so in 2016, ASCO released an ASCO policy statement on opioid therapy which emphasizes the unique pain management needs of patients with cancer and especially those with advanced disease. And in this policy statement, ASCO points out a lot of core principles to balance public health concerns and cancer patients' needs. Well, I really like the fact that ASCO is focusing not so much on specific individual needs, but rather making sure everyone recognizes that there is no one size fits all solution here and also you know acknowledging that there is a real problem with opioid misuse in the United States, but that our patients need to be considered carefully in this. One of the things I liked about your editorial was focusing on how physicians might actually be able to learn about managing pain in cancer patients and not necessarily just focusing on the use of opioids. Can you talk a little bit about that? Yes, sure. You know, just in general, as we all know, as oncologists, we rely heavily on the use of opioids. But we should never rely solely on the use of opioids. And we need to determine if opioids are indeed the right drug for particular type of cancer-related pain. And so ASCO published recent clinical practice guidelines for chronic pain management in cancer survivors that gives advice on careful assessment of pain and its effects on function and of the possible risk associated with an opioid. And so I generally recommend that clinicians review some of these practice guidelines because many of these recommendations can help reduce opioid prescribing and actually consider other good, viable non-opioid alternatives, such as using pain specialists and other interventional procedures. Yeah, I think everyone would benefit from being aware of the problem and making sure that they are using opioids appropriately. I guess I'm just a little concerned about how all this attention is impacting our patients and their access to drugs. We did a JOP podcast, oh, I think a year or so ago with Dr. Bruera, who is a palliative care specialist at MD Anderson, who published a study showing that palliative care physicians were actually prescribing significantly less morphine equivalents for cancer patients. And there was a lot of alternative treatments, such as tramadol, that were being used. And we had a nice discussion about how perhaps some of that was a good idea. But they're also putting sometimes patients at risk of being under treated. Yeah, that dynamic is very complex, because I think we all realize that are certain types of pain that do get effectiveness with opioids to get appropriate pain relief. But the palliative doctors are usually very good and many oncologists also about entertaining those alternatives. And so oftentimes there are many kinds of cancer pain syndromes, both acute and chronic that can be managed with non-opioid alternatives. We as oncologists, we realize that this is a really vulnerable patient population. And we'll continue to develop and utilize all the latest advances in the comprehensive management of cancer in accordance with published evidence-based physician developed guidelines. However, we also want to design the statutory and regulatory requirements do not unduly restrict access to opioids and acknowledge the need to exempt cancer-related pain in our opioid policies. And I think that's absolutely critically important. And you know this is exactly the kind of function that societies like ASCO and the AMA really exist for, to protect our patients and the physicians who are prescribing these necessary medications to our patients. Well, it's been my pleasure to share this publication with you. And I hope it will be an important educational tool for the oncologists to work on to deal the opioid access problem for our patients. Thank you so much for joining me. I also want to thank all of our listeners out there who joined us for this podcast. The full text of the paper will be available online at ascopubs.org/Journal/JOP in April 2019. This is Dr. Nate Pennell for the Journal of Oncology Practice signing off.