Managing Chronic Pain in Cancer Survivors Prescribed Long-Term Opioid Therapy: A National Survey of Ambulatory Palliative Care Providers

Merlin, Jessica S.; Patel, Kanan; Thompson, Nancy E.; Kapo, Jennifer; Keefe, F; Liebschutz, Jane M.; Paice, Judith A.; Somers, Tamara J.; Starrels, Joanna L.; Childers, Julie; Schenker, Yael; Ritchie, Christine S.

doi:10.1016/j.jpainsymman.2018.10.493

Cited by 52 publications

(49 citation statements)

References 25 publications

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“…Cancer survivors should be considered vulnerable patients, particularly for mood disorders. In these subjects, prescribing long-term opioid therapy can be challenging and require continued medical education, with specific familiarity with risk-mitigation tools and current guidelines, in light of the increasing fear about opioid abuse potential [107].…”

Section: Pain In Cancer Survivorsmentioning

confidence: 99%

Pain Management in Patients with Multiple Myeloma: An Update

Coluzzi

Rolke

Mercadante

2019

Cancers

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Most patients with multiple myeloma (MM) suffer from chronic pain at every stage of the natural disease process. This review focuses on the most common causes of chronic pain in MM patients: (1) pain from myeloma bone disease (MBD); (2) chemotherapy-induced peripheral neuropathy as a possible consequence of proteasome inhibitor therapy (i.e., bortezomib-induced); (3) post-herpetic neuralgia as a possible complication of varicella zoster virus reactivation because of post-transplantation immunodepression; and (4) pain in cancer survivors, with increasing numbers due to the success of antiblastic treatments, which have significantly improved overall survival and quality of life. In this review, non-pain specialists will find an overview including a detailed description of physiopathological mechanisms underlying central sensitization and pain chronification in bone pain, the rationale for the correct use of analgesics and invasive techniques in different pain syndromes, and the most recent recommendations published on these topics. The ultimate target of this review was to underlie that different types of pain can be observed in MM patients, and highlight that only after an accurate pain assessment, clinical examination, and pain classification, can pain be safely and effectively addressed by selecting the right analgesic option for the right patient.

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Section: Pain In Cancer Survivorsmentioning

confidence: 99%

Pain Management in Patients with Multiple Myeloma: An Update

Coluzzi

Rolke

Mercadante

2019

Cancers

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“…In addition, participants reported that referring clinicians assume palliative clinicians have expertise in managing opioid misuse and substance use disorders, despite studies suggesting significant gaps in training and knowledge in these areas. 3 In fact, some participants raised the question of whether treating opioid misuse and substance use disorders in patients with serious illness should even be within palliative care's scope. These palliative care clinicians reported that referring to appropriate specialty (eg, mental health, substance use disorder, and chronic pain clinics) or primary care clinics to manage opioid misuse, OUD, and related comorbidities is severely limited by resource constraints.…”

Section: Discussionmentioning

confidence: 99%

Managing Opioids, Including Misuse and Addiction, in Patients With Serious Illness in Ambulatory Palliative Care: A Qualitative Study

Merlin

Young

Arnold

et al. 2019

Am J Hosp Palliat Care

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Background: Pain and opioid management are core ambulatory palliative care skills. Existing literature on how to manage opioid misuse/use disorder excludes patients found in palliative care settings, such as individuals with serious illness or those at the end of life. Objectives: We conducted an exploratory study to: (1) Identify the challenges palliative care clinicians face when prescribing opioids in ambulatory settings and (2) explore factors that affect opioid decision-making. Methods: We recruited palliative care clinicians who prescribe opioids in ambulatory settings, which included open-ended questions and was conducted online. Results were analyzed qualitatively using a content analysis-based approach. Results: Eighty-three palliative care clinicians (mostly MDs/DOs) participated. Challenges faced when prescribing opioids included clinician differences in approach to care (eg, transitioning from another clinician with more permissive opioid prescribing), medication access (eg, inadequate pharmacy supply), resource constraints (eg, access to mental health and addiction expertise), managing problems outside the typical palliative care scope (eg addiction). Participants also discussed factors that influenced their opioid prescribing decisions, such as opioid-related harms and risks that they need to weigh; they also spoke about the necessity of considering other factors like the patient’s environment, disease, treatment, and prognosis. Conclusion: This study highlights the challenge of opioid management in patients with serious illness, particularly when misuse or substance use disorder is present, and suggests areas for future research focus. Our next step will be to establish consensus on approaches to opioid prescribing decision-making and policy in seriously ill patients presenting to ambulatory palliative care.

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“…Even fewer providers (36%) had training in medication-assisted treatment (MAT) for OUD, such as buprenorphine/naloxone or methadone maintenance therapy (MMT). 28 Furthermore, physician fellowship training programs in Hospice and Palliative Medicine are inconsistent in their approach to managing OUD in patients at their institutions, providing varied levels of exposure to newly minted subspecialists in Hospice and Palliative Medicine. In a survey of 38 PC fellowship program directors, for example, Tan et al 29 noted marked inconsistency in screening practices for opioid misuse; few programs (27%) had clear policies to screen for drug diversion, and fewer than half of programs had a written policy to guide patient screening for OUD.…”

Section: Oud In Cancer Survivorsmentioning

confidence: 99%

Managing Cancer Pain, Monitoring for Cancer Recurrence, and Mitigating Risk of Opioid Use Disorders: A Team-Based, Interdisciplinary Approach to Cancer Survivorship

Goodlev

DiScala

Darnall

et al. 2019

Journal of Palliative Medicine

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Background: Palliative care (PC) teams increasingly care for patients with cancer into survivorship. Cancer survivorship transcends distinctions between acute, chronic, malignant, and nonmalignant pain. Partnering with oncologists, PC teams manage pain that persists after disease-directed treatment, evaluate changing symptoms as possible signs of cancer recurrence, taper opioids and mitigate risk of opioid misuse, and manage comorbid opioid use disorder (OUD). While interdisciplinary guidelines exist for pain management in survivorship, there is a need to develop a conceptual model that fully translates the biopsychosocial framework of PC into survivorship pain management. Objective: This review frames a model for pain management in cancer survivorship that balances analgesia with the imperative to minimize risk of OUD, recognizes signs of disease recurrence, and provides whole-person care. Methods: Comprehensive narrative review of the literature. Results: Little guidance exists for co-management of pain, psychological distress, and opioid misuse in survivorship. We identified themes for whole-person pain management in survivorship: use of opioids and coanalgesic medications to prevent recurrent pain from residual tissue damage following cancer treatment, opioid tapering to the lowest effective dose, utilization of nonpharmacologic psychological interventions shown to reduce pain, screening for and management of OUD in partnership with addiction medicine specialists, maintaining vigilance for disease recurrence, and engaging in shared medical decision making. Conclusions: The management of pain in cancer survivorship is complex and requires interdisciplinary care that balances analgesia with the imperative to reduce long-term inappropriate opioid use and manage OUD, while maintaining therapeutic presence with patients in the spirit of PC.

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Managing Chronic Pain in Cancer Survivors Prescribed Long-Term Opioid Therapy: A National Survey of Ambulatory Palliative Care Providers

Cited by 52 publications

References 25 publications

Pain Management in Patients with Multiple Myeloma: An Update

Pain Management in Patients with Multiple Myeloma: An Update

Managing Opioids, Including Misuse and Addiction, in Patients With Serious Illness in Ambulatory Palliative Care: A Qualitative Study

Managing Cancer Pain, Monitoring for Cancer Recurrence, and Mitigating Risk of Opioid Use Disorders: A Team-Based, Interdisciplinary Approach to Cancer Survivorship

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