Has the Pendulum Swung Too Far Against the Use of Opioids?

MHE Publication, MHE April 2022, Volume 32, Issue 4

Patients with cancer who have a poor prognosis may face obstacles in accessing critical pain medications.

On Jan. 3, 2022, the federal government officially renewed a declaration that the opioid epidemic is a public health crisis. Although the COVID-19 pandemic has overshadowed the opioid epidemic, the number of people in the U.S. dying from opioid overdoses has recently increased. According to preliminary data from the CDC, the number of overdose deaths from opioids rose to 75,673 in the 12-month period, ending in April 2021, and there was a 35% increase from 56,064 deaths recorded during the prior 12 months.

Federal government agencies and state health officials have taken various steps to clamp down on opioid prescribing in response to the epidemic. For example, most states have set a limit on the amounts of opioids physicians can prescribe. But some oncologists say the well-intentioned efforts have had the unintended consequence of preventing patients with cancer from getting essential pain relief.

“There has been so much attention in the media about the opioid epidemic — the overdoses and inappropriate prescribing. But many cancer doctors are seeing a spillover effect in our patients,” says Andrea Enzinger, M.D., an oncologist at the Dana-Farber Cancer Institute in Boston, whose research focuses on palliative care. “Patients are more fearful now. Those in end-stage cancer and in terrible pain are telling us they are afraid to use opioids and don’t want to get addicted.”

But patient apprehension is not the only issue. Enzinger notes there are some patients with cancer who want to use opioids but face multiple obstacles to getting them, whether that be because of pharmacies not having the medications in stock, prior authorization requirements or questioning by pharmacists. “Stricter opioid regulations have not intended for cancer to be the targets, and certainly not [those] who are dying,” she says. Enzinger also found there has been very little research into opioid use among patients with cancer during the opioid epidemic and the crackdown on opioid prescription. She decided to change that.

Enzinger is the lead author of a study on trends in opioid access among patients with cancer who have a poor prognosis that was published last year in the Journal of Clinical Oncology. Enzinger and her team analyzed a data set that included almost 280,000 Medicare beneficiaries with cancer who had a poor prognosis and who died between 2007 and 2017. When they looked at metrics of opioid utilization during the last 30 days of life, they identified a 34% decrease in opioid prescription fills and a 38% decrease in the total dose of opioids filled per decedent.

“That gives a good overall sense of what’s happening. A 38% decline in the amount of opioids prescribed in the last month of life per patient who died is a huge drop, particularly because there is a lot of literature that shows undertreatment of cancer pain has been a major problem,” Enzinger says. “If you are cutting the supply of opioids going to cancer patients, it’s a big problem.”

Enzinger and her colleagues also found a 50% reduction in filled prescriptions for long-acting opioids, which is not surprising, because they’ve been more tightly regulated than short-acting formulations because of their potential for abuse. But Enzinger says patients with severe cancer pain often need long-acting opioids.

“If you have a tumor sitting on your nerve, causing severe pain all the time, (and) if you don’t have a sustained-release medication, you’re chasing your pain all day and have to take something every two hours, even when you are trying to sleep,” Enzinger says. “It’s troubling.”

As opioid prescriptions fell, the results of Enzinger and her colleagues’ study showed that the proportion of patients making pain-related trips to the emergency department increased by 50%. “Among patients with terminal cancer, there have been substantial declines in opioid access and an increase in treatment of pain through the emergency department,” Enzinger says. “That suggests strongly that people are not able to manage their pain as well at home or do not have something in their medicine cabinet when having severe pain at night.”

Addiction worries

As with all medications, opioids have benefits and risks. There is a risk of addiction, particularly for those with a prior history of substance use. Before prescribing, physicians are supposed to assess a person’s addiction risk with a variety of assessment tools. However, the risk of addiction for those with chronic pain and no prior history of substance use is not as common as some might think.

Nora Volkow, director of the National Institute of Drug Abuse, is on record as saying that, unlike tolerance and physical dependence, addiction is not a predictable result of opioid prescribing. “Addiction occurs in only a small percentage of persons who are exposed to opioids, even among those with preexisting vulnerabilities,” she said.

A study from the University of Michigan found that approximately 6% of patients who take opioids for the first time to relieve pain after surgery end up taking the medications for longer than clinically recommended. And dependency on opioids is a reality among patients with cancer. A number of studies have shown that because many patients with cancer require opioid analgesia (pain relief) for an extended period, they do, in fact, become dependent on the drug and will need higher and higher doses to get the same pain relief. If they stop taking the drug, they may experience withdrawal symptoms. But dependence and the need for greater doses are secondary concerns if patients are in pain and have a poor prognosis.

Navigating use the appropriate use of opioids is a challenge for patients and physicians, according to experts and countless physicians and patients. Many physicians would like to opioids used for a short while untill pain is treated in some other way — with PT, surgery or medications that are less likely to lead to dependency. But often that doesn’t happen. And many see a role for opioids in pain management for patients with cancer even if they are not at the end of life if the drugs help them be comfortable and can help with a good quality of life.

Cindy Steinberg, director of policy and advocacy at the U.S. Pain Foundation, a nonprofit organization sponsored by pharmaceutical companies, says that when pain persists for three months or longer, it becomes a disease of the nervous system and brain. “If it was caused by cancer, it could be from the disease itself damaging nerves or tissue, advanced disease causing increased damage, or the treatment itself, such as the type of chemotherapy or radiation causing damage,” she says.

“The best way to manage any type of chronic pain — including cancer pain — is through an individualized, multidisciplinary approach combining a number of treatment options,” Steinberg says. “There are many different medications that treat pain, and opioids are one important option in the toolbox, particularly for severe pain.”

Enzinger says efforts to combat the opioid epidemic must also balance the needs of patients with cancer who are experiencing pain.

“Patients face enough barriers as is,” she says. “(There is a) fear of being addicted or (some patients) think it’s a sign of weakness. Pharmacists asking why they are taking them, which sends the message they shouldn’t be using it. There needs to be more attention that this population needs protecting, even while we as a society are grappling with the opioid epidemic.” 

Keith Loria is a freelance writer in the Washington, D.C., area.