Skip to main content

Advertisement

Log in

Opioid Prescribing in an Opioid Crisis: What Basic Skills Should an Oncologist Have Regarding Opioid Therapy?

  • Palliative and Supportive Care (MP Davis, Section Editor)
  • Published:
Current Treatment Options in Oncology Aims and scope Submit manuscript

Opinion statement

Although clinical evidence supports the use of opioids for cancer-related pain, doing so amidst the current opioid crisis remains a challenge. A proportion of opioid-related deaths in the USA are attributable to prescription opioids, which implicates health care providers as one of the major contributors. It is therefore even more important now for all clinicians to follow safe and effective opioid prescribing practices. Oncologists are often in the frontline of cancer pain management. They are encouraged to use validated tools to screen all patients receiving opioids for high risk behaviors. Those identified as high risk for potential abuse of opioids should be monitored closely. When aberrant behavior is detected, the clinician will need to openly discuss the issue and its possible implications. Oncologists may then implement measures such as limiting the dose and quantity of opioids prescribed, shortening interval between follow-ups for refills to allow for increased monitoring, setting boundaries/limitations, weaning off opioid analgesics, or/and referring to a pain or palliative medicine or drug addiction expert for co-management when necessary. These efforts may aid oncologists in safely managing cancer pain in the environment of national opioid crisis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Caraceni A, Hanks G, Kaasa S, Bennett MI, Brunelli C, Cherny N, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. 2012;13(2):e58–68.

    Article  CAS  Google Scholar 

  2. •• Arthur J, Bruera E. Balancing opioid analgesia with the risk of nonmedical opioid use in patients with cancer. Nat Rev Clin Oncol 2018. Gives an up-to-date in-depth description of the topic.

  3. •• CDC NCfHS. Wide-ranging online data for epidemiologic research (WONDER). 2017; http://wonder.cdc.gov. Accessed May 7, 2018. Provides relevant current data on the epidemiology of the opioid crisis.

  4. • Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths–United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(50–51):1378–82 Provides relevant current data on the epidemiology of the opioid crisis.

    Article  Google Scholar 

  5. Report of the President’s Commission on Combating Drug Addiction and the Opioid Crisis. November 1, 2017. 2017; https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf. Accessed 01/18/2019.

  6. Drug Enforcement Administration DoJ. Schedules of controlled substances: rescheduling of hydrocodone combination products from schedule III to schedule II. Final rule. Fed Regist. 2014;79(163):49661–82.

    Google Scholar 

  7. ASCO Policy Statement on Opioid Therapy: Protecting access to treatment for cancer-related pain. 2016:16. http://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/2016_ASCO%20Policy%20Statement%20on%20Opioid%20Therapy.pdf. Accessed 01/24/2017.

  8. Commision TJ. Pain management 2018; https://www.jointcommission.org/topics/pain_management.aspx. Accessed May 28, 2018.

  9. Seth P, Scholl L, Rudd RA, Bacon S. Overdose deaths involving opioids, cocaine, and psychostimulants–United States, 2015-2016. MMWR Morb Mortal Wkly Rep. 2018;67(12):349–58.

    Article  Google Scholar 

  10. Lipari RN, Hughes A. How people obtain the prescription pain relievers they misuse. The CBHSQ report. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013;1–7.

  11. Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016;374(2):154–63.

    Article  CAS  Google Scholar 

  12. Hughes A, Williams, M. R., Lipari., R. N., Bose, J., Copello, E. A. P., & Kroutil, L. A. Prescription drug use and misuse in the United States: results from the 2015 National Survey on Drug Use and Health. 2015; http://www.samhsa.gov/data/sites/default/files/NSDUH-FFR2-2015/NSDUH-FFR2-2015.htm. Accessed 5/12, 2018.

  13. Schroeder AR, Dehghan M, Newman TB, Bentley JP, Park KT. Association of opioid prescriptions from Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA Intern Med. 2018.

  14. Howard R, Fry B, Gunaseelan V, et al. Association of Opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg. 2018:e184234.

    Article  Google Scholar 

  15. •• Blendon RJ, Benson JM. The public and the opioid-abuse epidemic. N Engl J Med. 2018;378(5):407–11 This articles gives new information about how the public percieves the opioid crisis.

    Article  Google Scholar 

  16. Doctor JN, Nguyen A, Lev R, Lucas J, Knight T, Zhao H, et al. Opioid prescribing decreases after learning of a patient's fatal overdose. Science. 2018;361(6402):588–90.

    Article  CAS  Google Scholar 

  17. Prevention CfDCa. Annual surveillance report of drug-related risks and outcomes — United States, 2017. 2017; https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf. Accessed 06/25, 2018.

  18. Murthy VH. Ending the opioid epidemic - a call to action. N Engl J Med. 2016;375(25):2413–5.

    Article  Google Scholar 

  19. •• Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. JAMA. 2016;315(15):1624–45. A very useful opioid prescribing guideline for clinicians.

    Article  CAS  Google Scholar 

  20. Paice JA, Portenoy R, Lacchetti C, Campbell T, Cheville A, Citron M, et al. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016;34(27):3325–45.

    Article  Google Scholar 

  21. Derogatis LR, Morrow GR, Fetting J, Penman D, Piasetsky S, Schmale AM, et al. The prevalence of psychiatric disorders among cancer patients. JAMA. 1983;249(6):751–7.

    Article  CAS  Google Scholar 

  22. Passik SD, Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 1: prevalence and diagnosis. Oncology (Williston Park). 1998;12(4):517–21 524.

  23. • Arthur JA, Edwards T, Lu Z, et al. Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic. Cancer. 2016;122(23):3732–9 Provides current information about aberrant opioid use in cancer patients.

    Article  CAS  Google Scholar 

  24. Rauenzahn S, Sima A, Cassel B, Noreika D, Gomez TH, Ryan L, et al. Urine drug screen findings among ambulatory oncology patients in a supportive care clinic. Support Care Cancer. 2017;25:1859–64.

    Article  Google Scholar 

  25. Carmichael AN, Morgan L, Del Fabbro E. Identifying and assessing the risk of opioid abuse in patients with cancer: an integrative review. Subst Abus Rehabil. 2016;7:71–9.

    Google Scholar 

  26. Kwon JH, Tanco K, Park JC, Wong A, Seo L, Liu D, et al. Frequency, predictors, and medical record documentation of chemical coping among advanced cancer patients. Oncologist. 2015;20(6):692–7.

    Article  CAS  Google Scholar 

  27. Kwon JH, Hui D, Chisholm G, Bruera E. Predictors of long-term opioid treatment among patients who receive chemoradiation for head and neck cancer. Oncologist. 2013;18(6):768–74.

    Article  Google Scholar 

  28. Koyyalagunta D, Bruera E, Engle MP, et al. Compliance with opioid therapy: distinguishing clinical characteristics and demographics among patients with cancer pain. Pain Med. 2018;19(7):1469–77.

    Article  Google Scholar 

  29. Starr TD, Rogak LJ, Passik SD. Substance abuse in cancer pain. Curr Pain Headache Rep. 2010;14(4):268–75.

    Article  Google Scholar 

  30. Arthur J, Hui D. Safe opioid use: management of opioid-related adverse effects and aberrant behaviors. Hematol Oncol Clin North Am. 2018;32(3):387–403.

    Article  Google Scholar 

  31. Katz NP, Adams EH, Chilcoat H, Colucci RD, Comer SD, Goliber P, et al. Challenges in the development of prescription opioid abuse-deterrent formulations. Clin J Pain. 2007;23(8):648–60.

    Article  Google Scholar 

  32. Kwon JH, Hui D, Bruera E. A pilot study to define chemical coping in cancer patients using the delphi method. J Palliat Med. 2015;18(8):703–6.

    Article  Google Scholar 

  33. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Washington: American Psychiatric Association; 2013.

  34. Kelly JF, Saitz R, Wakeman S. Language, substance use disorders, and policy: the need to reach consensus on an “addiction-ary”. Alcohol Treat Q. 2016;34(1):116–23.

    Article  Google Scholar 

  35. Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy. 2010;21(3):202–7.

    Article  Google Scholar 

  36. • Scholten W, Simon O, Maremmani I, et al. Access to treatment with controlled medicines rationale and recommendations for neutral, precise, and respectful language. Public Health. 2017;153:147–53 Provides alternative suggestions to common terminologies in describing the problem.

    Article  CAS  Google Scholar 

  37. Chou R. 2009 Clinical Guidelines from the American Pain Society and the American Academy of Pain Medicine on the use of chronic opioid therapy in chronic noncancer pain: what are the key messages for clinical practice? Pol Arch Med Wewn. 2009;119(7–8):469–77.

    PubMed  Google Scholar 

  38. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107–12.

    Article  Google Scholar 

  39. Reddy A, de la Cruz M, Rodriguez EM, Thames J, Wu J, Chisholm G, et al. Patterns of storage, use, and disposal of opioids among cancer outpatients. Oncologist. 2014;19(7):780–5.

    Article  Google Scholar 

  40. •• de la Cruz M, Reddy A, Balankari V, Epner M, Frisbee-Hume S, Wu J, et al. The impact of an educational program on patient practices for safe use, storage, and disposal of opioids at a comprehensive cancer center. Oncologist. 2017;22(1):115–21 Demonstrates the importance of opioid education.

    Article  Google Scholar 

  41. Edlund MJ, Martin BC, Fan MY, Devries A, Braden JB, Sullivan MD. Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP study. Drug Alcohol Depend. 2010;112(1-2):90–8.

    Article  Google Scholar 

  42. Williams N. The CAGE questionnaire. Occup Med (Lond). 2014;64(6):473–4.

    Article  Google Scholar 

  43. Bernadt MW, Mumford J, Taylor C, Smith B, Murray RM. Comparison of questionnaire and laboratory tests in the detection of excessive drinking and alcoholism. Lancet. 1982;1(8267):325–8.

    Article  CAS  Google Scholar 

  44. Dyson V, Appleby L, Altman E, Doot M, Luchins DJ, Delehant M. Efficiency and validity of commonly used substance abuse screening instruments in public psychiatric patients. J Addict Dis. 1998;17(2):57–76.

    Article  CAS  Google Scholar 

  45. Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain. 2004;112(1-2):65–75.

    Article  CAS  Google Scholar 

  46. Moore TM, Jones T, Browder JH, Daffron S, Passik SD. A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Med. 2009;10(8):1426–33.

    Article  Google Scholar 

  47. Butler SF, Budman SH, Fernandez KC, Fanciullo GJ, Jamison RN. Cross-validation of a screener to predict opioid misuse in chronic pain patients (SOAPP-R). J Addict Med. 2009;3(2):66–73.

    Article  Google Scholar 

  48. Koyyalagunta D, Bruera E, Aigner C, Nusrat H, Driver L, Novy D. Risk stratification of opioid misuse among patients with cancer pain using the SOAPP-SF. Pain Med. 2013;14(5):667–75.

    Article  Google Scholar 

  49. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool. Pain Med. 2005;6(6):432–42.

    Article  Google Scholar 

  50. Barclay JS, Owens JE, Blackhall LJ. Screening for substance abuse risk in cancer patients using the opioid risk tool and urine drug screen. Support Care Cancer. 2014;22(7):1883–8.

    Article  Google Scholar 

  51. Adams LL, Gatchel RJ, Robinson RC, Polatin P, Gajraj N, Deschner M, et al. Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients. J Pain Symptom Manag. 2004;27(5):440–59.

    Article  Google Scholar 

  52. Holmes CP, Gatchel RJ, Adams LL, Stowell AW, Hatten A, Noe C, et al. An opioid screening instrument: long-term evaluation of the utility of the pain medication questionnaire. Pain Pract. 2006;6(2):74–88.

    Article  Google Scholar 

  53. Butler SF, Budman SH, Fanciullo GJ, Jamison RN. Cross validation of the current opioid misuse measure to monitor chronic pain patients on opioid therapy. Clin J Pain. 2010;26(9):770–6.

    Article  Google Scholar 

  54. Wu SM, Compton P, Bolus R, Schieffer B, Pham Q, Baria A, et al. The addiction behaviors checklist: validation of a new clinician-based measure of inappropriate opioid use in chronic pain. J Pain Symptom Manag. 2006;32(4):342–51.

    Article  Google Scholar 

  55. Lawrence R, Mogford D, Colvin L. Systematic review to determine which validated measurement tools can be used to assess risk of problematic analgesic use in patients with chronic pain. Br J Anaesth. 2017;119(6):1092–109.

    Article  CAS  Google Scholar 

  56. Anghelescu DL, Ehrentraut JH, Faughnan LG. Opioid misuse and abuse: risk assessment and management in patients with cancer pain. J Natl Compr Cancer Netw. 2013;11(8):1023–31.

    Article  CAS  Google Scholar 

  57. Owen GT, Burton AW, Schade CM, Passik S. Urine drug testing: current recommendations and best practices. Pain Physician. 2012;15(3 Suppl):ES119–33.

    PubMed  Google Scholar 

  58. Magnani B, Kwong T. Urine drug testing for pain management. Clin Lab Med. 2012;32(3):379–90.

    Article  Google Scholar 

  59. Peppin JF, Passik SD, Couto JE, Fine PG, Christo PJ, Argoff C, et al. Recommendations for urine drug monitoring as a component of opioid therapy in the treatment of chronic pain. Pain Med. 2012;13(7):886–96.

    Article  Google Scholar 

  60. Feldman L, Skeel Williams K, Knox M, Coates J. Influencing controlled substance prescribing: attending and resident physician use of a state prescription monitoring program. Pain Med. 2012;13(7):908–14.

    Article  Google Scholar 

  61. Wang J, Christo PJ. The influence of prescription monitoring programs on chronic pain management. Pain Physician. 2009;12(3):507–15.

    PubMed  Google Scholar 

  62. Prescription drug monitoring program training and technical assistance center. http://www.pdmpassist.org/content/state-pdmp-websites. Accessed 10/01, 2017.

  63. Bao Y, Pan Y, Taylor A, Radakrishnan S, Luo F, Pincus HA, et al. Prescription drug monitoring programs are associated with sustained reductions in opioid prescribing by physicians. Health Aff (Millwood). 2016;35(6):1045–51.

    Article  Google Scholar 

  64. Comer SD, Sullivan MA, Whittington RA, Vosburg SK, Kowalczyk WJ. Abuse liability of prescription opioids compared to heroin in morphine-maintained heroin abusers. Neuropsychopharmacology. 2008;33(5):1179–91.

    Article  CAS  Google Scholar 

  65. Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy J, Ilgen MA, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315–21.

    Article  CAS  Google Scholar 

  66. Wightman R, Perrone J, Portelli I, Nelson L. Likeability and abuse liability of commonly prescribed opioids. J Med Toxicol. 2012;8(4):335–40.

    Article  CAS  Google Scholar 

  67. Vosburg SK, Severtson SG, Dart RC, Cicero TJ, Kurtz SP, Parrino MW, et al. Assessment of tapentadol API abuse liability with the researched abuse, diversion and addiction-related surveillance system. J Pain. 2018;19(4):439–53.

    Article  Google Scholar 

  68. Cicero TJ, Ellis MS, Kasper ZA. Relative preferences in the abuse of immediate-release versus extended-release opioids in a sample of treatment-seeking opioid abusers. Pharmacoepidemiol Drug Saf. 2017;26(1):56–62.

    Article  CAS  Google Scholar 

  69. Miller M, Barber CW, Leatherman S, Fonda J, Hermos JA, Cho K, et al. Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med. 2015;175(4):608–15.

    Article  Google Scholar 

  70. Defense USDoVAUSDo. VA/DoD clinical practice guideline for opioid therapy for chronic pain 2017; www.healthquality.va.gov/guidelines/Pain/cot/. Accessed May 9, 2018.

  71. Marsch LA, Bickel WK, Badger GJ, Rathmell JP, Swedberg MD, Jonzon B, et al. Effects of infusion rate of intravenously administered morphine on physiological, psychomotor, and self-reported measures in humans. J Pharmacol Exp Ther. 2001;299(3):1056–65.

    CAS  PubMed  Google Scholar 

  72. Dart RC, Iwanicki JL, Dasgupta N, Cicero TJ, Schnoll SH. Do abuse deterrent opioid formulations work? J Opioid Manag. 2017;13(6):365–78.

    Article  Google Scholar 

  73. Vadivelu N, Schermer E, Kodumudi G, Berger JM. The clinical applications of extended-release abuse-deterrent opioids. CNS Drugs. 2016;30(7):637–46.

    Article  CAS  Google Scholar 

  74. Jones CM, McAninch JK. Emergency department visits and overdose deaths from combined use of opioids and benzodiazepines. Am J Prev Med. 2015;49(4):493–501.

    Article  Google Scholar 

  75. Park TW, Saitz R, Ganoczy D, Ilgen MA, Bohnert AS. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study. BMJ. 2015;350:h2698.

    Article  Google Scholar 

  76. Mehta RD, Roth AJ. Psychiatric considerations in the oncology setting. CA Cancer J Clin. 2015;65(4):300–14.

    Article  Google Scholar 

  77. •• Gomes T, Juurlink DN, Antoniou T, Mamdani MM, Paterson JM, van den Brink W. Gabapentin, opioids, and the risk of opioid-related death: a population-based nested case-control study. PLoS Med. 2017;14(10):e1002396 Provides new and relevant data on the concurrent use of gabapentin and opioids.

    Article  Google Scholar 

  78. Walley AY, Doe-Simkins M, Quinn E, Pierce C, Xuan Z, Ozonoff A. Opioid overdose prevention with intranasal naloxone among people who take methadone. J Subst Abus Treat. 2013;44(2):241–7.

    Article  Google Scholar 

  79. Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, et al. Release from prison–a high risk of death for former inmates. N Engl J Med. 2007;356(2):157–65.

    Article  CAS  Google Scholar 

  80. • Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245–52 One of the very few recent studies demonstrating the benefits of naloxone use in opioid prescribing practice.

    Article  Google Scholar 

  81. Khantzian EJ, Treece C. DSM-III psychiatric diagnosis of narcotic addicts. Recent findings. Arch Gen Psychiatry. 1985;42(11):1067–71.

    Article  CAS  Google Scholar 

  82. Jamison RN, Ross EL, Michna E, Chen LQ, Holcomb C, Wasan AD. Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial. Pain. 2010;150(3):390–400.

    Article  Google Scholar 

  83. Mishra SI, Scherer RW, Snyder C, et al. Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database Syst Rev. 2012(8). https://doi.org/10.1002/14651858.CD008465.pub2.

  84. Choi TY, Lee MS, Kim TH, Zaslawski C, Ernst E. Acupuncture for the treatment of cancer pain: a systematic review of randomised clinical trials. Support Care Cancer. 2012;20(6):1147–58.

    Article  Google Scholar 

  85. Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni PA. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database Syst Rev. 2011;3:CD007519.

    Google Scholar 

  86. Meghani SH, Wiedemer NL, Becker WC, Gracely EJ, Gallagher RM. Predictors of resolution of aberrant drug behavior in chronic pain patients treated in a structured opioid risk management program. Pain Med. 2009;10(5):858–65.

    Article  Google Scholar 

  87. •• Arthur J, Edwards T, Reddy S, et al. Outcomes of a specialized interdisciplinary approach for patients with cancer with aberrant opioid-related behavior. Oncologist. 2018;23(2):263–70. This article describes a novel way of addressing aberrant opioid behavior in cancer patients.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Akhila Reddy MD.

Ethics declarations

Conflict of Interest

Joseph Arthur and Akhila Reddy declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Palliative and Supportive Care

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Arthur, J., Reddy, A. Opioid Prescribing in an Opioid Crisis: What Basic Skills Should an Oncologist Have Regarding Opioid Therapy?. Curr. Treat. Options in Oncol. 20, 39 (2019). https://doi.org/10.1007/s11864-019-0636-3

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11864-019-0636-3

Keywords

Navigation