Pain related to cancer is dynamic. Patients with cancer can experience pain related to the tumor itself. A tumor growing in an organ may stretch the part of the organ, causing pain. Tumors that metastasize to bone or to the spinal cord or a nerve can also cause pain. However, cancer-related pain can also be due to cancer treatment. Patients undergoing surgery, radiation therapy, chemotherapy, bone marrow transplant, or hormonal therapy can experience a variety of types and degrees of pain that may be long-lasting.5
“The management and care of cancer-related pain is quite complex and requires multiple disciplines to help cancer patients get control of their pain,” said Jiajoyce Conway, DNP, CRNP, AOCNP, an oncology nurse at Cancer Care Associates of York in York, Pennsylvania.
According to Dr Conway, opioids may be considered for cancer-related pain in several settings including short-term use in patients with pain due to treatment, and for the treatment of patients with advanced disease who are experiencing significant pain.
Unfortunately, since the recognition of and response to the growing opioid epidemic both Dr Conway and Ms Brady have begun to face difficulties in getting their patients their pain medication.
Opioid Epidemic Response
In 2016, several things happened to signal a growing recognition of the opioid epidemic in the United States. First, the Comprehensive Addiction and Recovery Act was signed into law. The legislation was a comprehensive attempt to address the opioid epidemic and authorized more than $180 million each year in funding to address 6 areas necessary for a coordinated response to the opioid epidemic: prevention, treatment, recovery, law enforcement, criminal justice reform, and overdose reversal.
In addition, the CDC released its “Guideline for Prescribing Opioids for Chronic Pain.”6 The guideline outlined voluntary, evidence-based recommendations for prescribing opioids in patients aged 18 years or older in a primary care setting. The guideline suggested starting with the lowest effective dose possible and prescribing only what is needed for the expected duration of pain. Specifically, it noted that a prescription for 3 days or less will often be enough to manage acute pain and a prescription for more than 7 days will rarely be needed. The CDC guideline recommendations are for the prescribing of opioid pain medications in outpatient settings outside of active cancer treatment, palliative care, and end-of-life care.
In recent years many states have also passed legislation limiting opioid prescriptions. According to the National Conference of State Legislatures, 24 states have enacted legislation limiting opioid prescribing or giving guidance related to opioid prescribing.7 Legislation in Minnesota and Kentucky limits first-time opioid prescriptions to a limit of 3 to 4 days; Hawaii, Alaska, Utah, Louisiana, Pennsylvania, New York, Massachusetts, Connecticut, Indiana, and Maine all limit first-time prescriptions to 7 days. Approximately half of the states with legislation specify that prescriptions must be for the treatment of acute pain. Similar to the CDC guidelines, most of these laws exempt treatment for cancer and palliative care.
“These opioid restrictions are supposed to carve out for cancer pain, and I think technically they do, but on a practical level it does not always work that way,” Ms Brady said. “Most people’s understanding of opioids is related to the crisis and often doesn’t distinguish between cancer pain and other pain.”
Ms Brady has seen these effects in her day-to-day care for patients. For example, some insurance companies and pharmacies are responding to the opioid crisis by being more restrictive with pain medications, she said. Brady will often have to call insurance companies and speak with several rounds of representatives in order to obtain insurance coverage for a patient to receive the type, strength, or length of opioid prescription necessary for their pain.
“This can be very frustrating and time consuming because sometimes we are making changes to pain management treatment on a day-to-day basis,” she said.
Dr Conway has also encountered these issues, adding that some insurance carriers will not authorize coverage beyond emergency 3-day or 7-day prescriptions.
Ms Brady has also heard from patients that even once an opioid prescription is approved by their insurance carrier, they may still run into issues when they go to a pharmacy to fill the prescription. “If a physician writes for 90 pills and the pharmacy says they only have 30 pills in stock, the patient may only get 30 pills and will not be able to come back to get the remainder of those pills,” she said.
“That is inadequate pain control,” Dr Conway points out. “This can lead to patients rationing out their pain medication, and in between pills they are suffering.”
Ms Brady said she has also heard of pharmacies requiring that opioid prescriptions be picked up in person by the patient. “For some patients with cancer that is a huge burden.”