Most patients with cancer experience pain during their journey: 55% during treatment; 66.4% during advanced, metastatic, or terminal disease stages; and 39.3% after curative treatment.

 Opioids are prescribed to manage cancer pain because the benefits generally outweigh the risks and because of the ethical imperative for quick relief.

However, although opioids relieve cancer pain, patients are exposed to a degree of risk for misuse and abuse.

 Even with the appropriate management of cancer pain, the possibility of misuse, abuse, addiction, and diversion exists.

Safe prescribing of opioids must be the cornerstone of practice for every prescriber.

 Several societies provide clinical guidelines to reduce the risk of misuse and abuse.

 The FDA’s Risk Evaluation and Mitigation Strategy (REMS) program details prescriber duties for management of pain with opioids.

 National Comprehensive Cancer Network (NCCN) guidelines describe the application of REMS for patients with cancer and outline strategies to identify patients’ potential for opioid misuse and abuse.

 However, guidelines from professional organizations that specifically address the assessment and management of opioid-use disorder for patients with cancer are lacking.

Table. A Framework for Managing Opioid use in Patients With Cancer Pain

Prescribers must consider multiple ways to screen and monitor for aberrant behavior among patients with cancer who receive opioids.

At Vanderbilt-Ingram Cancer Center, we use the following strategies in our Supportive Oncology Care Clinic based on best evidence and recommendations (

Universal precautions, the current approach to screening and monitoring patients who receive opioid therapy, require interventions and diagnostic tools to assess risk and monitor patients for aberrant behavior.

The NCCN Guidelines for Adult Cancer Pain recommend an evaluation of patient risk factors for aberrant use of opioids prior to prescribing opioid therapy.

Both a sensitive screening tool and comprehensive interview should be used to obtain patient-reported information related to previous and current status of mental health, sexual abuse, substance abuse, social functioning, and family history.

The guidelines suggest using the revised Screener and Opioid Assessment for Patients with Pain

Based on identified risk factors for abuse and misuse, providers should categorize patients as low, moderate, or high risk and inform patients of their classification. The risk category determines the amount of support and appropriate safety measures necessary to deter possible aberrant behavior throughout opioid treatment.4,13 Patients must understand the rationale of the assessment and that their risk category will not impede proper care.5,11

Patients who receive opioids to manage pain should be monitored routinely for aberrant drugtaking behaviors or diversion, in combination with red flag behaviors that require additional inquiry.

 These behaviors, such as a request for an early refill or a claim of a lost prescription, may indicate uncontrolled pain or other bothersome symptoms (eg, anxiety or depression) or diversion of the prescriptions.

 Prescribers should inform patients that monitoring strategies are routine practice for all patients to ensure the safety of their pain management.

Prescribers should review patients’ pain diaries to monitor the quantity and time of each scheduled and as-needed opioid dose.

Providers should confirm diary records with pill counts to monitor for aberrant behavior.

Prescribers should use a valid assessment tool throughout management of patients’ pain to monitor for aberrant behavior.

 A common and validated tool is the Current Opioid Misuse Measure,

a self-assessment that rates indicators based on the previous 30 days. The Addiction Behavior Checklist

 is another reliable tool for examining a patient’s report and the prescriber’s direct observations over time.

Prescribers should have patients complete a urine drug test at the initiation of opioid therapy and then at least twice a year, with frequency based on risk level, to determine the presence of an illicit or nonprescribed substance and the presence or absence of prescribed medication.

Prescription drug monitoring programs collect dispensing data about controlled prescription drugs. Depending on individual state laws and program availability, prescribers should use the database to search a patient’s history regarding this information.

Prescribers should include patients and caregivers in the care plan and educate them about risks for misuse and abuse, as well as the responsible use of opioids.

 Education should include the dangers of sharing opioids and the importance of safe storage and disposal, effects of combining opioids with alcohol or illegal substances, and precautions to take opioids just as prescribed.

Patient—provider agreements are not required by law, but prescribers may mandate an agreement with patients for whom they prescribe opioids. Agreements describe expectations for both patient and provider, formalize the agreed-upon plan to manage pain, and state the risks and benefits of opioids.

In conclusion, safety for patients and families must be at the forefront of each prescriber’s protocols, with careful screening and monitoring of every patient who receives opioids incorporated into the treatment plan. Despite a gap in the practice of mitigation strategies among prescribers who manage cancerrelated pain,

providers should at least follow best evidence to assess and monitor for opioid abuse and misuse.

van den Beuken-van Everdingen MJ, Hochstenbach LJ, Joosten EA, Tjan-Heijnen VC, Janssen DJ. Update on prevalence of pain in patients with cancer: systematic review and meta-analysis. 

 June 2016;51(6):1070-1090. doi: 10.1016/j.jpainsymman.2015.12.340.

National Academy of Medicine (NAM). First do no harm: marshaling clinician leadership to counter the opioid epidemic. Washington, DC: National Academy of Medicine; 2017. nam.edu/wp-content/uploads/2017/09/First-Do-No-Harm-Marshaling-Clinician-Leadership- to-Counter-the-Opioid-Epidemic.pdf. Accessed May 29, 2018.

Passik SD. Issues in long-term opioid therapy: unmet needs, risks, and solutions. 

 2009;84(7):593-601. doi: 10.1016/S0025-6196(11)60748-9.

Anghelescu DL, Ehrentraut JH, Faughnan LG. Opioid misuse and abuse: risk assessment and management in patients with cancer pain. 

. 2013;11(8):1023-1031. doi: 10.6004/jnccn.2013.0120.

NCCN clinical practice in guidelines in oncology: adult cancer pain version 1.2018. nccn.org/professionals/physician_gls/pdf/pain_basic.pdf. Accessed July 3, 2018.

Paice JA, Portenoy J, Lacchetti C, et al. Management of chronic pain in survivors of adult cancers: American Society Of Clinical Oncology Clinical Practice Guideline. 

2016;34(27):3325-3345. doi:10.1200/JCO.2016.68.5206.

Chou R, Fanciullo G J, Fine PG, Miaskowski C, Passik SD, Portenoy RK. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors. 

 2009;10(2):131-146. doi:10.1016/j.jpain.2008.10.009.

Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain— United States. 2016 [Erratum in: MMWR Recomm Rep. 2016;65(11):295]. 

. 2016;65(1):1-49. doi:10.1001/jama.2016.1464.

Risk evaluation and mitigation strategies (REMS) for extended-release and long-acting opioids. US Food and Drug Administration website. fda.gov/drugs/drugsafety/informationbydrugclass/ ucm163647.htm. Updated February 27, 2018. Accessed May 30, 2018.

Carmichael AN, Morgan L, Del Fabbro E. Identifying and assessing the risk of opioid abuse in patients with cancer: an integrative review.

Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R).

. 2008;9(4):360-372. doi: 10.1016/j.jpain.2007.11.014.

Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool.

2005;6(6):432—442. doi:10.1111/ j.1526-4637.2005.00072.x.

Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. 

2012;15(3 suppl):ES67-ES92. thblack.com/links/RSD/PainPhys2012_15_ES67_ RxOpioidAbuseInChronPain-26p.pdf Accessed May 30, 2018.

Butler SF, Budman SH, Fanciullo GJ, Jaminson, RN. Cross validation of the Current Opioid Misuse Measure to monitor chronic pain patients on opioid therapy. 

 2010;26(9):770—776. doi:10.1097/AJP.0b013e3181f195ba.

Wu SM, Compton P, Bolus R, et al. The addiction behaviors checklist: validation of a new clinician-based measure of inappropriate opioid use in chronic pain.

. 2006;32(4):342-351. doi: 10.1016/j.jpainsymman.2006.05.010.

Owen GT, Burton AW, Schade CM, Passik S. Urine drug testing: current recommendations and best practices. 

, 2012;15(suppl 3):ES119-ES133. painphysicianjournal. com/current/pdf?article=MTcxMA%3D%3D&journal=68. Accessed May 30, 2018.

Articles

Opioids are prescribed to manage cancer pain because the benefits generally outweigh the risks and because of the ethical imperative for quick relief. However, patients are exposed to a degree of risk for misuse and abuse.

M. Rachel McDowell, ANCP-BC

Articles

Developing Best Practices to Mitigate Opioid Abuse Is a Priority in Cancer Care