There are a lot of factors driving the current opioid epidemic and crisis. And new data suggests that persistent postoperative opioid use in patients with cancer who have undergone curative-intent cancer surgery is one of those factors, according to the research published online ahead of print in the Journal of Clinical Oncology (2017; doi:http://doi.org/10.1200/JCO.2017.74.1363).
The study followed 68,463 patients with melanoma, breast, colorectal, lung, esophageal, or hepato-pancreato-biliary/gastric cancers who underwent curative-intent surgery and filled opioid prescriptions. For the patients who had never taken opioids previous to the surgery, the risk of new persistent opioid use (meaning those who continued to fill prescriptions 90-180 days after surgery for a daily dose of the medication) was 10.4 percent.
Significantly, that's higher than the risk of persistent opioid use among opioid-naïve patients undergoing non-cancer procedures. Approximately 6-8 percent of those patients stay on opioids following their procedure.
“Patients with cancer who undergo curative-intent surgery have several potential reasons for persistently requiring opioids,” the researchers noted in the paper, including substantial postoperative pain and the fact that, because of the burden of disease, it's documented that patients with cancer are at higher risk for psychosocial distress. But an important point is that there's also research that suggests patients are unlikely to achieve relief from chronic pain by using opioids.
The findings from this new research suggest that some attention needs to be paid to cancer doctors' opioid prescribing habits, as well as how cancer care providers are educating and counseling their patients on how opioids should be used and resources to address pain and other distresses, explained the study's lead author Jay S. Lee, MD, Surgical Oncology Research Fellow at University of Michigan. Here's what else he told Oncology Times about the research and the problem it identified.
1 Why did you and your colleagues conduct this research and what was significant about these findings that wasn't known previously?
“We wanted to look at patients who had potentially curable disease, such as early stage breast cancer, colon cancer, or melanoma. These patients deserve special attention, because if they're going to be free from cancer, we'd also like them not to be on opioids long term.
“Our key finding of this study is that 10 percent of people who had never taken opioids prior to curative-intent surgery for cancer continued to take the drugs 3-6 months later. The risk is even greater for those who are treated with chemotherapy after surgery. Although previous studies have examined opioid use after non-cancer operations, our findings show that patients with cancer are particularly vulnerable to developing long-term opioid use after curative-intent surgery.
“The findings were very surprising. We're trying to help these patients. We've performed this operation to cure them of their cancer. But we've left one in 10 as chronic opioid users. That's a tremendous burden to leave with cancer survivors.”
2 Given these findings, what steps would you say need to be taken to address these concerns about such a high number of cancer patients continuing on opioids after surgery?
“First and foremost, we need to make sure we're prescribing the appropriate amount. We're conducting follow-up studies to evaluate how much patients are actually taking, and using that information to prescribe lower amounts. What we've found in our initial work is people take far less than we prescribe. Having extra pills puts these patients at risk.
“An equally important step is providing better pain management education to patients about opioids. That means that we shouldn't just hand them a pill bottle and say: ‘This is for pain; take it and good luck.’ We should be telling them that this is for severe pain only. You should use Tylenol and Motrin first—and if the pain gets really bad, then you can take opioids as a last resort.
“We also need to do a better job of counseling patients on the risks associated with opioid use. If we can do a better job educating patients, they will take less opioids with improved pain control.”
3 What would you say is most important for practicing oncologists and cancer care providers to know about these findings and postoperative opioid use among cancer patients?
“Many patients with early-stage, curable cancer continue using opioids long after curative-intent surgery. This iatrogenic complication is a substantial burden on cancer survivors and requires changes to prescribing guidelines, physician education, and patient counseling during the surveillance and survivorship phases of care. All cancer care providers must engage with patients to ensure appropriate, safe use of opioids.
“Opioids are often not effective for treating long-term pain. Patients with cancer need to be aware of these risks and engage with their care team to use opioids appropriately and safely.”