Deaths from addiction, driven by the opioid crisis, increased nearly 10 percent in 2017, according to the CDC. To put that number in perspective, drug overdoses now outpace automobile collisions as the leading cause of accidental death in the U.S.
While it's clear the opioid crisis has reached epic proportions, cancer patients are often excluded from the discussion surrounding responsible use. Why?
Historically, it's most likely due to limited treatment options for cancer pain management, forcing physicians to include opioids in their treatment plan. Clearly the treatment landscape has broadened and now includes a range of options from multimodal analgesics to radiation therapy to interventional pain management—but opioids continue to play a role.
While there have been government initiatives to address the opioid crisis, the pain experienced by cancer patients is unique. Because of this, ASCO is working with lawmakers to ensure that the creation of new safeguards for pain management does not create barriers to access for cancer patients. It will be important to continue to monitor these discussions closely because the broader epidemic isn't going away any time soon.
While media coverage surrounding opioid misuse in the cancer patient population is sparse, it is becoming clear that cancer patients are not immune to the opioid crisis. Recent studies show that opioid prescribing rates among cancer patients are substantially higher than those of other patients. According to a 2018 study published by the Journal of Clinical Oncology, cancer patients who use opioids continuously after diagnosis are at increased risk of continued use even after 5 years of survival (2018;36(15):suppl.6520).
Prescribing opioids should be approached with a complete understanding by physicians, patients, and caregivers of risks and benefits associated with these medications. Because cancer treatment can be a physically painful experience, it's important for doctors to address treatment with a multidisciplinary approach to pain management that includes the use of opioids when appropriate, but also evidence-based opioid alternatives such as minimally invasive pain medicine procedures and palliative radiation therapy. If opioids are prescribed, it is important that doctors screen for known abuse risk factors, closely monitor patients for signs of dependency, and be able to rapidly implement alternatives to opioid medication and supportive care, if necessary.
Surgery & Prolonged Opioid Use
Responsible use of opioids and increased awareness of opioid alternatives cannot be understated. It is an obligation for physicians and medical professionals to pursue reasonable solutions to this growing problem. Contrary to old-fashioned teachings that postsurgical patients were not at risk for slipping into long-term use of opioids, current evidence suggests the contrary.
For example, retrospective analysis has shown that after colectomy and knee replacement surgeries, 17.6 percent and 16.7 percent of patients, respectively, become persistent opioid users (United States for Non-Dependence: An Analysis of the Impact of Opioid Overprescribing in America). In this post-surgery realm, enhanced recovery pathways—including pain management with non-narcotic pain relievers—have proven to greatly reduce patients' exposure to narcotics. At Cancer Treatment Centers of America (CTCA) in Atlanta, we call this our ASURE program (Advanced SUrgical REcovery).
ASURE Program for Surgery Patients
We consider the ASURE pathway to be an important step in opioid reduction, setting patients on an operative course without solely relying on narcotics for pain control, thus decreasing their risk of long-term opioid dependence. Our current experience with major open intra-abdominal cancer surgeries shows that opioid reduction is possible after implementing our ASURE pathway.
Studies by CTCA surgical oncologist Kevin Watkins, MD, show opioid consumption decreased by approximately 85 percent on postoperative day 3 in patients undergoing pancreaticoduodenectomy (Whipple). This was complemented by a decrease in the incidence of Clavien-Dindo 3+ surgical complications, from 47.8 percent to 20.8 percent and a decrease in mean length of stay from 15.1 to 5.1 days.
Also, in patients undergoing open radical complete debulking for ovarian cancer, patients experienced a 94.1 percent decrease in IV narcotic use and 74.5 percent decrease in total narcotic use. Findings by CTCA gynecologic oncologists John Geisler, MD, and Kelly Manahan, MD, show that 90 days after surgery, the use of narcotics decreased from 6 percent to 1.3 percent (p<0.001) after initiation of the program (Decrease in narcotic use after initiation of an advanced surgical recovery program. 2019 Society of Gynecologic Oncology Annual Meeting). These results were accompanied by significant decreases in mean length of stay from 7.1 to 2.6 days for ovarian debulking (Changes in length of stay and 30-day readmission rates after starting an advanced surgical recovery program. 2019 Society of Gynecologic Oncology Annual Meeting).
The ASURE program is delivered by a multidisciplinary team including surgeons, anesthesiologists, nutritionists, mind-body therapists, nurses, and other clinicians working collaboratively to implement evidence-informed protocols, all under one roof. ASURE combines post-surgical rehabilitation with pre-habilitation by preparing patients before surgery. Since the start of our ASURE program, we have stopped relying on epidurals and patient-controlled analgesia for postoperative pain. Instead we use abdominal wall blocks with long-acting liposomal bupivacaine.
The old concept of opioids as a mainstay for postoperative pain control has been laid to rest; the new mainstay for postoperative pain control should be local anesthetics administered by anesthesiologists and surgeons, combined with multimodal non-opioid analgesic medications with opioid relegated to the role of rescue medication. The success of this new paradigm is underscored by compelling cases of Whipple patients leaving the hospital 3 days after surgery having received no narcotics during their entire hospital stay. Furthermore, these patients are going home with alternating doses of ibuprofen and acetaminophen for home pain management instead of opioids. Although opioids were available as a “rescue” medication, these patients show us that the old dogma—that opioid use must be part of the surgical experience—is not an absolute; even for major surgery.
With increased treatment success leading to improved rates of patients surviving cancer, care often extends well into survivorship. Therefore, we no longer can exclude cancer patients from the opioid discussion. Evidence and statistics serve as a clear warning that the opioid crisis does extend into the cancer patient population and the consequences of inaction are too great to ignore. We must act now before we get to a stage where we are treating cancer patients for opioid addiction in survivorship. How tragic it would be to win the fight against cancer but lose the war to opioid addiction.
NEIL SEELEY, MD, is the Chief of the Division of Anesthesia at Cancer Treatment Centers of America and Medical Director of Anesthesiology at CTCA Atlanta. NATHAN NEUFELD, DO, is Chief of the Division of Pain Management at Cancer Treatment Centers of America, as well as Medical Director of Pain Services and Supportive Therapies and an interventional pain management specialist at CTCA Atlanta.
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