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PHOENIX-In the midst of the national opioid epidemic, two new studies explore opioid use in cancer care. The studies compared opioid deaths among cancer patients to the general population and looked at an initiative to reduce opioid use after oncology surgeries. Researchers presented their findings at the 2018 ASCO Quality Care Symposium.

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Deaths Attributed to Opioids

Cancer patients were 10 times less likely to have deaths attributed to opioid use than the general population, according to a new retrospective study from researchers at Duke University, Durham, N.C. The study, conducted over a 10-year period (2006-2016), is the first to comprehensively explore the risks associated with opioid use among cancer patients.


"Patients with cancer often rely on opioids to help manage their pain during treatment and to live comfortably with the disease. Without adequate pain management, patients can be forced to take breaks from life-saving therapy or become hospitalized due to the side effects of treatment," said Fumiko Chino, MD, lead author of the study and Radiation Oncologist with the Duke Cancer Institute. "This study should provide both oncologists and patients with some reassurance that opioids can be a safe and effective option for managing cancer-related pain."


To determine the number of opioid deaths among patients with cancer, researchers evaluated death certificates from the National Center for Health Statistics where opioids were listed as the primary cause of death and cancer was noted as a contributing cause. For the general population, they reviewed certificates where opioids were listed as the primary cause, but cancer was not mentioned. According to Chino, a limitation of this study is that the certificates did not provide any indication of the stage of cancer or treatment status at death. In addition, recent evidence suggests that opioid-related overdose deaths may be under-reported on death certificates because of incomplete cause-of-death reporting, indicating that the actual number of opioid-related deaths may be higher than they appear.


According to the death certificates, from 2006 to 2016, there were 895 deaths caused by opioids in cancer patients, compared to 193,500 in the general population. Researchers found that the incidence of opioid deaths increased significantly in the general population (from 5.33 to 8.97 per 100,000 people) but only slightly among patients with cancer (from 0.52 to 0.66 per 100,000). Deaths from opioid use were highest in patients with lung (22%), gastrointestinal (21%), head and neck (12%), hematological (11%), and genitourinary (10%) cancers.


Chino and colleagues noted that further research should explore how regulations to address the opioid crisis are affecting access to opioids for patients with cancer and the ability of their physicians to prescribe these medications to help manage cancer-related pain.


Opioid Use in Surgical Oncology

In a study conducted by Stanford Health Care, researchers achieved a 46 percent reduction in opioid use among 443 patients with cancer who underwent a range of urologic surgeries without increasing their pain or anxiety. They achieved this reduction through a two-pillared approach: 1) maximizing the use of over-the-counter non-opioid therapies, and 2) changing the nature of post-surgery discussions with patients.


"While opioids can be an effective pain management tool for cancer patients, there is a risk of addiction, particularly for people who have recently undergone surgery," said lead author Kerri Stevenson, MN, NP-C, RNFA, CWOCN, a nurse practitioner at Stanford Health Care. "We found that when you have conversations with patients about pain control, including non-opioid therapies available and the potential risks associated with opioids, they appreciate being involved in their own care and, subsequently, have a reduced need for opioid medications."


Many patients first encounter opioids when they are prescribed for acute pain management after surgery, and an estimated 6 percent of patients who are not regular opioid users become newly addicted to these medications post-surgery.


The first pillar of the researchers' strategy entailed developing care pathways for postoperative pain control utilizing non-opioid medications and therapies as first line. This included educating providers and nurses about the availability and efficacy of the treatment plans. Patients were still prescribed opioids but at lower doses and only escalated if necessary.


The second pillar involved changing postoperative conversations with patients. Rather than having nurses routinely asking patients whether they wanted any pain medication, referring to opioids, they discussed the current non-opioid medications patients were receiving for pain, along with their frequency and dosage, and asked whether those medications were sufficient. In addition, the care team was trained to discuss the potential side effects of opioids of which patients may not be aware.


The authors developed these processes after reviewing daily opioid use, pain scores, and anxiety scores for patients recovering from surgery for urologic cancers over a 4-month period (from November 2017 to March 2018) and analyzing the factors contributing to excessive opioid use. They also designed pain regimens using varying combinations of non-opioid medications. Researchers found that after the new processes were put in place, there was no increase in pain and anxiety among patients in the 24- and 48-hour window post-operation, compared to the previous approach.


"With the new approach, opioids were never withheld, but they were no longer the automatic default for patients and providers," Stevenson said. "Our study shows that it's possible to decrease patients' reliance on opioids after surgery, and that health care providers have an important role to play in the nationwide effort to combat the opioid epidemic."


The authors believe their approach could be applicable to other types of surgeries in various diseases, but that it would need to be tested under different circumstances and with a greater number of patients.