How does the ongoing opioid crisis in the United States impact prescription opioid pain management in patients with cancer for whom opioids are not only appropriate, but in many cases the standard of care? That's the question Hailey W. Bulls, PhD, Assistant Professor of Medicine and Associate Director of the CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center at the University of Pittsburgh, and colleagues set out to answer in a recent study (J Oncol Pract 2022; doi: 10.1200/OP.22.00251).
Earlier in the year, Bulls and other researchers published a framework for understanding and evaluating opioid stigma in cancer pain, which was intended to guide future research in the area (Pain 2022; doi: 10.1097/j.pain.0000000000002343). The framework outlines five domains to consider stigma around opioids that patients with cancer may experience: contributors to stigma, intersecting stigmas, stigma manifestations, proximal outcomes, and long-term impacts. It's the conceptual foundational work for the new study that included in-depth qualitative interviews with 20 patients with advanced cancer and 11 support providers between March 2020 and May 2021. The recent paper focused on the ways opioid stigma is manifested in patients, clinicians, and the community. "This paper is among the first to examine the concept of stigma around prescription opioids with cancer, especially for outpatients who are using opioids as day-to-day pain management," Bulls told Oncology Times.
The new work concluded that opioid stigma could be described in three primary manifestations among patients and support providers: 1) direct experiences with opioid stigma and discrimination in health care settings (such as negative or stigmatizing interactions in a pharmacy or clinic); 2) concern about opioid stigma impacting patient care in the future; and 3) opioid-restricting attitudes and behaviors that may reflect internalized stigma and fear of addiction. Bulls, who is also a clinical psychologist at UPMC Hillman, discussed why more research on this topic is important.
1 Why did you and your colleagues decide to conduct this research now?
"The intersection of the opioid crisis with cancer pain care is a very complex area to navigate. That's because prescription opioids are guideline-concordant care for patients with moderate-to-severe cancer pain, but also carry real risks, like negative side effects, potential for misuse, addiction, and even overdose.
"I first became interested in the idea of stigma around prescription opioids on my postdoctoral fellowship at Moffitt Cancer Center because I heard patients with active disease in the supportive care clinic talk about how opioid attitudes, fears, and legal limitations (like state prescribing laws) were impacting their access to guideline-concordant opioid pain management. That initial work was a brief survey to get the outlines of what stigma could look like, and this recent work here at the University of Pittsburgh Medical Center was the next step in our process to develop a comprehensive understanding of how stigma around prescription opioids impacts patient lives."
2 Were you surprised by the findings from this data that opioid stigma could be categorized in three primary manifestations?
"When I first started learning about opioid stigma, I was surprised to hear patients with cancer had negative experiences with prescription opioid management because opioids are so commonly used for cancer pain management and are exempted from many state laws and national prescribing guidelines.
"However, what I've learned since is that patients with cancer and their loved ones have real fears about addiction and safety, [as well as] challenges to accessing guideline-concordant care despite these exemptions, and these concerns deserve to be addressed in a way that balances the risks and benefits of prescription opioids for this population."
3 What's the next step of your work-and what's the takeaway for practicing oncologists and cancer care providers?
"We are working on designing and testing an intervention to improve opioid stigma among patients with active disease in partnership with patients who are likely to have unique barriers to access (such as People of Color or people who live in rural areas). As part of that work, we will explore ways to expand that intervention to clinicians, support people, and others involved in cancer pain care.
"We are also working on expanding this research to understand what challenges there are in long-term pain management for patients in remission, who may still have chronic cancer pain but less clarity on appropriate pain management strategies.
"Practicing clinicians should be aware of the challenges their patients face accessing guideline-concordant pain care. We should also be aware of the ways we talk about prescription opioids to these patients to make sure we are offering nuanced, personalized information about the risks and benefits of prescription opioids for pain management in a supportive and non-stigmatizing way. Our initial study suggests that some patients worry about how their clinicians will perceive them if they talk about their pain and prescription opioids, so it is important for clinicians to initiate and be open to these conversations."