Clarification on Pain Management Recommendations for Cancer and Sickle Cell Disease

Representatives from the National Comprehensive Cancer Network (NCCN), American Society for Clinical Oncology (ASCO), American Society of Hematology (ASH), CDC, FDA, and the authors of the JAMA Oncology article detailing the meeting convened to address the perceived variance among clinical practice guidelines for disease management in patients with cancer and those with sickle cell disease.¹

Though there was not disagreement among cancer and sickle cell disease pain management recommendations when applied to the appropriate patient and clinical situation, the meeting participants agreed that there should be further clarification and education regarding the clinical practice of each rather than harmonization of the guidelines. 

“Clinical practice guidelines offer an important tool to inform evidence-based state, federal, and coverage policies addressing pain management for individuals with sickle cell disease, patients undergoing active cancer treatment, and cancer survivors,” the authors wrote. “The hope is that publication of this paper represents a first step toward providing clarity regarding perceived guideline variance.”

Although clinical practice guidelines for pain management varied in terms of their patient population, target audience, and purpose, they were found to have some overlap in scope and included a number of common themes and recommendations.

Common themes for pain management that were endorsed by all guidelines reviewed were:

• Use of nonpharmacologic therapy and nonopioid pharmacologic therapy

• Assessment of an individual’s likely benefit and risk prior to initiating opioid treatment

• Development and implementation of strategies to maintain patient safety and minimize the risk of opioid misuse based on patient history and risk factors

• Continuous monitoring and regular evaluations of effectiveness and necessity of opioid therapy

• Patient education on goals of treatment and safer use of opioid analgesics

• Optimization of adjuvant analgesics, psychosocial support, and interventional therapies in conjunction with opioid therapy

• Gradual opioid dose reduction, when indicated, to prevent withdrawal symptoms

“We all have the same goal: to help patients have the best quality-of-life possible,” Robert W. Carlson, MD,chief executive officer for NCCN, said in a press release.² “That means ensuring access to appropriate, safe pain management, while not contributing to inappropriate opioid use and addiction. In recent years, the rise of opioid addiction and overdose in the United States has rightly led to increased scrutiny of opioid prescribing practices. However, multiple reports indicate that well-meaning regulatory and coverage policies have created significant barriers for many patients with cancer and sickle cell disease where careful opioid use may be clinically indicated for pain management. This is especially challenging for cancer survivors. Clinical practice guidelines can serve as a tool for policymakers to account for special populations and mitigate harm in policymaking.” 

The article also called for additional coverage across payers for non-opioid pain management therapies and additional training for prescribers on how to appropriately transition patients with substance use issues of opioids. 

“As an oncology nurse, I regularly see patients experiencing major challenges accessing appropriate pain management, including opioids” Judith Paice, PhD, RN, director of the Cancer Pain Program in the Division of Hematology-Oncology at the Feinberg School of Medicine and member of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, chair of the ASCO Clinical Practice Guideline for Management of Chronic Pain in Survivors of Adult Cancers, and member of the NCCN Clinical Practice Guidelines in Oncology for Adult Cancer Pain, said in the release. “The barriers they experience can include challenges with their insurer or limited supplies in the pharmacy. Additionally, prescriber confusion around recommendations, including misunderstandings about guidelines can contribute to these challenges. We hope this clarification will facilitate better use of guidelines for payers, policymakers, and prescribers.” 

Scott Gottlieb, MD, who was serving as Commissioner of the FDA at the time of meeting, spoke about the agency’s position against a one-size-fits-all approach to opioid restriction policies, and emphasized the importance of science-based prescribing criteria that takes specific clinical situations into consideration. Additionally, Commissioner Gottlieb highlighted his support for evidence-based guidelines as a tool to differentiate between clinical situations in which opioids are overprescribed and conditions for which opioids may be the only effective pain management tool. 

Following the initial meeting, which took place in November 2018, the CDC issued a letter of clarification which illustrated that the agency’s guidelines were developed to provide recommendations for primary care clinicians who prescribe opioids for patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care. Further, the letter clarified that the CDC’s guidelines are not intended to deny clinically appropriate opioid therapy, but rather ensure that physicians and patients consider all safe and effective treatment options for pain management with the overall goal of reducing inappropriate use.

“Gaining clarification from the CDC on its pain management guideline was critically important because, while it clearly states that it is not intended to apply to people with cancer, many payers misinterpreted it and are using it to make opioid coverage determination – inappropriately – for that exact population,” Clifford A. Hudis, MD, FACP, FASCO, chief executive officer for ASCO, said in the release. “Addressing the misuse of opioids will require changes within the health care delivery system that protect the public and limit the potential for abuse, while also ensuring access to medically appropriate medication for individuals who live with severe chronic pain. An evidence-based approach will help make sure that one national crisis does not become two.” 

References:

1. Schatz AA, Oliver TK, Swarm RA, et al. Bridging the Gap Among Clinical Practice Guidelines for Pain Management in Cancer and Sickle Cell Disease. JCO Oncology Practice. doi:10.1200/JOP.19.00675.

2. Alleviating Confusion around Pain Management Recommendations [news release]. Plymouth Meeting, PA. Published April 7, 2020. prnewswire.com/news-releases/alleviating-confusion-around-pain-management-recommendations-301036847.html. Accessed April 8, 2020.