Managing Cancer Pain With Non-Opioid Modalities

Cancer Network spoke with Jeannine M. Brant, PhD, APRN-CNS, AOCN, FAAN, about her presentation, "Opioids: They’re Not Always the Answer,"  during the 2018 ONS Congress held in Washington, DC, from May 17–20. Dr. Brant works as an oncology clinical nurse specialist, pain consultant, and a nurse scientist at the Billings Clinic in Montana. Brant’s presentation focused on the use of non-pharmacologic and non-opioid modalities to be used in pain management, and the need for nursing support.

The topic of opioid use and management is of utmost importance, since the medical community faces an emerging problem with substance abuse and opioid dependence. Brant highlights that while 23 million Americans struggle with substance use disorders, treatment rates are low. In fact, nearly 22% of those hospitalized in the US are abusing substances of some type, including addictive drugs or alcohol.

– Interviewed by Lori Smith, BSN, MSN, CRNP

Cancer Network: What has led to the opioid crisis that we are facing today?

Jeannine Brant: A multitude of factors have led to the opioid crisis we face today. It is important to keep in mind that pain remains significantly untreated, especially in patients with cancer. Clinicians should be aware that current Centers for Disease Control and Prevention (CDC) guidelines on opioid use do not apply to patients with an active disease.

The guidelines are really related to chronic non-cancer pain, and there is application in cancer survivors who may suffer from chronic pain syndromes related to cancer treatment. With that said, opioids are potent analgesics and tolerable in most patients. Even in patients with non-cancer pain, a subset do well on opioids. Their pain is lessened, they are functional, they have minimal side effects, and they lack aberrant behaviors. However for some patients, addiction is a concern.

The science has matured in this area, and we now have a better understanding of the problem. But overall, clinicians were always trying to alleviate pain in people suffering from chronic pain.

Unfortunately, not all clinicians were appropriately trained in the management of chronic pain, and lack of consistent assessment and follow-up is one concern. It is also difficult to determine which patients are at the highest risk for developing a substance use disorder (SUD). There is suggestion of some high-risk factors, but this is not yet clear.

Additionally, large amounts of opioids have been prescribed following procedures, thus putting more opioids into the community and resulting in theft and diversion. For example, a colleague of mine shared a story about her 92-year-old mother who had a dental procedure and was sent home with 120 hydromorphone 4-mg tablets. For anyone who knows opioids, you know that that is an inappropriate prescription that exceeds patient need. Lack of education regarding opioid prescribing is also prevalent. Both physician and nurse curricula have minimal content dedicated to pain management and SUDs.

Cancer Network:Which opioid is the most commonly abused substance, and why?

Jeannine Brant: According to the CDC (2016), opioid-related deaths have skyrocketed since 2000. I think this gives us a snapshot view regarding which opioids were most likely abused or misused. The CDC describes the first wave to be related to methadone and semisynthetic opioids such as hydrocodone, oxycodone, and hydromorphone.  During the second wave in 2009, deaths were related to heroin; and then after 2013, illicitly produced fentanyl.

Cancer Network:What are some of the non-opioid options that are effective in treating pain?

Jeannine Brant: I want to continue to reinforce that opioids are still the treatment of choice for cancer pain. But the opioid crisis has allowed us to pause and think about maximizing other options that will improve pain control and either minimize opioid requirements or, in some cases, be used instead of opioids.

For example, a variety of co-analgesics are available to manage various pain syndromes: gabapentin, pregabalin, and duloxetine for neuropathic pain; NSAIDS and bone-modifying agents for bone pain; and corticosteroids for certain types of visceral pain. Other non-opioid options include nerve blocks, such as a celiac plexus block for pancreatic cancer. My colleagues and I at the Oncology Nursing Society recently published a supplement on pain management. A series of four systematic reviews discusses evidence to support these non-opioid options. 

Cancer Network:Can you explain the role of cannabis in managing pain, and describe what is being done to make cannabis more widely available to more patients?

Jeannine Brant: The evidence is building for the use of cannabis/cannabinoids in the management of cancer pain. According to the Oncology Nursing Society Putting Evidence into Practice Guidelines, cannabinoids are likely to be effective, but the publication suggests that more evidence is needed. One randomized controlled trial (RCT) found patients taking a THC/CBD combination had better pain control compared with those taking THC alone or a placebo. Another RCT, however, found no differences between the novel cannabinoid nabiximol and placebo. One open-label study found that THC spray improved pain severity. These findings are limited by the small sample sizes, lack of long term follow-up, and descriptive design of some studies.

Cancer Network:How can oncology nurses and providers manage pain with opioids and monitor for a developing dependency in patients?

Jeannine Brant: Screening for risk is important. Several screening tools are available, such as the Opioid Risk Tool (ORT), but controversy exists about whether these should be rolled out in a standard way across oncology settings.

Nurses will see patients daily with SUDs. The most important aspect of care is to have an open and honest conversation with patients about their pain management.

For some patients, we may need to talk them into taking opioids, because they fear addiction. For others, we need to use a team approach to monitor opioid use and the total pain experience. This means finding out about each patient’s physical complaints of pain, psychological status and impact on pain, social situation, and spiritual needs. Embedding palliative care programs and mental health programs into outpatient oncology is vital to meet these holistic patient needs.