Dr Bob Twillman Discusses Opioid Risk Assessment in Cancer Pain and New Opioid Policies

Typically, cancer pain management is carved out of policies that try to restrict opioid prescribing in an effort to combat the opioid epidemic, but with more and more patients surviving their cancer, there is some uncertainty regarding who is affected by these policies, explained Bob Twillman, PhD, executive director for the Academy of Integrative Pain Management.

The American Journal of Managed Care^® (AJMC^®): How does pain management with cancer maybe differ from pain management in patients with other diseases?Bob Twillman, PhD (BT): In many ways, cancer pain management is similar to treating pain in people who don’t have cancer. There are a few key differences, though. I think when we’re treating cancer pain, we more often know what is causing the pain than we do in people who have what we call chronic non-cancer pain. And in a lot of chronic non-cancer pain cases, it’s hard to tell exactly what’s causing the problem from a physical standpoint. And that’s not so true in cancer.

We have additional treatment options, oftentimes, in cancer that we don’t have with other types of pain, such as radiation therapy, chemotherapy even can be something that works well against certain types of pain, and there are a variety of other options that we have. I think, also, there may be some differences in terms of the goals of the pain treatment. If we have a cancer patient who has a highly advanced degree of cancer, then we’re really not looking so much to improve their function. We’re more interested in controlling their pain. And, so, we may make some trade-offs that increase the degree of pain control, while at the same time reducing the amount of functioning that they’re able to do, simply as a means of providing good palliative care.

So, there may be a few little differences, but, for the most part, the same principles apply: We still have to identify what the specific type of pain is and tailor our treatment to that type of pain.

AJMC^®: With more and more patients surviving cancer, has there needed to be a change in how pain is managed in this population?BT: Pain in cancer survivors is something that’s really gained more attention over the past few years as survival has increased in people with cancer. When I began doing cancer pain management 20 years ago, most patients didn’t survive their cancers, and so they had entirely different goals of care. Now that most patients are actually surviving their cancer experience, we have to look at what’s going to be the best for the long term. So, we do have to pay greater attention to issues related to substance use disorder.

We also have to pay greater attention to the long-term pain that patients experience as a result of those very treatments that are helping them survive. Many patients are surviving longer because they’re getting chemotherapies and other treatments that are more neurotoxic, and as a result, they’re winding up with long-term neuropathic pain syndromes that we have to be able to treat effectively. So as that has been something that’s emerged, the need to treat that pain appropriately and over the long term has really emerged, as well.

AJMC^®: How can providers identify and assess the risk of opioid abuse in patients with cancer?BT: To assess the risk of opioid abuse in patients with cancer, you really have to do a comprehensive assessment of the patient. So, you really have to be assessing, first of all, their pain from a comprehensive standpoint. You have to be looking at what’s going on with their pain biologically, psychologically—and by that, we mean in terms of emotions and thoughts and behaviors—and also socially.

But you also have to assess their risk for potential substance use disorder in that same manners. You have to be looking for the biology of it. Do they have a predisposition to addiction in their family? Is there a history of addiction in the family? Is there a history of substance use in the patient? Including alcohol and nicotine, because nicotine, actually, has been shown to be one of the strongest predictors of patients who get in trouble with their opioids.

You have to be looking at what’s going on with them psychologically. How are they dealing with the stress that they’re under in their lives? Those that aren’t dealing with it so well are the ones who are more prone to developing a substance use disorder. And so we have to assess that and intervene when appropriate. And we also have to do what we can to minimize the exposure to the opioids. Just for the mere fact that we’re not very well able to predict who it is who is going to be most vulnerable.

So, it really involves a comprehensive assessment that also involves also looking at who is around the patient. And do they have any problems with substance use disorder that might sort of be something that reinforces that behavior in the patient.

AJMC^®: How do new policies to combat the opioid epidemic have unintended consequences for patients dealing with chronic pain?BT: The primary way in which policy makers have so far attempted to deal with the opioid problem in our society is to restrict the prescribing of opioids. Now, generally, when they’ve instituted policies to do that, they have carved out people who have cancer, they have carved out people who are getting palliative care or hospice or end-of-life care. So, to some extent, that really shouldn’t be a problem for them, these new policies. However, what we know is that the way those policies are perceived by prescribers is such that it could have an unintended consequence of causing them to pull back on prescribing for everyone, not just those who may have a predisposition to addiction, but for every patient who gets opioids.

So, we’re concerned that there may be a generalized pull back in prescribing that could unintentionally harm people who really need these medications. We certainly seeing that happen in people who have non-cancer pain. We get reports all the time from patients who had been doing well on long-term opioid therapy and are having that therapy withdrawn as a result of some of the new policies that have come out. So, we’re concerned that that same thing can happen for people who have cancer, and we’re keeping a close eye on that.

And the other thing to consider is: while many of these policies carve out treatment of pain in people who are on active cancer treatment, many of them don’t specifically mention treatment of pain in cancer survivors. And it’s a little bit unclear at what point treatment of pain in cancer survivors ceases to be cancer pain management and becomes non-cancer pain management. So, there’s some things we still have to work out in terms of who the policies really do apply to.

AJMC^®: What policies does AIPM advocate for to address the opioid addiction crisis?BT: We advocate for policies that make it possible for us to use every tool in the toolbox to treat pain. Part of that means that we advocate for policies that allow us to use the opioids when they need to be used. So, we advocate against policies that put undue restrictions on the use of opioids. In addition to that, we advocate for policies that make it possible for us to use all the other ways to treat pain. Make it possible for us to use chiropractic care, acupuncture, massage therapy, biofeedback, mindfulness techniques, and so forth. All of which have great evidence that they really help people with pain. But many of which are not reimbursed by insurance companies. So, we really focused our efforts over the last couple of years on trying to get those services available for people and covered by their insurance policies. So, those are the main things that we’re focused on.