Opioid misuse is prevalent among the U.S. population—so much so that President Trump declared it a public health emergency in 2017. At the same time, research shows that 20%–50% of patients with cancer and 80% of those with advanced-stage disease report experiencing moderate to severe pain. Balancing the dichotomies is difficult, but oncology nurses and other cancer care providers have a responsibility to provide comprehensive pain management for patients with cancer.

Best Practices to Prevent Drug Diversion Among Staff

In a related article in the April 2020 issue of the Clinical Journal of Oncology Nursing, Ghuman and Maletich discussed drug diversion among nursing staff and shared the best practices they learned while creating a supportive drug diversion investigation and response process at their institution.

Maintain confidentiality: Protect employees from unsubstantiated claims by limiting discussion to a specific, interprofessional diversion response team with representation from pharmacy, nursing, unit management, drug diversion, quality and patient safety, and human resources.
Use open-minded interviewing: Approach employee conversations without bias or predetermined notions of guilt.
Minimize intimidation during high-stakes crucial conversations: Involve only the drug diversion specialist and employee’s manager in initial interviews.
Ensure confidentiality during drug testing: Test specimens off site to protect employees’ privacy.
Close the case: For positive tests, offer employees the opportunity to enroll in state-sponsored rehabilitation programs. For negative tests with other red flags, place employees on a watch list.

In their article in the April 2020 issue of the Clinical Journal of Oncology Nursing, Rodriguez et al. provided an overview of how opioid misuse affects cancer pain management and shared their institution’s approach to reduce risk factors for misuse and safely manage cancer-related pain.

Managing Pain in Patients With Cancer

Cancer-related pain can be treated with pharmacologic interventions (e.g., non-opioid analgesics, adjuvant analgesics, radiopharmaceuticals, opioids), nonpharmacologic interventions (e.g., music therapy, hypnosis), or a combination of both, Rodriguez et al. said. Other treatment options include radiation therapy, nerve blocks, or implanted devices.

The National Comprehensive Cancer Network recommends opioids for moderate to severe cancer pain, the authors said, and the American Society of Clinical Oncology recommends a stepwise approach starting with non-opioid analgesics, then judicious use of opioids in patients who do not respond to conservative approaches, Rodriguez et al. said. However, because of the opioid epidemic, providers may be reluctant to prescribe opioid medications even when indicated, reducing patient access.

Opioid Misuse in Patients With Cancer

Rodriguez et al. explained that patients with cancer may be vulnerable to opioid addiction because of disease-associated stress and a lack of coping skills, resources, and support. Risk factors include younger age, personal or family history of opioid use or substance abuse disorders, mental illness, history of legal problems or incarceration, and Caucasian race. Oncology nurses can screen patients for risk, and providers should conduct a comprehensive pain assessment to determine pain etiology and appropriate intervention.

Strategies to Reduce Opioid Misuse Risk

The authors proposed that a standardized opioid stewardship program would ensure patients received successful pain management treatment while reducing the risk of opioid misuse. They conducted a literature review and found evidence to support implementing:

Validated tools to screen patients for risk of opioid misuse
Universal precautions to assess patients for risk of misuse
Patient and staff education
Dedicated prescriber or team to manage pain
Standard prescribing practices
Risk-reduction strategies (e.g., toxicology screening, referrals for specialist management)

One Institution’s Approach

Rodriguez et al. developed the Pain Close Care screening tool for providers to use to assess patients’ risk for opioid misuse and set it to automatically populate to the electronic health record when a patient meets the criteria. It cues providers to a patient’s increased risk so they can prescribe safely and institute additional monitoring protocols (e.g., regular urine toxicology, opioid contracts, use of methadone or buprenorphine).

They also enacted hospital-wide patient and staff education. Staff resources provided information on the opioid epidemic, cancer pain management and opioid misuse, the new screening process and validated tools, updated documentation and workflows, and recognizing at-risk patients. Patient education included links to the Centers for Disease Control and Prevention and Substance Abuse and the Mental Health Services Administration helpline, potential opioid risks, and safe opioid use.

For more information on the cancer center’s approach, as well as the challenges they encountered, refer to the full article by Rodriguez et al. ONS members can also receive free nursing continuing professional development credits by reading the article.

Learn more about opioids, addiction, and complex care on the Oncology Nursing Podcast.

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