Policy Issue Brief: Prescription Opioids

Curbing Misuse and Abuse While Protecting Access for Cancer Patients
October 10, 2017

ASCO’s Policy Issue Briefs provide succinct overviews and relevant data on major policy issues impacting patients with cancer and the physicians who care for them. These briefs are designed to be especially helpful for journalists, offering background information on key issues across health policy today. Access ASCO’s full collection of Policy Issue Briefs.

Opioid Misuse and Abuse

The escalation of abuse, addiction and diversion of opioids – both prescription pain medications and illicit drugs – has led to declaration of an “opioid epidemic” in the United States, and in August 2017, President Trump announced that the United States intends to declare the opioid epidemic a national emergency To prevent and respond to prescription drug abuse, federal, state, and local governments are implementing new laws and programs to tighten controls and increasing education in the use of drugs. Some have raised concern that these initiatives could have the unintended consequence of limiting access to treatment of pain for cancer patients.

Pain Management in Quality Cancer Care

It’s widely acknowledged that too much pain goes untreated in cancer patients[1], [2], and while not all patients require opioids, they remain an essential part of some pain treatment plans. Pain does not only afflict cancer patients receiving active treatment; many of the 14 million cancer survivors in the United States.[3] who have concluded treatment also suffer from pain.

Pain in cancer patients is often caused by the tumor itself, which can stretch organs, put pressure on nerves, compress the spinal cord as it grows or spreads, or in other ways cause pain. Side effects from radiation therapy and chemotherapy can also cause pain during and after treatment – and sometimes the pain can be permanent. Physicians work closely with their patients to understand the type, prevalence, and severity of the pain, and develop tailored pain management plans for each patient.

In July 2016, ASCO issued a new clinical practice guideline on management of chronic pain in adult cancer survivors. The guideline recommends a full range of evidence- and consensus-based strategies for safe and effective treatment of persistent pain, including:

  • Routine screening for chronic pain.
  • The use of alternative pain management approaches, such as hypnosis, acupuncture and meditation.
  • The use of medical cannabis in certain settings in states where it’s legal.
  • Assessing the potential for opioid abuse.

Existing Barriers to Access to Opioids

Cancer patients already face a complex and often fragmented health care system and experience many barriers to access and appropriate use. Barriers include:

  • Limits on the number of pills (or patches) dispensed per fill, which requires more refills with additional copays.
  • Limits on the mix of opioids dispensed every 30 days, meaning patients with a need for more than one type of opioid may need to wait days for approval.
  • Requirements to wait 30 days or obtain prior authorization when dose is adjusted upwards or the original prescription is used sooner than originally planned (due to prescriber instructions to patient to increase dose for better pain control). Prior authorizations often take 72 hours or longer to obtain, which means patients either go without medication or pay out-of-pocket for a few days’ supply.

Congressional Action to Curb Misuse and Abuse

In July 2016, Congress overwhelmingly passed the Comprehensive Addiction and Recovery Act (CARA), which President Obama signed into law on July 22, 2016. While the new law authorizes $181 million in new funding, Congress will need to appropriate funding as part of its annual – often uncertain – appropriations process. Congress fully funded the law in FY 2017.

The legislation includes a number of provisions, including:

  • A requirement that the U.S. Department of Health and Human Services (HHS) convene an interagency task force to examine best practices for chronic and acute pain management
  • Expanded availability of naloxone and potential grants to states to implement “standing orders” for naloxone
  • The reauthorization of the National All Schedules Prescription Electronic Reporting (NASPERS) Act and grants to states for state-based prescription drug monitoring programs
  • Grants to states to fight the opioid abuse/misuse epidemic and to expand addiction treatment
  • “Partial fills” of opioid prescriptions, which allow patients to obtain less than the original, full prescription

The Need to Balance Patient Access

It’s vitally important for physicians and patients to discuss the benefits and risks of opioids, and to provide education on proper pain assessment, management of patients with substance abuse issues, alternatives to opioid pain management, and pain management in the context of end-of-life care. While ASCO generally supports federal efforts to address these issues, the society has been working with lawmakers to ensure that the creation of new safeguards for pain management do not create barriers to access for cancer patients.

Supporting Data

Opioid Misuse and Abuse

  • The rate of overdose deaths involving opioids (including prescription opioid pain relievers and heroin) has nearly quadrupled since 1999.[4]
  • Rates of opioid overdose deaths have increased significantly even from 2013 to 2014 – a 14% increase.
  • From 1999 to 2014, more than 165,000 people died from overdose related to prescription opioids.[5]
  • On average, more than 650,000 opioid prescriptions are dispensed each day.[6]
  • The economic impact of prescription opioid misuse/abuse is $55 billion in health and social costs each year.[7]

Pain Management in Cancer Care

  • Untreated or undertreated pain is common in patients with cancer, with little evidence of recent improvement.[8]
  • A meta-analysis of cancer patients showed 59% of cancer patients in active treatment experience pain, 33% of survivors experience pain, and 64% of those with advanced cancer experience pain.[9]
  • Approximately 5% to 10% of cancer survivors have chronic severe pain that interferes with functioning.[10] 
  • Cancer patients often have multiple sites of pain, and patients rated pain between a 4 to 6, with exacerbations rated as high as 7 (severe).[11]
  • Untreated or undertreated pain significantly decreases a patient's quality of life by causing sleep disorders, depression, impaired activity, mood alterations, abnormal appetite, inability to focus, and poor hygiene. [12]

A study of New York City pharmacists showed only 25% of pharmacies in predominantly nonwhite neighborhoods had sufficient opioid supplies, compared to 72% of pharmacies in predominantly white neighborhoods. [13]

More Information

 

[1] Fisch MJ, Lee JW, Weiss M, et al: Prospective, observational study of pain and analgesic prescribing in medical oncology outpatients with breast, colorectal, lung, or prostate cancer. J Clin Oncol 30:1980-1988, 2012.

[2] Breuer B, Fleishman SB, Cruciani RA, et al: Medical oncologists’ attitudes and practice in cancer pain management: A national survey. J Clin Oncol 29:4769-4775, 2011.

[3] American Cancer Society: Cancer Facts and Figures 2015. http://www.cancer.org/acs/groups/content/@editorial/ documents/document/acspc-044552.pdf.

[4] CDC. Morbidity and Mortality Weekly Report (MMWR). Past Volume (64). http://www.cdc.gov/mmwr/index2015.html. Accessed July 20, 2016.

[5] CDC. Injury Prevention & Control: Opioid Overdose. http://www.cdc.gov/drugoverdose/opioids/odprevention.html. Accessed July 20, 2016.

[6] Ibid.

[7] Pain Medicine. Societal Costs of Prescription Opioid Abuse, Dependence, and Misuse in the United States. http://painmedicine.oxfordjournals.org/content/12/4/657.figures-only. Accessed July 20, 2016.

[8] Ibid.

[9] van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, Schouten HC, van Kleef M, Patijn J. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol. 2007;18:1437-1449.

[10] Glare P, et al.: Pain in Cancer Survivors.  JCO.2013.52.4629.

[11] Gutgsell T, Walsh D, Zhukovsky DS, et al.: A prospective study of the pathophysiology and clinical characteristics of pain in a palliative medicine population. Am J Hosp Palliat Care 20 (2): 140-8, 2003 Mar-Apr.

[12] Manjiani D, Paul DB, Kunnumpurath S, Kaye AD, Vadivelu N. Availability and Utilization of Opioids for Pain Management: Global Issues. The Ochsner Journal. 2014;14(2):208-215.

[13] Morrison RS, Wallenstein S, Natale DK, et al. “We don’t carry that”—failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med 2000 Apr 6;342(14):1023-6. Accessed 5/12/2016.