Multimodal Approach Considered to Relieve Opioid Abuse Crisis

Cancer pain management has often been exempt or “carved out” from policy efforts to combat the opioid-abuse crisis, according to Bob Twillman, PhD. This implies that cancer patients are not vulnerable to the misuse of opioids and provokes confusion regarding who is ultimately affected by these policies as more cancer patients become long-term survivors.

During a presentation at the 2018 Community Oncology Conference, hosted by the Community Oncology Alliance, Twillman emphasized a lack of understanding within the medical community on pain management. He referenced a survey conducted by the Association of American Medical Colleges, which found that a significantly small percentage (3%) of medical schools included a separate course in pain management in their curriculum.¹

For example, several oncology and pain communities advocate for increased access to opioids for patients with cancer, with prescribing opioid rates 1.22 times higher among cancer survivors than for patients with no history of cancer.²This was true even among survivors who were 10 years or greater past their cancer diagnosis.

Twillman, however, argued that there is no defined distinction between cancer patients and non-cancer patients. “All pain harms people. We need everyone to be getting good treatment. But, I’m not sure that this is a distinction that makes a difference.”

He suggests, instead, a multimodal approach to all victims of pain with the goal of improved function, rather than pain intensity. This can most effectively be done, Twillman noted during his presentation, with a “complete biopsychosocial pain assessment” for each patient. This form of individualized treatment assesses 3 main components: biology, psychology, and social.

First, we need to “assess the patient’s history of substance use, including marijuana, nicotine, and alcohol, as well as the patient’s family history of substance use.” Twillman pointed out that there are several forms of cancers, such as lung, kidney, and colon, that are already associated with addiction and could lead to a higher risk of opioid- and other substance-use disorders.

Twillman also calls for an assessment of the psychological factors that may influence the patient’s use or need for opioids. Such factors include: “stressors affecting the patient, symptoms of mental health disorders, the patient’s history of abuse and trauma, and the patient’s coping skills.”

The last component of Twillman’s multimodal approach involves a social assessment for the presence of others with substance-use disorders. Conversely, Twillman identifies people within the patients’ lives who may provide positive support for their management of pain.

With all of these components considered, Twillman assures that medical physicians could “reduce [the] reliance on opioids. And reduce the risk that is associated with [the drug.]” A prescription for opioids could become 1 option or tool within a variety of “tools in the toolbox.” Such tools include non-pharmacologic methods or interventions for pain management.

For example, “if the patient has a big component that is cognitive, the way in which they think about there problem, then they need to be seen by a counselor. If they have a problem that is behavioral, then somebody needs to be addressing that problem. Things like cognitive behavioral therapy, physical therapy, occupational therapy, mindfulness training, acupuncture, or yoga [can better manage the pain].”

In support of this claim, a recent study evaluated the outcomes of effective interventions towards opioid-abuse behaviors.³While further research is needed, the trial concluded that the Compassionate High Alert Team (CHAT) intervention was associated with a reduction of aberrant opioid-related behavior (AB) and opioid use for patients with cancer and receiving chronic opioid therapy.

Of the 100 patients included in the study, 30 patients with evidence of AB underwent the CHAT intervention. A second arm of 70 patients without evidence was included for comparison of key clinical characteristics.

The CHAT intervention was defined as a specialized team consisting of a palliative care physician and 2 or more of the following: a palliative care trained registered nurse, physiologist or counselor, pharmacist, social worker, and/or patient advocate.

Patients met with the interdisciplinary team during his or her clinical visit to discuss issues or potential risks related to the patient’s use of opioids, goals for opioid therapy, and alternative pain management strategies. The attending physician later decided whether or not the patient needed would continue the intervention based on an overall assessment.

The Wilcoxon rank sum test was used to examine changes in the Edmonton Symptom Assessment System from the time of intervention to the last follow-up visit and to examine the number of ABs before and after intervention per month.

Three months after the intervention, the median number of ABs decreased from 3 preintervention to 0.4 postintervention (P<.0001). The highest frequency AB prior to the intervention, &ldquo;request for opioid medication refills in the clinic earlier than the expected time,&rdquo; was noted to have the most significant improvement during the study period. Additionally, every documented AB decreased in frequency.

While a multimodal approach seems to signify improved results in pain management for people with cancer and chronic pain, Twillman touched upon the hurdles that insurance companies bring during his presentation. &ldquo;To some extent, this is what created the problem we have with opioids. It is the fact that it may be cheaper to get a month supply of Vicodin than it is to get 1 physical therapy session.&rdquo;

Twillman faults the &ldquo;for profit&rdquo; insurance companies for not identifying the long term financial benefits of nonpharmacologic care. &ldquo;If [insurance companies] sink a lot of money in providing a lot of nonpharmacologic care upfront, that we know over the course of a couple of years is going to benefit them, they can&rsquo;t show that to their shareholders.&rdquo;

Some efforts have been made to address this issue, including the Senate Bill 243, &ldquo;An act relating to combating opioid abuse in Vermont.&rdquo; Passed in 2016, the law includes $200,000 for a Medicaid pilot to use acupuncture as a nonopioid option for pain management.

Outside of such barriers, Twillman provided self-management strategies during his presentation in an effort to &ldquo;empower&rdquo; patients and &ldquo;treat them as members of the pain care team.&rdquo; Such strategies include: weight loss, proper nutrition, good sleep habits, regular relaxation practice, and maintaining positive social connections. All of which, Twillman noted, have been shown to improve cancer and chronic pain.

References:

1. Vadivelu N, Kombo N, Hines RL. The urgent need for pain management training.Acad Med. 2009;84(4):408. doi: 10.1097/ACM.0b013e31819a8358.
2. Sutradhar R, Lokku A, Barbera L. Cancer survivorship and opioid prescribing rates: a population-based matched cohort study among individuals with or without a history of cancer.Cancer. 2017;123(21):4286-4293. doi: 10.1002/cncr.30839.
3. Arthur J, Edwards T, Reddy S, et al. Outcomes of a specialized interdisciplinary approach for patient with cancer with aberrant opioid-related behavior.Oncologist. 2018;23(2):263-270. doi: 10.1634/theoncologist.2017-0248.