February 2018

In this Issue: Improving Cancer Care
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Helping Optimize Information for Cancer and Effective Pain Management

Feature Article

The role of opioid treatment of cancer pain is evolving, in part due to the growing number of cancer survivors. Increasing cancer longevity suggests the need to recognize the existence of "chronic cancer pain," the management of which would differ from treatment of end-of-life related pain. This paradigm was first introduced in the VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain (2010) that acknowledged the "somewhat artificial" distinction between chronic non-cancer and cancer pain, the latter of which might persist as a result of the disease or its treatment. Despite concerns about the similarities between chronic non-cancer and cancer pain, there is uncertainty as to how to weigh the risks of opioid use for cancer pain and potential benefits with regard to pain relief, and how signature opioid informed consent (SOIC) might affect opioid prescribing practices and communication.

This ongoing study (2016-2018) seeks to characterize patterns and settings of opioid use including long-term opioid therapy (LtOT) – and will compare pain and adverse outcomes between cancer and other conditions over a decade, using a large national database. Investigators also are conducting interviews with oncologists, primary care clinicians, and Veterans living with cancer, including those with histories of opioid misuse, to characterize their perceptions and experiences with LtOT and SOIC, as well as their views about how it should be implemented. Study participants were recruited from two VA healthcare systems in Connecticut and California. Oncologists will review SOIC materials and provide feedback on barriers, facilitators, and recommended modifications.

Findings: Thus far, preliminary themes from 19 interviews with oncologists, palliative care providers, primary care physicians, and advanced practice nurses indicate:

• Perceived appropriateness of SOIC depends on patient characteristics, such as: stage, state, prognosis, age, mental health, previous substance misuse.
• Perceived benefits of SOIC include patient awareness of medication safety, patient activation (i.e., how they manage opioids), and promoting shared decision-making.
• Perceived risks include the SOIC may be unnecessary (i.e., patient with widely metastatic disease and poor prognosis), it limits access to medicine, and represents a trade-off of time for addressing other concerns.
• Opioid consent processes should be comparable to other treatments with similar benefit/risk profiles (i.e., warfarin for stroke).

Both primary care and oncology physicians perceive risks in using opioids among Veterans with cancer and suggest specific accommodations in implementing SOIC and other interventions (e.g., allowing opt-outs for emotional fragility). Clinicians stress the need for a balanced perspective that includes monitoring unintended consequences and ensuring safeguards to minimize risks when appropriate.

Impact: Findings will enhance VA knowledge on long-term opioid therapy, the role of signature opioid informed consent, its application to cancer, and its use in the context of other efforts to improve opioid prescribing among Veterans at risk.

Principal Investigator:  Karl Lorenz, MD, MSHS, HSR&D’s Center for Innovation to Implementation (Ci2i), Palo Alto, CA.

Helping Optimize Information for Cancer and Effective Pain Management project abstract