Opioid Guidelines

Between doses of chemotherapy and radiation, while enduring needle sticks and blood draws, during oral administration of nausea-inducing drugs, patients with cancer often find themselves inundated with a number of painful symptoms associated with their litany of treatments and the disease itself. Unfortunately for many, this pain may never go away. 

With more than 14 million cancer survivors alive today, oncology nurses know that pain management is an important part of survivorship. However, survivors may have a more difficult time managing chronic pain than ever before. On March 15, the Centers for Disease Control and Prevention (CDC) released new opioid guidelines that may prevent access to pain-mitigating medications for cancer survivors. 

The CDC has focused its efforts on limiting potential opioid abuse among non-cancer populations. According to its research, nearly 2 million Americans abused opioids in 2014. Although the new guidelines offer exemptions for patients currently undergoing cancer treatment, they make no mention of survivors who are already on pain management plans that encompass a combination of therapies, including the use of opioids, to address pain. Oncology nurses, those often in the forefront of pain assessment, know that many patients suffering from chronic pain are not in active treatment. The guidelines do offer exemptions for patients in palliative care and at end-of-life stages. However, palliative care isn’t clearly identified and might lead to confusion among the healthcare community when addressing pain needs for cancer survivors. 

One particular guideline addresses the prescription of immediate-release opioids: “When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting opioids (recommendation category: A, evidence type: 4).” Unfortunately, patients with chronic pain after their cancer treatment are likely already on a regimen that uses extended-release opioids to manage pain, which hasn’t been accounted for in the guidelines. Any change or alteration in their treatment plan could cause significant disruptions in pain control.

Regarding the timeline of prescribing opioids, the CDC guidelines state, “Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed (recommendation category: A, evidence type: 4).” As many oncology nurses know, patients with cancer—even those not in active treatment—may require doses that could exceed customary indications as compared to those without cancer. Moreover, survivors may require opioid treatment that lasts beyond the specified seven days. 

During the CDC’s brief open comment period, ONS in collaboration with the Patient Quality of Life Coalition submitted a response indicating that these guidelines may marginalize or isolate members of the survivorship community. There was no exemption added for those outside of active cancer treatment.

Will Creating a National Pain Strategy Help?

The U.S. Department of Health and Human Resources released the first National Pain Strategy on March 18, 2016 to coincide with the CDC’s guidelines. The Interagency Pain Research Coordinating Committee (IPRCC) was formed to create the national strategy and included members from the Department of Defense, the Department of Veterans Affairs, the Agency for Health Research and Quality, the CDC, the U.S. Food and Drug Administration, the National Institute of Health, along with public researchers and scientists. Together, the IPRCC developed the National Pain Strategy, which aims to use a multidisciplinary approach to ameliorate pain in American patients.

The goals of the National Pain Strategy indicate a coordinated move away from opioid-centric treatment by improving provider education and encouraging team-based treatment options—procedures which the oncology practice has consistently engaged. Moreover, the pain strategy calls for improved patient education of self-management techniques, along with clearer explanations regarding the risks and benefits of prescribed pain medication. Many of these practices will be common to oncology nurses who deal with pain management prescriptions. The IPRCC is also focusing on improving public education of pain management strategies and the benefits of a multidisciplinary approach. However, it’s still too early to tell how this national strategy will affect survivors suffering from chronic pain. 

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