Opioids Are Not Always the Answer
As the opioid crisis continues in the United States, helping patients find effective and safer ways to manage their pain becomes increasingly important. During a session at the 43rd Annual Congress in Washington, DC (https://congress.ons.org/), Jeannine Brant, PhD, APRN, AOCN®, FAAN, of Billings Clinic in Montana, instructed nurses on ways to treat cancer-related pain (https://ons.confex.com/ons/2018/meetingapp.cgi/Session/1543) and discomforts other than (or in addition to) opioid pain medicines.
Opioids medications have been an important part of acute and cancer pain management because they generally have fewer side effects than many treatment modalities. However, their use can be controversial when improper patient selection and overprescribing occurs, especially in the era of increased substance abuse and overdosing. According to data in Brant’s presentation:
- 23 million Americans have a substance use disorder
- Only 10% receive treatment annually
- 22% of hospitalized patients have an active drug or alcohol use disorder
- Overdoses are now the leading cause of death in Americans younger than 50
As an example, providers should screen cancer survivors for pain at each encounter, prescribing systemic nonopioid analgesics and adjuvant analgesics to relieve chronic pain and/or to improve function, and using opioids in selected patients with cancer that are still experiencing distress and pain, but only if they are not responding to more conservative pain management.
When it comes to choices for more conservative pain management treatments, options include both nonopioid pharmacologic and nonpharmacologic. Nonopioid pharmacologic options are:
- Bone modifying agents (zoledronic acid and denosumab) that are used for metastatic bone pain. Side effects include osteonecrosis of the jaw, nausea and vomiting, and hematologic toxicity.
- Nonsteroidal anti-inflammatory drugs (NSAIDs), enzyme inhibitors that block inflammation and pain, such as ibuprofen and naproxen. These options come with their own warnings and side effects, such as acute renal failure, platelet inhibition by the nonselective NSAIDs, cardiovascular toxicity, and central nervous system toxicity.
- An anticonvulsant, specifically gabapentin (Brant noted that studies in patients with cancer are lacking for pregabalin). This is a first-line treatment for neuropathic pain of all types, but side effects can include dizziness, ataxia, edema, weight gain, dyspepsia, and leukopenia.
Other nonopioid pharmacologic options that are likely to be effective according to Brant are antidepressants (specifically tricyclics and serotonin-norepinephrine reuptake inhibitors), NMDA receptor antagonists, and cannabis.
Nonpharmacologic options and procedures that are recommended for practice include:
- Celiac plexus blocks, injections of pain medication often used for pancreatic and abdominal cancers, which can help lower the need for opioid treatment
- Radiation therapy, which can be used to control metastatic bone pain in patients in 15–22 weeks
Brant noted that the nonpharmacologic options likely to be effective are psychoeducational interventions and medical improv. For other nonpharmacologic options, effectiveness is not established because of small sample sizes in studies, lack of rigor in conducting the study, and more. Continued studies are needed in areas of pain control such as acupuncture, scrambler therapy (a rapidly changing electrical impulse that sends a non-pain signal to block painful stimuli), and yoga.