While I can barely muster up the chutzpah to write this blog, I’ve finally reached the end of my rope in tiptoeing around the subject.
Call me a TURKEY if you must, but everybody is entitled to pain management.
Not everybody is entitled to opioids if they are non-compliant or the risks are shown to outweigh the benefits.
And here it is if you’re ready….
Cancer patients, and their “caregivers” are NOT entitled to a free pass. What possible reason could there be to think that cancer patients or their caregivers are less likely to have a personal or family problem with opioid and/or alcohol abuse?
What, you ask???
I get it. I began my career in hematology/oncology over 30 years ago, and I was involved in building one of the first hospice and palliative care units in our entire region. So, I understand the mindset when colleagues tell me, “No we are not going to have our dying patients sign an opioid consent and no, we are not going to test their urine.”
Fast forward three decades, and we are in the midst of a presumed opioid epidemic. State after state is capping the quantity of opioids, prescribers are running scared especially following the recently release CDC guidelines, and chronic non-cancer patients requiring long-term opioid therapy are being discharged often for no good reason with nowhere to turn.
Report after report talks about the increase in prescription opioid deaths. The CDC reports that in 2014, prescription opioid related deaths rose to almost 19,000. But the statistic that is often left out is that the far majority of deaths also involve combined alcohol and/or benzodiazepines. In fact, Dasgupta and colleagues pointed out that of 2,182,374 patients prescribed opioids, the attributable death total was 0.022%.1 His group further revealed that in 80% of mortality cases attributable to opioid-related deaths, 80% were also receiving benzodiazepines. And, about half of the patients that died from opioids did not have an active legal prescription. So realistically, chronic opioid therapy in the absence of benzodiazepines and at reasonable doses is quite low for compliant patients.
Here’s a big question in my mind? Where did the prescription opioids come from for those other 50%? Most pain patients won’t part with them; hell, they’re lucky these days if they can even find a prescriber. Yes, some come from medicine cabinets when teens or other non-suspecting persons steal opioids. Yes, opioid quantities have often been overprescribed. And yes, there are other places to illegally find opioids.
But, God forbid that we even think for a minute that a patient with cancer, or worse yet, their caregiver is diverting drug. Do you suppose it’s possible that when an unsuspecting cancer patient keeps complaining of pain, perhaps they aren’t actually receiving their opioid? Is it even possible that their dose keeps getting increased because they have pain in the absence of their prescribed opioid? Do you think that if a savvy diverting caregiver knew that urine screens were being done that they’d give a few doses to the dying patient to make it look legit? Is it possible that the urine would be opiate positive after a single 15mg oral dose of morphine (the answer is yes) even though a dose of 200mg was prescribed? A serum morphine level would answer this question.
Another population that seems to get a free pass are dialysis patients. “Oh, well we can’t do a urine analysis because the patient doesn’t make urine.” Hello people, does the patient have blood?
In the last several years I have been referred patients on mega-doses of opioids as single agents or 2-3 different opioids combined. Additionally, I frequently receive emails and phone calls from colleagues asking for advice on how to treat a patient that is dying from cancer and the opioid doses are so high, they don’t know what to do. Sure, there are situations where this is possible but it is at least equally or more possible that the patient is not taking or not given the drug.
Here are some real examples:
- Morphine 200mg oral every 8 hours and oxycodone 10mg oral four times daily as needed for breakthrough pain. Family keeps asking for higher doses – dad is in severe pain. Urine screen is opiate positive, no oxycodone in urine even though prescription is filled monthly, and serum shows a miniscule amount of morphine – enough for a mouse. WHERE’S THE MORPHINE AND OXYCODONE GOING?
- Fentanyl 500mcg/hour transdermal patch (5 x 100mcg/hour patches) every 48 hours, plus methadone 40mg oral four times daily and morphine 60mg oral four times daily as needed. Urine is opiate negative which we’d expect from fentanyl and methadone, but the morphine is filled regularly which should cause a positive urine. This prompted a serum analysis which showed no fentanyl and enough methadone to treat a rat. WHERE’S THE FENTANYL, METHADONE, AND MORPHINE GOING?
- I could give 50 more examples with varying opioid combinations and doses.
I want to give cancer patients and everyone the benefit of the doubt, but seriously people, use your brains!
Here’s some food for thought…
- It is just as demoralizing for noncancer chronic pain patients requiring long-term opioid therapy to give a urine sample as it is for cancer patients.
- It is simple to take a blood from someone already hooked up for hemodialysis.
- Monitoring cancer patients similarly to non-cancer patients, especially when high dose opioids have limited or no effect on pain, may actually be doing the patient a great service if they aren’t receiving their drug(s).
- If the two cases above had been identified earlier, perhaps we could have prevented several deaths in people that bought these drugs on the street.
ASCO recently published practice guidelines, Management of Chronic Pain in Survivors of Adult Cancers. Here they talk about reasonable and universal precautions. Since cancer survivors are more commonplace these days, we need to be cognizant of these guidelines.2
Believe me when I say that I have a big heart for hospice and palliative care patients and I do support their entitlement to receive pain medicines, which should also be the case for non-cancer patients when opioids are clinically indicated. But what possible reason could there be for trusting cancer patients and their caregivers more than noncancer chronic pain sufferers that wish they had cancer so they could get their medicine, or so their prescribers believed them, or so their prescribers had an allayed fear for writing their opioid prescription?
In closing on the cusp of this Thanksgiving Holiday, I wish to remind clinicians from every specialty area that if you have a Turkey that’s diverting drugs, perhaps when assessing risk and monitoring patients universally we should remember, what’s good for the goose is good for the gander!
As always, questions and comments are enthusiastically welcomed!
- Dasgupta, N., Funk, M. J., Proescholdbell, S., Hirsch, A., Ribisl, K. M., & Marshall, S. (2016). Cohort study of the impact of high-dose opioid analgesics on overdose mortality. Pain medicine, 17(1), 85-98.
- Paice, J. A., Portenoy, R., Lacchetti, C., Campbell, T., Cheville, A., Citron, M., … & Koyyalagunta, L. (2016). Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. Journal of Clinical Oncology, 34(27), 3325-3345.