Management strategies are evolving for patients with cancer who have chronic pain, with an emphasis on reducing opioid use wherever possible. In this interview with First Report Managed Care, Dr Andrea Ruskin shares the main takeaways from her recent session on pain management at the 2022 AVAHO Annual Meeting.

Patients with cancer are living longer due to innovative treatments. Since patients are living longer, some of them are developing chronic pain.

Chronic pain management has evolved. Traditionally, we have used opioids for chronic pain in patients with cancer. When I joined the Veterans Affairs (VA) Connecticut Healthcare System, opioid prescriptions often were renewed automatically without determining whether the patient’s pain was acute or chronic and cancer related. We have since developed an opioid prescribing protocol to determine if a patient still needs opioids.

Are opioids necessary? Is the patient using them properly? Are they using opioids for pain or potentially for a nonpain situation? Is this really the safest and best treatment for patients?

Data shows an estimated 10% of cancer survivors have persistent opioid use. The definition of a cancer survivor can vary based on different studies. The way we define it is a patient that has been diagnosed and is beyond acute cancer treatment. Head and neck cancers are associated with the highest opioid use because the treatment of head and neck cancer is very complicated with multiple modalities. Many of these patients end up with chronic pain and a lot of emotional distress.

In our opioid prescribing, we make sure patients are using medications properly and there is no nonmedical opioid use, which is a term that came into use a few years ago. Nonmedical opioid use could be taking your friend's opioid or something you have not been prescribed in addition to your own, or it can be taking opioids not as prescribed. We have identified nonmedical opioid use in about 20% of our patients, which is similar to what has been found in other studies.

When we look at chronic pain, we first determine whether this patient may need to stay on opioids long-term. Secondly, is there nonmedical opioid use? If there is nonmedical opioid use, how can we intervene to make sure we are giving them the safest treatment? Interventions can be as simple as education or saying, as a team, that we think a patient has developed opioid use disorder.

Perhaps our full agonists are not the best treatments, and a patient needs to see a substance use disorder specialist. Maybe the patient needs to go on medications for opioid use disorder. A certain type of pain might be better addressed with an adjuvant, nonopioid, or nonpharmacologic treatment—perhaps physical therapy, cognitive behavioral therapy, or a spiritual intervention.

Chronic pain is very complex, and I think in the future, every patient with chronic pain should have a full pain assessment. Is this physical pain, and if it is physical pain, is it neuropathic pain? Is it post-thoracotomy pain? Is it pain where an opioid may not be the best treatment? Patients should also have a psychologic assessment. Is this patient in pain because they have psychological distress? A spiritual assessment can determine if it is spiritual distress. All of these are treated differently.

It is a great time to be in this field because our patients are living longer. We want them to live their best lives, and chronic opioid use has side effects that may impede or impair the patient from doing so.

The VA is such a unique place. There are so many available experts in different fields. The future holds comprehensive pain assessments of our cancer survivors and a multidisciplinary approach to pain management.

About Dr Ruskin

Andrea Ruskin, MD, currently works as medical director of palliative care at the VA Connecticut Healthcare System, which she joined approximately 3.5 years ago. Previously, she worked as a hematologist-oncologist for 23 years in private practice.