'Pendulum Has Swung Too Far' in Opioid Limits for Cancer Pain

Kathy D. Miller, MD


April 25, 2019

This transcript has been edited for clarity.

Hi. It's Dr Kathy Miller from Indiana University. Today I want us to think together about the impact of the opioid epidemic and the response to that devastating epidemic on our patients with advanced cancer.

I've been noticing this more and more in my own clinic, and I came across an editorial in a recent edition of the New England Journal of Medicine talking about structural iatrogenesis.[1] I have to admit, that's a term I had not seen before, but it describes this problem perfectly. It refers to how the structures that we put in place—in many cases, to improve care, improve safety, improve efficiency, and in this example, to respond to the opioid epidemic—have unintended consequences for patients who are not the target and are unintentionally harmed.

I'll give you a couple of examples of how I've seen the response to the opioid epidemic play out in my clinic over the past 2 weeks since I read that editorial. I saw a patient yesterday who is in her late 70s with metastatic breast cancer and who presented with a pathologic fracture and significant pain. She is extremely functional and her pain has been well controlled on fairly low doses of chronic narcotics for the 3 years since she was diagnosed.

However, 2 months ago, she lost her son to the heroin epidemic. Since then, without my knowledge or instruction, she began to wean herself off her chronic narcotics. She ended up in the emergency department with withdrawal, refused to go back on narcotics, and now has struggled to get adequate pain control.

While she is no longer taking narcotics, her functional status has decreased rather than improved. This was her personal response, but it is still related to the devastating effect of the opioid epidemic.

Two other patients of mine now have to drive 50 miles one way to the closest pharmacy that carries the chronic narcotics they need to manage pain for metastatic disease. These are not patients of means, and transportation is difficult. There is a stigma associated with picking up those medications at that pharmacy; however, that's the closest location because the pharmacies in their hometown no longer carry those medications, for fear that they will be targeted by people who are struggling with opioid abuse.

Finally, patients from our fellows clinic, who may see different fellows at different visits, have now been targeted for having multiple prescribers. Indeed, their prescriptions come from different fellows—different signatures—but in the same clinic, under the same supervision, and for the same problem. [There have been] no escalating doses and no suggestion of misuse in their history other than that their prescriptions come from different people.

This is an example where I think perhaps we've lost balance and the pendulum has perhaps swung too far. We, as a community, need to think about how we can tackle the devastating effects of opioid abuse but still respect that those powerful drugs have a real role for some of our patients whose needs are valuable, too.

I'll be thinking more about this in my own clinic, and I'd love your thoughts on how this has played out in your clinical lives and in your towns.

This is Dr Kathy Miller for Medscape, from Indiana University.

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