The literature identifying the causes of and solutions to physicians' and patients' fears of opioid risks and side effects appears to be having little effect.
That physician and patient fears regarding the risks and dangers of opioids are overblown, particularly when it comes to addiction and dependence, has been much discussed. Yet despite the consensus that properly selected and administered opioids are a safe and effective pain management option in both the cancer and noncancer settings, we still seem to be having the same conversations about the need for more education, training, and outreach designed to improve physicians’ knowledge and awareness of effective opioid prescribing practices.
A review article published recently by Alaa Bashayreh, RN, MSN, in the Journal of Pediatric Hematology/Oncology titled “Opioidphobia and Cancer Pain Management” stated that “opioidphobia is one of the major issues in cancer pain management,” a phenomenon that, left unaddressed, “could limit the efficacy of the treatment process.” Bashayreh noted that inadequate/ineffective cancer pain management can result from health care provider, patient/family, and health system-related barriers, and identified poor provider knowledge of opioids and fear of opioid overuse as among the key provider-related barriers to care. A fear of opioid addiction and dependence among patients and family members is also a barrier.
Ineffective pain management in patients with cancer resulting from “opioidphobia” (which for the purposes of this article we’ll refer to as “opiophobia”) and other barriers “could lead to unnecessary suffering, decreased ability to cope with the disease, interference with activities of daily living, and extended or repeat hospital admissions. Uncontrolled pain may also delay or disrupt anticancer treatment, compromising its effectiveness.”
The author identified opiophobia as a fear shared by “regulatory agencies, healthcare professionals, clients experiencing acute and chronic pain, and their families,” despite the fact that “studies confirm that [opioid] abuse and addiction are rare among chronic pain clients including cancer patients.”
To further address the issue of opiophobia and its impact on the effectiveness and quality of cancer care, Bashayreh conducted a brief literature review and interviewed members of the oncology care team at a university-affiliated hospital about their perceptions of opiophobia and its effects on quality of care.
Based on the results of the literature review and interviews, the author identified several themes common to providers regarding the use of opioids during cancer treatment. Fear of addiction and fear of opioid-induced side effects were the two main concerns among providers. Bashayreh reported that providers’ opiophobia stemmed from several common factors: inadequate training and knowledge about cancer pain management, lack of knowledge of and/or failure to follow treatment guidelines, greater focus on cancer treatment rather than pain management, and being swayed by the fears and concerns of patients and their families. The main sources of patients’ opiophobia were lack of education about the myths and facts of cancer pain management and management of the associated symptoms, and lack of knowledge about opioid medications and their side effects.
The author recommended the development of standardized protocols and tools for cancer pain management, and that greater emphasis should be placed on educating providers, patients, and families and assessing these groups for opiophobia. She also recommended the development of “continuous quality improvement programs for applying and monitoring of cancer pain management protocols and tools.”
If everyone agrees it’s a problem, then what’s the solution?
An editorial, titled “Opioids, Pain, and Fear,” published by Marco Maltoni in the January 2008 issue of Annals of Oncology also acknowledged several “system barriers” to effective opioid analgesia for cancer pain. The author noted that “various legal and regulatory obstacles to the use of opioids for cancer pain” risk turning the cancer patient into “an innocent victim of a war waged against opioid abuse and addiction if the norms regarding the two kinds of use (therapeutic or nontherapeutic) are not clearly distinct.” Additional physician-based barriers include lack of physician education and failure to follow existing guidelines, fear of patient addiction and analgesic tolerance, and “insufficient experience of pain management (poor knowledge of opioid pharmacology, conversion, equianalgesia, rotation, doses, and ratio for breakthrough pain drugs).” Physicians’ “concern about and failure to treat opioid side-effects” is also a important barrier to care.
Maltoni identifies several patient-centered barriers to effective treatment with opioids as well, including “reluctance in taking pain medications due to the well-known ‘myths about opioids’, represented by fear of addiction and/or of being thought of as an addict, fear of analgesic tolerance, and fear of side-effects.”
He also noted the study “Opioid Analgesics for Cancer Pain: Symptom Control for the Living or Comfort for the Dying? A Qualitative Study to Investigate the Factors Influencing the Decision to Accept Morphine for Pain Caused by Cancer,” also published in the January 2008 issue of Annals of Oncology, which looked at “the factors that influence a patient's decision to accept or refuse a strong opioid to treat cancer pain.” According to Maltoni, this study provides several interesting insights into physician barriers to opioid treatment in the cancer setting, chief of which is that “the way in which physicians broach the issue of starting opioid therapy… strongly influences the patient's decision, as does the existing relationship between physician and patient.”
However, this communication with patients regarding the safety and efficacy of opioid therapy can be distorted or colored by the fact that “even professional figures fall victim to ‘the myths about morphine’ despite overwhelming evidence of the safety of opioids.” Indeed, in order to competently provide patients with accurate information about the benefits and risks of opioid treatment for their cancer pain, physicians must “be confident that treatment with opioids does not have a negative impact on survival, that the principle of double effect is not needed to justify this therapy from an ethical point of view, and that pain has an important antagonist effect on the modest respiratory depression of the drug.”
That is to say that misinformed or inadequately trained physicians only reinforce their patients’ misconceptions about the true risks and benefits of opioids; groundless fear leads to more fear, especially if patients falsely conceive of treatment with opioids as a “last ditch” effort at palliation. As Maltoni put it, “if patients receive unspoken confirmation from physicians of their idea of opioids as ‘a last resort’ and of the fact that treatment is linked to prognosis rather than to severity of pain, their determination to refuse treatment will be reinforced from a theoretical point of view.” Meanwhile, patients’ fears about the side effects of opioid treatment will blossom into justified (in the patients’ mind) refusal of treatment if “limited confidence and skills are shown by doctors in managing opioid side-effects.” Maltoni wrote that patients’ refusal “will take on empirical characteristics because of the ensuing damage they fear the drugs will cause.”
The only thing we have to fear…
In “Overcoming Opiophobia and Doing Opioids Right,” Forest Tenant, MD, described the prevailing fears about opioids as irrational, with the resulting reluctance to use them often leading to major complications in patients with untreated chronic pain. In addition to producing “profound” benefits (including normalized blood pressure, pulse rate, and pituitaryadrenal secretions, along with other biologic and physical enhancements that improve quality of life), opioids are “the only treatment that can consistently and predictably control pain.” Tenant stressed the importance of initiating opioid therapy at low doses and titrating “until a dose is reached that reduces pain 70% to 90%, but does not impair or sedate the patient.” Ascribing the majority of overdoses and deaths to patients who fail to take their medications properly and/or who use other drugs or substances that cause an adverse interaction, he concluded that “opioids as formulated, marketed, and properly prescribed… are quite safe and have minimal clinical risk when they are taken as prescribed.”
If that is the case, then what is the cause of the irrational fear of opioids? Tenant blamed the constant barrage of negative and misleading information about opioids in the media, along with the pervasive belief among the public and many in the medical community that pain is a natural part of disease and illness, that patients in pain should just “deal with it” (when they’re not being accused of exaggerating their pain), and that patients who need pain medications are “weak-willed.”
However, these claims, beliefs, and stances have been identified and largely debunked. A quick search online can easily retrieve many links to articles and commentary decrying the fact that physicians and patients are undereducated regarding the true benefits and risks of opioid medications, identifying patients’ and providers’ belief in the myths about opioid side effects (especially regarding addiction and dependence) as key contributors to the chronic undertreatment of pain, and pointing to clinical studies demonstrating that these fears are overblown while calling for more robust education of physicians and patients about these medications.
This knowledge gap has been the impetus behind the creation of an assortment of CME programs that outline the steps clinicians can take to identify the right candidates for opioid therapy and devise an effective treatment plan that maximizes palliative effect and minimizes risk of addiction and other side effects (see sidebar). There are even CME programs specifically designed to counter the prevailing myths and misconceptions regarding opioid therapy.
And yet, even with all of the attention devoted to this topic, one can also find article after article lamenting the fact that patients and physicians still harbor (unwarranted) fears regarding these medications, discussing why cancer and non-cancer chronic pain is still criminally undertreated, and calling for increased educational efforts to inform patients and physicians of the pros and cons of opioid medications for pain management. And round and round it goes…
So, we put it to our readers: from whence springs this disconnect between a near universally identified problem and the oft-expressed solution to that problem? Why, with so much having been written about the problem, the nature of the misconceptions, the probable solution, etc are we still talking about “opiophobia?”
Opioid Prescribing Guidelines
This report, commissioned by the American Pain Society, “evaluates evidence on use of opioids in adults with chronic noncancer pain” and was used to “develop evidence-based clinical practice guidelines for use of chronic opioid therapy in adults with chronic noncancer pain.” These guidelines were published in the February 2009 issue of the Journal of Pain.
The expert panel that created these guidelines concluded that “chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain.” However, the panel also acknowledged that “opioids are also associated with potentially serious harms.” The recommendations in these guidelines “provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices.”
Prepared by the Utah Department of Health, these guidelines “provide recommendations for the use of opioids for management of pain that are intended to balance the benefits of use against the risks to the individual and society.” These guidelines provide recommendations on the use of opioid medications for the treatment of both acute and chronic pain, and are based on information compiled during the evaluation of 40 pain management guidelines.
This updated guideline intended for primary care physicians using opioid medications to treat patients with chronic noncancer pain provides information on “the scope of the challenge, recommendations for prudent prescribing and monitoring, advice on how to get consultative assistance, and resources for educating patients.” The guideline revisions include “scientific evidence to support the 120mg MED dosing threshold;” tools for calculating drug dosages; validated screening tools for assessing substance abuse, mental health, and addiction; guidance on the use of urine drug testing in practice, and more.
This guideline, which updates the previous version published in 2003, widens the scope of practice to include opioid therapy for all forms of chronic pain (the previous version focused on chronic noncancer pain) and is intended for use in the ambulatory care setting. It offers best practice advice for the assessment and evaluation of appropriate patients for opioid therapy; discusses initiation, titration, and maintenance of opioid therapy, and provide formal treatment plans and treatment agreements. The guidelines also include a comprehensive, three-page treatment algorithm.
Opioid Prescribing CME
This three-module, Web-based activity “offers clinicians necessary education in how to work with their patients who are living with chronic pain — how to define chronic pain, how to manage its treatment, the tools available to assess pain and the risk involved in prescribing opioids, and how to discontinue treatment if necessary.” The first module addresses opioid efficacy, safety, assessment, and monitoring in the primary care setting. Module #2 focuses on communicating with patients about safe and effective use of opioids and treating patients with addiction and/or psychiatric comorbidities. The third module presents a case study that will enable participants to apply the knowledge developed in this activity.
The authors of this CME activity discuss shared decision making for opioid treatment of chronic noncancer pain, contraindications for chronic opioid therapy, and strategies for evaluating appropriate patients for opioid therapy.
Complete this activity to learn more about the importance of conducting a risk-benefit analysis when prescribing opioid therapy and about the clinical signs that necessitate discontinuing treatment with opioids.
Selecting appropriate analgesic agents based on individual patient needs and characteristics; developing strategies to decrease the risk of drug misuse, abuse, and addiction; formulating safe and effective treatment plans; and raising awareness of factors that affect provider prescribing habits are among the topics addressed by the program.
Available in video and podcast format, this CME activity discusses “the implementation of a pain management plan that utilizes risk assessment tools and monitoring strategies and provides considerations for the use of abuse-deterrent formulations of opioid therapy.”
Download this video CME course for a thorough review of the methodology in abuse resistance and deterrence as well as newer formulations of opioids, as well as a discussion of the implications of these new formulations for physicians, payers, and other stakeholders.
Risk assessment, the use of safety and efficacy data to identify appropriate opioid agents as part of a treatment plan, opioid titration and rotation, and effective physician-patient communication as the basis for developing individualized treatment plans are key components of this activity.