Opioids and Chronic Pain in Cancer Survivors: Evolving Practice for Palliative Care Clinics.

Dear Editor: In the September issue of the Journal of the Palliative Medicine, Tan and collaborators bring to our attention the problem of opioid misuse in the palliative care setting. The authors call for a similar level of screening and monitoring for opioid misuse among palliative care patients as has been recommended for noncancer patients. We support rigorous monitoring of palliative care patients as necessary for safe opioid prescribing and propose that palliative care clinicians adopt a more deliberate shift in an approach to pain management among cancer survivors. In recent decades palliative care clinicians have been increasingly involved in the longterm pain management of cancer survivors. This is both a reflection of improved survival and the rapid growth of outpatient palliative care as well as an acknowledgement of the challenges faced by survivors with chronic pain transitioning care back to the community. We have seen this in our practice at a National Cancer Institute designated cancer center. Approximately 40% of our outpatient clinic population are cancer survivors without evidence of disease. Many of these individuals were initiated on opioids during active treatment and had dose escalations in response to progressive pain. With the transition to survivorship, the approach to the treatment of pain in this group of patients must undergo significant transformation. The goals of therapy are markedly changed. During active cancer treatment the goal of pain management was to rapidly reduce the progressive pain that interfered with comfort and ability to receive treatment. Now, long-term management strategies that focus on improving overall function while minimizing side effects move to the forefront. Pain management in cancer survivors presents a unique opportunity and a challenge. The palliative team seems ideally positioned to lead the ongoing management. However, our care of these patients is complicated by a lack of clear guidelines, the prevalence of chronic opioid use, and high levels of psychosocial distress among this population. Opioid therapy may be still the right choice of treatment for some survivors. This demands discussions with our patients, both initially and ongoing, about risks and goals of long-term opioid therapy and attempts to lower the total daily dose. Unfortunately, it is unclear how this should be done safely and effectively without compromising patients’ pain control and preserving the therapeutic relationship. Practices that highlight ongoing monitoring for opioid misuse and abuse need to be established as part of standard clinical care. As patients move into survivorship there are new opportunities to trial coanalgesics as well as involve physiatrists, interventionalists, and mental health clinicians. There remains a paucity of data related to opioid misuse and abuse among cancer survivors. Screening and risk stratification is one aspect of a complex issue. Multimodal therapies and thoughtful, goal-oriented communication around opioid prescribing is required. Let the impetus for the regulatory response to the opioid crisis be informed by our own best practices rather than being imposed on us. The current climate demands it and our growing survivor population deserves no less.