Chronic pain now with cancer

[deleted875186]

Have a few of these patients, they were on opioids before, or had some back pain issues, now they get cancer and “need to see the pain clinic for their cancer pain”. Heme ONC doesn’t want to do the type of opioids they need, and now I’m stuck doing cancer pain with high dose opioids and many of the headaches that I don’t want to deal with ..... out early, pain is always worse, discussion that there is a limit to how high I can go on the dose, etc.

Anyone else have a way to deal with this. Obvious answer is don’t take the patient, but assuming you’ve already taken the patient on. Do you ever stop prescribing got cancer patient? Do you have upper limits in cancer pain?

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[Agast]

Depends on the cancer and prognosis. If they're expected to recover after treatment/surgery I would not escalate beyond MED 150mg. Lower threshold to use methadone for patients with bone mets.

 

[painfree23]

Depends on the cancer and prognosis. If they're expected to recover after treatment/surgery I would not escalate beyond MED 150mg. Lower threshold to use methadone for patients with bone mets.

I like having limits like this but what do I do when they say their cancer hurts?

 

[lobelsteve]

Same thing you do when they OD on your Rx and you get sued because now they won't be cured with next round of CTX/XRT.

 

[Ducttape]

I have discontinued opioids on patients that failed UDS. One argued he was going to die anyways so what’s a little heroin going to do any different than the cancer.

I still set limits. Some people respond to being told that some preliminary studies suggest that certain cancers may get worse on opioids.

For the very sick, a palliative care referral for end of life pain is a consideration as is an intrathecal pump.

 

[deleted875186]

I like having limits like this but what do I do when they say their cancer hurts?

Literally just had this conversation .... can’t explain why your having this pain based off all the scan, patient says “cancer is getting worse” ....

 

[Orin]

The data for opioids with cancer pain is sadly not that strong. The issue is that it really does help calm down their anxieties/fears of mortality and chemically cope with the stress of treatments. I do a lot of dancing around the risks, remind them that opioids can kill them faster than some cancers, remind them that it can make some cancers worse or effect some immunotherapies, and then if they struggle with my limits, swap them to Suboxone or let them find a palliative prescriber. All the interventions are on the table, but the question is really whether they're dying soon or just faster than the usual bear.

Just because they have cancer, it's not a carte blanche for opioids. It's hard to not feel like a jerk for that, but if someone isn't safe for higher doses, that's the discussion.

 

[kstarm]

Agree with others. Palliative/Heme/Onc has been exempt from all the chronic opioid prescribing changes over the last 5-10 years and I think that has been a detriment. Cancer diagnosis doesn't all of a sudden make you a good candidate for opioids. It also doesn't change your biology to make you immune to OIH, addiction, and all the other side effects. Prognosis is so important to the risk/benefit consideration with opioids and this is rarely provided by heme/onc. I think goals of care are really important. Opioids are one option out of many to manage pain, and as a pain doctor that is where you can provide better care for your patients with cancer: Adjuvants, interventions, advanced procedures.

 

[Ferrismonk]

Risk of OD is 10x higher with MMED >90. There is also evidence that higher doses show diminishing returns, cancer or not. I don't go above 90 unless palliative (i.e. not trying to cure the cancer) and the cancer is a painful and possibly deadly one.

Patients are free to seek a second opinion elsewhere.

 

[Frazier]

I have discontinued opioids on patients that failed UDS. One argued he was going to die anyways so what’s a little heroin going to do any different than the cancer.

I still set limits. Some people respond to being told that some preliminary studies suggest that certain cancers may get worse on opioids.

For the very sick, a palliative care referral for end of life pain is a consideration as is an intrathecal pump.

I'm curious if you are referring to the works of Moss and Grandhi from 2012-2017? I believe they spoke of potential relationships with breast, lung, prostate CA.

Wondering if there is something more recent you have come across? Thanks