The opioid crisis remains at the forefront of national concern. As of March, more than 100 people overdose on opioids and die every day across the United States, according to the National Institute of Drug Abuse.
Carroll County is no exception.
There were 42 overdoses in September, compared to 39 during the same month in 2017, according to Carroll County Sheriff’s Office data. Six of those overdoses were fatal, one more than September last year, the data show, and there have already been at least 55 fatal overdoses through three-quarters of 2018. The Sheriff’s Office records primarily the overdoses that law enforcement agencies in the county respond to. The true number could be higher.
Lawmakers across the nation, both at the federal and state levels, have pursued legislative action to crack down on the misuse of opioids.
While some of those efforts have netted positive results, they can also create unintended consequences affecting those who arguably need opioids most: Cancer patients and survivors, said David Woodmansee, directors of state and local campaigns for the American Cancer Society Cancer Action Network.
“The key word is ‘Balance,’” Woodmansee told the Times. “Balance of policies that do in fact mitigate the abuse and diversion of opioids but at the same time, while that’s going on, still allows our cancer patients and cancer survivors, who might need opioids to manage their pain and get through their day or night with a decent level of quality of life [access to opioids].”
Woodmansee added that opioids remain the “gold standard” for advanced cancer patients and end of life care.
Cancer care providers — oncologists, palliative care specialists, pain management doctors — can try a variety of pain-calming techniques.
Opioids are just one of a host of classes of pain medication that can, under certain conditions, be used to treat cancer- and non-cancer-related pain, said Dr. Dermot Maher, medical director of Interventional Pain Management at Sibley Memorial Hospital in Washington, D.C.
“Medications such as a neuropathic pain medications, non-steroidal anti-inflammatories, and then you can even get beyond that into the nonpharmacologic realm, where you start talking about interventional pain management,” Maher said.
Maher, an assistant professor at the Johns Hopkins University School of Medicine, specializes in the latter.
To further complicate things, some cancers are regarded as more painful than others, said Dr. Flavio Kruter, medical director of The William E. Kahlert Regional Cancer Center at Carroll Hospital.
Cancers that go into the bones are a chief cause of pain, he said.
“There are certain diseases that tend to go to the bone earlier than others, like for instance prostate cancer, breast cancer,” Kruter said. “Diseases that are involving certain organs in the abdomen for instance, like pancreatic cancer, is very known for causing a lot of pain because of the location of the pancreas.”
And then there are a few different treatment options for patients with pancreatic cancer, Maher told the Times, “such as celiac plexus blocks, when we use surgical-grade alcohol to prevent the pain nerves in the abdomen from conducting as much pain and really provide improved quality of life and long-term decreases in pain for abdominal malignancies for months and often years.
“It’s hard to really, looking at a patient in the office or in any setting, say, ‘You’re going to respond well to this therapy and you’re going to respond really well to this other therapy,’ ” Maher explained. “It really depends on a patient: Some people will find Therapy A very effective and some people will find Therapy B very effective. There’s no real way to tell who is who.”
There are different ways to treat and reach different nerves.
Interventional pain doctors like Maher use different injections to combat different types of pain, he said. To reach the superior hypogastric plexus (another bundle of nerves), “some of my colleagues do intrathecal pumps, which are essentially tiny catheters that deliver medication directly into the spinal fluid, that really greatly magnifies the effects of some of these medications from a pain standpoint, without causing systemic side effects.”
Medical cannabis is emerging as an option, too, though research has yet to yield definitive findings.
“It’s something that I’m definitely asked about very frequently, for the treatment of both cancer pain and non-cancer pain. I would say that the jury is still out as to how effective it is, relative to other treatment strategies and overall,” Maher said. “The risks associated with it are likely relatively minimal, but then again the risks associated with a number of pain treatment strategies are also relatively minimal. I just think that we haven’t really established that risk-benefit ratio yet.”
Determining the best treatment plan for each pain patient — cancer or otherwise — is a team effort, and there are no blanket solutions. Just because opioids work for one patient doesn’t mean they’ll work for another. Pain is a complicated condition. Not black and white.
It involves some trial, and hopefully little error, Maher said. Keeping an open mind when evaluating each patient is of paramount importance, he added.
“It definitely starts with meeting the patient face-to-face, giving that patient enough time to really tell you where they’re having pain,” Maher said. “Let them describe the pain, when it started, all the associated factors, what makes it better and worse, and what they’ve tried to treat it.”
It’s also crucial not to jump to conclusions. The answers aren’t always lying in plain sight, nor is the course of treatment universal.
“Just because you have cancer doesn’t mean that you don’t also have pain coming from other sources,” he said. “Just because you have a certain cancer and now you’ve got very classic symptoms suggestive of low back pain doesn’t mean that the only treatment out there for you is more and more pills.”
Other ways of treating that pain can be appropriate and effective. And that’s something a lot of cancer patients should perhaps be much more aware of.
And oncologists and others involved in treating cancer and cancer-related pain don’t just prescribe opioids with reckless abandon.
Kruter told the Times that usually the first step to treating cancer-related pain is starting with over-the-counter drugs such as acetaminophen, like Tylenol, or a non-steroidal anti-inflammatory, like ibuprofen.
“So we kind of add one medication to the next because the whole idea is that using different drugs with different mechanisms of action means you can use less of a particular drug,” Kruter said. For example, “If you have a patient that has widely spread breast cancer and that patient is in a lot of pain, if you’re going to be using an opioid up front, you may end up needing a much higher dose of the opioid as opposed to if you combine that with, let’s say, acetaminophen with a non-steroidal or sometimes a little bit of steroids, and then use the opioids.”
Kruter said there are some common myths regarding opioids and cancer pain. One is that patients often think they’ll get addicted if they use opioids. Another is that patients worry if they start with a strong medication, they’ll be out of options when their pain worsens.
Developing an addiction is unlikely, Kruter said.
As for the latter, he said: “There’s always a regimen of pain medication that will keep most patients pain controlled. Sometimes it’s a matter of dosing. And we have had patients that have had extremely high doses of opioids needed to control pain and then again, you start combining other medications and control the pain. That’s kind of the backbone of how we use opioids in cancer.”
There’s also a spectrum of different opioids. There are short-acting opioids that relieve pain for three to six hours and long-acting opioids that stay in an individual’s system for 12 to 24 hours, Kruter said. And there’s a variety of methods of administering long-acting drugs, like patches that stick to a patient’s skin and slowly release medication over a period of three days.
“The important thing is this aspect of the long acting and short acting. Something quick like pain from a surgery, then you need a short-acting pain medication because it’s a short-lived pain,” he said. It’s different when “you have somebody with a cancer that is not going to go away fast at all. And so you start with the short-acting, and then if the need for the short-acting escalate, then it’s time to start something long-acting in preparation for long-term use of narcotics.”
Kruter said he doesn’t think the opioid epidemic and increased national scrutiny of the drugs has influenced the way oncologists employ the use of opioids.
“I think that oncologists are very sensitive to the patient’s needs and they are, for the most part, well trained,” he said. “What we’re seeing a difference in is obtaining those drugs from providers, because they are now under scrutiny. So it has become a lot more complicated and there’s a lot more paperwork involved, which is not beneficial to the physician that’s treating the patient and, more importantly, to the patient.”
And that ties back in to Woodmansee and the cancer society’s work. They try to ensure that there aren’t hurdles for patients and physicians that legitimately employ the pain-reducing drugs, while recognizing the justified concerns of elected officials working to curb the rampant overdose crisis.
Opioids are an important tool for treating cancer-related pain — that’s straightforward. However, the policy surrounding the drugs is far from simple.
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It’s an all-hands-on-deck effort to employ opioids properly and to sculpt policies that assure they’re available to those that need them, legitimately.